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Application of Theory-Based Health Behavior Change Techniques to the Prevention of Obesity in Children Heidi Beckman, PhD Suzanne Hawley, PhD, MPH Tho...
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Application of Theory-Based Health Behavior Change Techniques to the Prevention of Obesity in Children Heidi Beckman, PhD Suzanne Hawley, PhD, MPH Thomas Bishop, PsyD

Few studies that apply behavior change constructs such as goal setting, self-efficacy, and readiness for change to childhood obesity interventions exist. The purpose of this study was to adapt these constructs for use within a community-based obesity prevention program designed for fifth and sixth graders and their families. Games, worksheets, and a helpful acronym made the constructs developmentally appropriate and comprehensible to 11- and 12-year-olds. The age-adapted techniques have the potential to enhance obesity programs in a population for whom the obesity issue is critical. n 2006 Elsevier Inc. All rights reserved.

ESPITE OUR INCREASING knowledge about the health hazards of obesity, the problem has risen to the status of a bglobal epidemicQ (Wadden, Foster, & Brownell, 2002). In our country alone, obesity has been listed as 1 of the top 10 major public health issues influencing the health of individuals and communities (U.S. Department of Health and Human Services, 2000). The problem of obesity is thought to be the result of a toxic environment that promotes sedentary activity over physical activity and that encourages the consumption of high-calorie and high-fat foods (Wadden et al.). The most recent literature in the area of obesity prevention and management has demonstrated the success of implementing theory-based interventions

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From Prairie View, Inc., Newton Medical Office Plaza, Newton, KS, Department of Health Psychology, University of Wisconsin Hospital and Clinics, Madison, WI, Department of Preventive Medicine and Public Health, University of Kansas School of Medicine, Wichita, KS, and Cherokee Health Systems, Talbott, TN. Address correspondence and reprint requests to Heidi Beckman, PhD, Health Psychology Department, University of Wisconsin Hospital and Clinics, 600 Highland Avenue E3/218, Madison, WI 53792-2424. E-mail: [email protected] 0882-5963/$ - see front matter n 2006 Elsevier Inc. All rights reserved. doi:10.1016/j.pedn.2006.02.012

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that apply psychological principles of behavior change to improve health outcomes. The research indicates that certain constructs have been integrated into obesity programs and have helped individuals to become more motivated for action toward their nutrition- and exercise-related goals. These constructs include goal setting (Cullen, Baranowski, & Smith, 2001; Schnoll & Zimmerman, 2001; Strecher et al., 1995; Task Force on Community Preventive Services, 2002), self-efficacy (Byrne, 2002; Dallow & Anderson, 2003; Pinto, Clark, Cruess, Szymanski, & Pera, 1999; Roach et al., 2003), and readiness for change (Berg-Smith et al., 1999; Campbell et al., 1994; Dallow & Anderson, 2003; Frenn, Malin, & Bansal, 2003; Marcus et al., 1998; Marcus et al., 2000; Marshall & Biddle, 2001; Sarkin, Johnson, Prochaska, & Prochaska, 2001). Interventions that incorporate these constructs are tailored to each participant’s needs and preferences. They aim to change the way people think and behave in relation to eating and physical activity, instead of simply being knowledge based like more traditional obesity programs. Strong research evidence supports these interventions that are based on behavior change theory (Centers for Disease Control and Prevention [CDC], 2001; Dallow & Anderson, 2003; Kahn et al., 2002; Task Force on Community Preventive Services, 2002). Many of the studies in this area

