Case Study B
Modern life is becoming increasingly sedentary realizing the fact that inactivity contributes to health problems (Blair, 1997; cited in Sallis & Owen, 1999). Controlled research on physical activity interventions is a relatively new area of investigation for exercise scientist. However “there is increasing recognition that interventions to change behavior should draw on theories of behavior and behavior change in their development” (Michie et al., 2008, p.661). Particularly it is preferred using theory-based interventions because the evidence that they include indicate further understanding on how to develop interventions. After acknowledging the theory, comes the modeling phase of the intervention (Michie et al., 2008). The modeling develops the actions that need to be taken, in order to achieve the preferred behaviors by hypothesis and testing its target. The present study will examine a 39 year old, obese male with type 2 diabetes and mild depression, with the purpose of maximizing his adherence to the doctors’ recommended scheme. Reinforcing strategies in adopting exercise are complex because people react differently to the same reinforcement (Weinberg & Gould, 1999). Therefore the unique needs of the client should be considered.
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The most important health behavior theories include self-efficacy. Self-efficacy is a proximal and direct predictor of intention and of behavior (Schwarzer & Luszczynska, no date). According to Social Cognitive Theory (Bandura, 1997) self-efficacy is a personal sense of control that facilitates a change of health behavior. Schwarzer & Luszczynska (no date) state that “self-efficacy beliefs are cognitions that determine whether health behavior change will be initiated, how much effort will be expended, and how long it will be sustained in the face of obstacles and failures” (p. 1). In addition self-efficacy influences the effort one puts forth to change risk behavior and the persistence to continue striving despite barriers and setbacks that may undermine motivation. Self-efficacy is directly related to health behavior, but it also affects health behaviors indirectly through its impact on goals behavior (Schwarzer & Luszczynska, no date). Therefore to maximize the client’s adherence to the exercise scheme; the client needs to develop a strong self-efficacy. The way that is suggested to the client to develop self-efficacy is through the Health Belief Model (HBM).
According to the HBM when people are feeling vulnerable to a disease wouldn’t take immediate action to prevent it unless the disease was to be perceived as severe to them (Weinberg & Gould, 1999). It is critical then to indicate to our client his present medical condition and prove to him the future severity of his condition if he does not follow the doctor’s exercise scheme. For the client’s obesity problem they should be pointed out some evidence-based interventions. For instance that obesity is linked to various cardiovascular diseases, hypertension, and cancers. Statistics have found that 17.5 million people died from cardiovascular diseases only in 2005 (Anne, J, 2008). Also another study has found that high-fit men reduced their risk of dying by 71%, compared with the low-fit men (Barlow et al., 1995; cited in Sallis & Owen, 1999). This study can be presented to the client as vicarious experience and show him that it is not impossible to become fit. A severe fact for our client that should be concerning is that between 60-90% of cases of obesity, develop diabetes II (Diabetes Data Group 1979; cited in Shephard, 1997). In addition, to signify the clients’ severe position, evidence suggests that depression plays an important role in the worsening of diabetes (Talbot & Nouwen, 2000; cited in Sacco et al., 2005). Therefore these findings should be used in order to facilitate the HBM to act upon our client and make him realize the necessity of the immediate action that needs to be taken.
By now, if the previous strategy is applied to the client; he should have developed a positive attitude and motivation regarding exercise. Even though, according to the Theory of Planned Behavior (Ajzen & Madden, 1986) his intention to exercise will likely to be weak unless he has a positive subjective norm towards exercise and perceived behavioral control (Weinberg & Gould, 1999; Schwarzer & Luszczynska, no date). “This subjective norm is the product of beliefs about others’ opinions and the individual’s motivation to comply with others’ opinions” (Weinberg & Gould 1999). For this it is suggested to the client to inform his social circle that he is taking an exercise program. Consequently he would not want to fail his social circle expectations and this would boost him with some extrinsic motivation. Therefore the support of his social environment is crucial on developing a positive subjective norm. Schwarzer & Luszczynska (no date) acknowledge self-efficacy and behavioral control as almost synonymous constructs and therefore there is no need for further implementations.