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conclude that behavioral, theory-based nutrition and physical activity programs are more successful at producing behavior change than knowledgebased programs. However, most of the research that has been conducted on this topic has focused on adults and older adults, not children. For instance, the CDC assigned a task force to conduct a systematic review of published studies that applied individually adapted health behavior change techniques with the goal of increasing physical activity. The task force found 18 studies that qualified for their review (Kahn et al., 2002). Of the 18 studies, 14 investigated adults, and the remaining 4 considered older adults. Although there is strong support for the applicability of behavior change theory to the issue of diabetes treatment adherence among children with Type 1 diabetes mellitus (Grey & Berry, 2004; Wysocki, 2004) and to the issue of asthma management in children (Guevara, 2003), little is known about the place of behavior change theory in the prevention of obesity in children. Still, the problem of obesity is as great of a problem for children as it is for adults. The number of overweight children has risen significantly over the past four decades (National Center for Health Statistics [NCHS], 2002). The CDC indicates that approximately 16% of children between the ages of 6 and 11 currently have a body mass index (BMI) greater than or equal to the 95th percentile. This is the BMI level that the CDC identifies as boverweightQ (NCHS, 2002). When children are overweight or obese, they are at risk to become obese adults (Must & Strauss, 1999). They are at higher risk for the onset of illnesses such as high blood pressure, high cholesterol, and Type 2 diabetes (Dietz, 1998). Besides these physical effects, they may also face emotional consequences such as peer pressure and teasing, negative self-image, lowered self-esteem, and difficulty making healthy choices (Faith, Saelens, Wilfley, & Allison, 2001). This highlights the importance of effective prevention programs for children that are individually tailored to bmeet them where they are at Q in their readiness to acquire healthy eating and exercise habits. The purpose of this pilot study was to apply theory-based health behavior change constructs to the prevention of obesity in children. We used the constructs of goal setting, self-efficacy, and readiness for change within a community-based obesity prevention program designed for fifth and sixth graders and their families. To do this, we had to modify these constructs to make them develop-

mentally appropriate and comprehensible to 11and 12-year-olds. This report summarizes our efforts to do this. DEVELOPMENTAL CONSIDERATIONS We chose to target our obesity prevention efforts toward 11- and 12-year-old children and their families for several reasons. First, while many adolescents struggle with a negative body image and unhealthy eating patterns, the body image attitudes of children are more malleable, and thus, prevention efforts may meet less resistance (Kater, Rohwer, & Levine, 2000). Second, as children approach the age of 11 or 12, they become more autonomous in their health-related self-management behaviors as compared to when they are younger (Pradel, 2000). Some evidence suggests that children’s health locus of control (i.e., their beliefs about the degree of reinforcement and control they have over the status of their own health) peaks during the transition to adolescence (Cohen, Brownell, & Felix, 1990). This is consistent with the model of childhood cognitive development advanced by Jean Piaget. Piagetian theory suggests that when some children reach the age of 11 or 12, they enter the stage of bFormal Operations,Q which is characterized by the development of abstract thought and hypothetical reasoning (Piaget, 1972). Children at this cognitive stage can begin to imagine the potential positive and negative consequences to a given health behavior, which allows them to assume a more internal locus of control with regard to their health management choices. Although maturation establishes the basis for the Formal Operations stage when children reach the age of 11 or 12, not all children will automatically move to this cognitive stage as they biologically mature, and it seems that a special environment is required for most individuals to attain this stage completely. Some estimates suggest that only 35% of high school graduates in industrialized nations obtain the Formal Operations stage (Kuhn, Langer, Kohlberg, & Haan, 1977). This raises some questions about the application of theory-based change constructs to childhood obesity prevention programs. It would be a challenge for most 11- and 12-year-olds to think abstractly about change and to consider all of the logically possible outcomes to a situation as some change constructs (e.g., the transtheoretical model) require. However, these potential concerns may be reduced by incorporating age-appropriate language into the intervention,

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eliciting concrete examples from the children and making the learning process interactive. Another related concern is that the negative consequences of an unhealthy behavior might be too far off in the future for a pre-Formal Operations child to imagine (e.g., imagining heart disease or diabetes as an outcome of a sedentary lifestyle). Children may need some more concrete or immediate examples to consider before making a decision in favor of change. To address this issue, the children may be asked to give personally relevant examples to make sure they comprehend the concepts that are being introduced. Because our prevention program was designed for children, program strategies had to be tailored to the cognitive–developmental level and interests of the target group. INVOLVEMENT OF THE FAMILY We chose to include families in the obesity prevention program because parental involvement is an important component of childhood obesity treatments. Obesity tends to run in families, and it would be counterproductive to treat a child when one or both parents may be modeling or supporting unhealthy lifestyle choices such as overeating or underexercising (U.S. Department of Health and Human Services, 2001). Parents play an important role in treatment by increasing the child’s access to physical activity and by identifying physical activities that can be enjoyed by the family as a whole. Parents can also learn behavioral reinforcement strategies that they can use to reward their child’s efforts at building healthy fitness and nutrition habits (Faith et al., 2001). Several studies have examined the impact of family involvement on the success of childhood obesity treatments. One study found a strong and consistent association between family support for physical activity and children’s level of physical activity (Sallis, Prochaska, Taylor, Hill, & Geraci, 1999). A review of four family-based treatment studies also suggested that outcomes are better when both a parent and child are targeted and reinforced for weight loss, as compared to when children are targeted alone (Epstein, Valoski, Wing, & McCurley, 1994). In a review of the current status of the behavioral treatment of childhood obesity, Faith et al. (2001) concluded that family-based programs have been studied the most and have reliably produced the best short- and long-term effects on weight. Because we wanted to involve families in our obesity prevention program, the family of each

participating child was given a Family Field Guide that included information on getting started (i.e., goal setting and self-efficacy), changing behaviors, charting and monitoring goals, having fun working toward health goals, and health basics (i.e., eating from the five food groups, lowering fat, and decreasing sedentary activity). The packet of materials included forms for self-monitoring of progress toward goals. GOAL SETTING Goal-setting approaches help people set goals that are measurable, realistic, behavioral, and desirable. They help people sort through their values and priorities and commit to change. Typically, the goal-setting process involves several steps: recognizing a need for change, establishing a goal, creating an action plan, self-monitoring, and rewarding goal attainment (Sobel & Ornstein, 1996). Researchers in health behavior change have stressed the importance of goal setting as a way of attaining desired personal health outcomes (Schnoll & Zimmerman, 2001; Strecher et al., 1995). For example, goal-setting strategies have been shown to enhance the behavior change process in nutrition education programs for both adults and children (Cullen et al., 2001). One largescale, school-based intervention (Child and Adolescent Trial for Cardiovascular Health) demonstrated that self-regulatory processes such as self-monitoring and goal setting could help fourth and fifth graders change diet and exercise behaviors to reduce their risk for cardiovascular disease (Edmundson et al., 1996). Goal setting is also an important part of individually adapted health programs designed to help participants incorporate physical activity into their daily routines (Task Force on Community Preventive Services, 2002). To make the construct of goal setting understandable to the children in our study, we designed a series of worksheets that were included in the Family Field Guide. The worksheets were written in simple language that most 11- or 12-year-olds could understand (as determined by a Flesch– Kincaid Grade Level score of 6) and were enhanced with illustrations and visual aids designed to appeal to a young person. The worksheets guided the families through specific exercises that helped them build an action plan or contract that satisfied each family member. The worksheets started by defining the characteristics of a goal that enhance the likelihood that it will be

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achieved (measurable, realistic, behavioral, and desirable) and requiring the family to practice writing goals. Then, there was a series of exercises that prompted the family to align their healthrelated goals with their highest values and priorities. Next, an exercise guided families in identifying the steps that they would need to take to achieve their goals, the details of their action plan, a method of monitoring progress toward goals, and a method of rewarding themselves for taking action. These worksheets culminated in an action plan form (see Appendix A) that the family could post in a prominent place in their home. An experiential exercise called bMoonballQ was also implemented in our study to make the construct of goal setting understandable to the child participants (adapted from Schoel & Maizell, 2002). In this game, the children stood in a circle and were given a large ball. They were told that their objective was to keep the ball moving but to prevent it from having any contact with the ground. They were encouraged to try different strategies and to use the various components of goal setting to help them achieve their objective. Familiar concepts and terms were used to lead them through this process, such as the idea of a bgame planQ and other simple sports analogies. The children developed a game plan of their own and a method of monitoring their progress during the activity. When their initial plan did not allow them to reach their objective, the facilitators encouraged problem solving. The activity engaged the children, and they saw their performance improve when they solved problems and evaluated their approaches. The collaborative nature of the game prompted the children to encourage and support each other.