Having mild depression, our client has symptoms that affect negatively his mood. Having depressive mood is generally accepted that not only you have disturbed psychological well-being but also connections between mood and health have been discovered (Melamed, 1995; cited in Berger & Motl, 2000). As the doctor prescribed to the client the alternative treatment of exercise we can understand that exercise is related to desirable changes in mood (Berger & Motl, 2000). The type of exercise for mood enhancement is more effective when it is enjoyable (Berger & Motl, 2000). However, Berger & Motl suggest that four aspects of exercise mode are the most important for mood improvement: abdominal and rhythmical breathing, absence of competition, closed or predictable activities, and repetitive and rhythmical movements (Berger, 1996; Berger & Owen, 1988; cited in Berger & Molt 2000). These should be taken in account for the clients exercise so he can maximize the benefits of exercise. For the frequency of the exercise literature suggests a regularly weekly schedule with a minimum of five days and duration of 30 minutes. The exercise suggested for the type II diabetes and obesity patients should be of moderate intensity (Department of Health, 2007).
Hypothetically if the client succeeds in achieving the recommendations of the strategy mentioned before, Prochaska et al (1992; cited in Weinberg & Gould 1999) argues that individual’s progress is moving back and forth through stages of change while trying to adapt in an exercise program. This is the Transtheoretical Model (TTM) and it has five stages. First stage is where our client is at the moment and it’s called the pre-contemplation stage. In this stage the client has little or no intension to start exercising and he is uninformed about the long term consequences of his present behaviour. The second stage is where the client needs to be after the exercise adherence strategy is introduced to him for the first time. In this stage he is still inactive but he is considering starting exercising. With the help of the HBM on improving his self-efficacy towards exercise, the client will then move to the third stage which is the preparation stage. In this stage he will be exercising but not as much as he is suppose to. When his self-efficacy is strong enough then he can move to the fourth stage; the Action stage where the client is expected to perform his weekly exercise routine but with a great risk of relapse. The strategy for preventing the relapse from happening that will be use in our clients case is the method of reinforcement. Positive reinforcement should be use in the case of a potential relapse as “psychologists highly recommend a positive approach to motivation to avoid potential negative side-effects of using punishment as the primary approach” (Weinberg & Gould, 1999). In our clients case the positive reinforcement should be achieved using feedback that motivation serves as a stimulus for positive feelings (Weinberg & Gould, 1999). With the positive reinforcement the client should be motivated in continuing the exercise scheme for longer duration than the doctor subscribed him; leading him to the Maintenance stage of the TTM. In this ideal stage the client will be exercising regularly for more than six months with a low risk for relapse.
For further understating of the TTM, Self Determination Theory (SDT) could be useful because they motivation given to the client progress though stages with the ideal stages of intrinsic motivation. However much of what people do is extrinsic motivated by i.e. social pressures, rewards etc (Deci & Ryan, 2000). According to SDT when a person initiates certain behaviour, his motivation type can range from amotivation to intrinsic motivation (Deci & Ryan, 2000). Therefore applying this to our client; different motivation needs throughout the stages 1 and 5 of the TTM are needed in order to get the wanted behaviour. This can be achieved again through different types of reinforcement. During the initial stages of the exercise program, desirable outcomes should be rewarded (Weinberg & Gould 1999). This will facilitate an extrinsic motivation but as the client progress from stage 4 to stage 5 of the TTM, intrinsic motivation could be more helpful through feedback (Weinberg & Gould, 1999).
In this assignment we have seen how from theory interventions are extracted in order to facilitate our client maximize his adherence to the suggested exercise scheme. To sum up our clients’ strategy to do so we start with that basic framework of the TTM. In this 5 stages of the model the client will need to develop strong self-efficacy in order to progress. To achieve strong self-efficacy we used the HBM that according to; people that are feeling vulnerable to a disease wouldn’t take immediate action to prevent it unless the disease was to be perceived as severe to them. The HBM with the assistance of reinforcement methods will help initially the client to adhere to the scheme but he will be extrinsically motivated until the 4th stage of the TTM. For the client to move to the 5th and final stage his motivation towards exercise should be intrinsic for avoiding relapse. Consequently the most important part of the strategy is gaining strong self-efficacy before starting exercising because self-efficacy is what influences one’s effort to change risk behavior (Schwarzer & Luszczynska, no date).
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