sense of self-efficacy is enhanced when they are successful in taking small steps toward their goals or when they learn to associate positive feelings (or the absence of aversive physiological or affective arousal) with their new behavior (Bandura, 1997). In the area of health behavior change, interventions are being developed to assist individuals in their weight loss attempts by enhancing their sense of self-efficacy (Dallow & Anderson, 2003; Roach et al., 2003). For example, Roach et al. (2003) attempted to increase young adults’ sense of selfefficacy for weight loss during a 12-week weight loss promotion program. They found that as the participants’ self-efficacy improved, their eating habits improved and their health outcomes were more positive. A review of studies conducted by Byrne (2002) concluded that level of self-efficacy has an important effect on the behaviors involved in weight maintenance and relapse in obesity. Finally, Pinto et al. (1999) discovered that selfefficacy for both eating and exercise behaviors improves when weight loss attempts are successful. To make the construct of self-efficacy understandable to the children in our study, we facilitated an experiential exercise called bGroup JuggleQ (adapted from Schoel & Maizell, 2002). In this game, the children were split up into groups of 5–10 and stood in a circle. They were told that their objective was to pass three or four objects in a pattern without dropping the objects. Each child received every item from a specific person, passed it to another specific person, and handled each object only one time. Each item represented a particular nutrition goal. For example, an apple represented the goal of increasing fruit and vegetable consumption, whereas a water bottle represented the goal of drinking enough water each day. In a sense, then, the children were juggling the different goals of health behavior change. The groups were timed during this exercise and were encouraged to try to improve their time with subsequent trials. They were asked to describe how their confidence in their ability to juggle these goals changed as they took small steps in the right direction (i.e., improved their time by a few seconds) or as they started experiencing the exercise less as bworkQ and more as bfun.Q The children were able to identify small increases in their sense of self-efficacy over the course of the game.

SELF-EFFICACY Self-efficacy is the belief in one’s ability to organize and carry out the courses of action necessary to achieve a goal or manage a situation (Bandura, 1986). This personal belief influences the choices people make, the effort they put forth in working toward a goal, how long they persist when confronted with obstacles, and how they feel in the process of working toward goals. According to selfefficacy theory, certain cognitions are important in people’s decisions about working toward a goal. First, they must consider the goal to be important or desirable. Second, they must believe that they are capable of performing the set of behaviors that is required to reach the goal. In general, individuals’

READINESS FOR CHANGE Most health behavior change interventions are designed for individuals who are already prepared

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for action (Campbell et al., 1994). However, people differ in their degree of readiness to work toward a goal, and some individuals belong in much earlier stages of change. These stages of change were first identified in the area of addiction treatment, and the comprehensive model of behavior change that grew from this work was called the transtheoretical model of change (Prochaska & DiClemente, 1986; Prochaska, DiClemente, & Norcross, 1992). According to the model, when people are changing a behavior, they move through distinct stages: (1) precontemplation, when they are unaware of the need for change or not interested in making a change; (2) contemplation, when they are thinking about changing but experience ambivalence; (3) determination/preparation, when they are making definite plans to change; (4) action, when they are actively modifying their behavior or habits; and (5) maintenance, when they are sustaining their newer behavior and preventing relapse. People do not necessarily move through the stages in a linear fashion. They may relapse and repeat stage progressions, and they may enter or exit the stages at any point (Miller & Rollnick, 2002). After the stages of change construct was validated on addictive behaviors, it was applied to and validated on several other issues, including health behaviors such as diet (Berg-Smith et al., 1999; Campbell et al., 1994; Frenn et al., 2003) and exercise/physical activity (Dallow & Anderson, 2003; Marcus et al., 1998; Marcus et al., 2000; Marshall & Biddle, 2001; Sarkin et al., 2001). When the model is applied to health behavior change, it is not assumed that people are automatically ready to act to change a personal health habit. Instead, interventions are individually tailored to meet people where they are at in their readiness for change. For example, if individuals are in the precontemplation stage, they might be provided with more information about their health problem. In contrast, if they are in the preparation stage, they might be encouraged to develop an action plan and to elicit support from friends and family. In a recent application of the transtheoretical model, the investigators found that an intervention to improve dietary adherence in adolescents, which was designed to target each participant’s unique stage of change, was positively received by the adolescents and popular with the interventionists (Berg-Smith et al., 1999). This finding supports the utility of the model when applied to nutritional habits. In a family practice setting, Campbell et al. (1994) designed and distributed individually tailored computer printouts

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based on patients’ stages of change to give them the message about the need to reduce fat intake. At a 4-month follow-up, the tailored intervention produced significant decreases in fat intake scores compared with those of a control group. The transtheoretical model has been applied to the domain of physical activity as well. For example, in one study (Dallow & Anderson, 2003), the researchers demonstrated significant and positive changes on a measure of processes of change when obese women were engaged in a program that aimed to change the way they thought and behaved in relation to physical activity. A meta-analysis of empirical studies that applied the transtheoretical model to physical activity and exercise revealed that membership in a particular stage of readiness for change is correlated with different levels of physical activity (Marshall & Biddle, 2001). Overall, the readiness for change construct is recognized as an important new tool in consultations about health behavior change. It is an approach that can be used to bridge several different conceptual models (Epstein, 1998). The application of the model helps people to be more active agents in behavior change, rather than being the passive recipient of a medical professional’s bfixQ (Rollnick, 1996). Barlow and Dietz (1998) point out that if a behavioral health intervention does not give consideration to a patient’s stage of change, it may actually be harmful to the patient. For example, if a weight-management program is prescribed to a child who is not ready to make a change, it may actually decrease the child’s self-esteem and impair his or her future efforts to manage weight. To make the construct of readiness for change understandable to the children in our study, we developed an acronym that would help children remember the series of stages: bIGNITEQ (see Appendix B). Each letter of the acronym stands for a simple phrase that describes the main task of each stage of change. The bIQ stands for bIgnore the problemQ and represents the precontemplation stage. Because individuals in this stage are not aware of a problem or a need to change, their main task is to gather more information. The bGQ stands for bGet a clueQ and represents the contemplation stage. The main task of this stage is to weigh the costs of making a change against the potential benefits. The bNQ stands for bNow what?Q and represents the determination stage, when the scales begin to tip in favor of making a change. The main task of this stage is to solidify the commitment to change by telling others about it. The second bI Q

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stands for bI am ready!Q and represents the preparation stage, when an individual must make a solid plan for change and identify how to get around the obstacles that may arise. The bTQ stands for bTry it!Q and represents the action stage, when an individual moves forward with his or her plan. Finally, the bEQ stands for bEncourageQ and represents the maintenance stage. The main task of this stage is to strengthen self-efficacy by getting positive feedback on one’s progress toward his or her goals. The IGNITE model was a simple and fun way to introduce the concept of the stages of change to children. The participants in our pilot study were able to understand the main concepts and use the acronym to decide which stage they were in with regard to their readiness to change particular health behaviors.

ipants who do not possess much intrinsic motivation. For example, in the contemplation stage, individuals are asked to weigh the pros and cons for a particular health behavior and determine the costs and benefits of making a change. These costs and benefits could very well be tangible and external to the individual. For example, some parents establish a system in which children may only watch a favorite television program if they finish all of their vegetables at dinner. Children have the intellectual capacity at a young age to understand such a system of rewards and consequences. These concepts are fundamental to behavior modification in children and may be especially appropriate when used in exercise and nutrition programs designed for children. Future studies would benefit from examining this issue more closely. Other questions exist about the application of theory-based change constructs to childhood obesity prevention programs. As mentioned above, it is a challenge for most 11- and 12-year-olds to think abstractly about change as the transtheoretical model requires. We attempted to address this concern in our study by incorporating age-appropriate language into the intervention, eliciting concrete examples from the children and making the learning process interactive. We also asked the children to give personally relevant examples of each stage to make sure they comprehended the concepts that were being introduced. The children were readily able to produce such examples. The current study gives promising support to the idea that theory-based health behavior change techniques can be applied to childhood obesity prevention programs. Because no child-friendly version of the stages of change model currently exists, the IGNITE model provides a basic foundation to begin a program of research that can address the abovementioned concerns and questions more thoroughly. Future research should examine if obesity programs based on health behavior change techniques are more effective for children than knowledge-based programs, as they are for adults. In the meantime, though, the implications of the current study are compelling. The age-adapted techniques presented here provide powerful change technology to enhance obesity prevention programs in a population for whom the obesity issue is critical.

CONCLUSIONS The purpose of our pilot study was to apply theory-based health behavior change constructs to the prevention of obesity in children. We used the constructs of goal setting, self-efficacy, and readiness for change within a community-based obesity prevention program designed for fifth and sixth graders and their families. By translating these constructs through games, worksheets, and a helpful acronym, we demonstrated that they could be made developmentally appropriate and comprehensible to 11- and 12-year-olds. We achieved high participation rates for the games, and the children expressed great satisfaction. In addition, participants were able to recall key concepts at 1-week follow-ups. Although we successfully adapted the theorybased change constructs for children, it is not clear if these constructs are as central to the process of health behavior change for children as they are for adults. It is possible that compared to adults, different techniques are required to get children to take responsibility for their health. Children tend to be more extrinsically motivated in general, and it is not clear when they shift from being extrinsically motivated to intrinsically motivated with regard to health-related goals, although it is suspected that this happens during the transition to adolescence (Cohen et al., 1990). Programs that incorporate goal setting and self-efficacy assume that the participants need to enhance their sense of confidence and personal responsibility for improving health. On the other hand, programs that incorporate the transtheoretical model can still be effective with partic-

ACKNOWLEDGMENTS This project was funded in part by a grant from the Sunflower Foundation of Kansas.

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APPENDIX A

Action Plan Form

Example: We, the Smith family, because we value health, are going to do a walk around the block two times, after dinner, for 4 days per week. We will monitor our progress by charting it below. We will reward ourselves with a weekend camping trip if we stick to our plan for 6 weeks. If we find ourselves getting off track, we will meet to identify the barriers to our success and we will problem-solve around these barriers. Day of Week

Completed Plan?

Comments

Sunday Monday Tuesday Wednesday Thursday Friday Saturday APPENDIX B

Changing Stripes. . .Beginning Adventures Have you ever tried to be better at doing homework, playing a sport, or learning to play an instrument? Have you wished that things were different for your family, or have you attempted to be more active and eat healthier? Below you will find six stages that are important to change. If we know what stage we are in, then we can have a better idea of how to work at change. I—Ignore the problem A person is not aware of a problem or a need to change anything. A person may also not want to change. Task: Get information to see if change makes sense. Check it out.

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G—Get a clue The person is thinking about the good parts of change and the costs of making a change. Task: Get help. Share thoughts of change. Weigh the costs against the benefits.

N—Now what? The person knows that a change would help. Task: Tell others that you have decided to make a change and start thinking about your goal.

I—I am ready! The person makes a plan that will work for him or her. Task: Make a step-by-step plan for change. Talk with others about things that have worked or not worked for them. Plan how to get around the obstacles that might come up.

T—Try it! The person takes action and moves forward with the plan. Task: Make changes if needed. Keep an eye on how the plan is working.

E—Encourage The person seeks help to stay on plan and helps others with their plans. Task: Check in with family, friends, and teachers about how your progress is going. Share the good and the bad. Get positive feedback on your decision and your successes. Be excited that you are making change happen!

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