Health Promotion Framework Paper
Health Promotion Framework Paper
Marie Wilcox
Rush University
Reference Citation
Study Purpose
Sample Characteristics
Methods
Findings
Baptist, A. P., Ross, J. A., Yang, U., Song, P.X., & Clark, N. M. (2013). A randomized controlled trial of a self-regulation intervention for older adults with asthma. Journal of the American Geriatrics Society, 61(5), 747-753. Doi:10.1111/jgs.12218
To evaluate an asthma self-regulation intervention for older adults, specifically observing the effects on asthma quality of life and asthma control.
Participants were outpatients aged 65 and older with asthma who were currently taking daily medications to control their asthma.
There were 70 patients enrolled.
The average age was 73.3 years old.
Women made up 27% of the enrolled population.
The mean number of years diagnoses with asthma was 27.3 years.
Caucasians made up 28% of the enrolled population.
Randomized, double-blind, controlled trial.
Patients assigned randomly to control or intervention group.
Control group (n=35) participants received standard asthma education administered by a health educator. …show more content…
Topics included proper inhaler technique, asthma triggers, asthma control, and signs of exacerbation.
Intervention group (n=35) participants received standard care and participated in a six-session program conducted over the telephone and group sessions. Participants selected an asthma-specific goal, identified problems, and addressed potential barriers.
Outcomes were assessed at 1, 6, and 12 months and included the mini-Asthma Quality of Life Questionnaire (mAQLQ), Asthma Control Questionnaire (ACQ), healthcare utilization, fraction of exhaled nitric oxide level (FENO), and percentage of predicted forced expiratory volume in 1 second (FEV1%).
The mean mAQLQ score was significantly higher in the intervention group than in the control group at 1, 6, and 12 months. Higher scores indicated greater quality of life.
Mean ACQ score was significantly lower at 1 month for the intervention group than the control group and was lower at the 6 and 12-month time points as well. Lower scores indicated greater asthma control.
Lung function was evaluated at 6 and 12 months. No difference was seen in FENO, but predicted FEV1% favored the intervention group.
There was no significant difference found for hospitalizations or ED visits between the intervention and control groups, although both favored the intervention group. For a composite healthcare utilization index (hospitalization, ED, or unscheduled visit) the intervention group had significantly fewer visits than the control.
A self-regulation intervention is effective for improving asthma quality of life, asthma control, and healthcare utilization in older adults.
Byrne, J., Khunti, K., Stone, M., Farooqi, A., & Carr, S. (2011). Feasibility of a structured group education session to improve self-management of blood pressure in people with chronic kidney disease: An open randomized pilot trial. BMJ Open, doi:10.1136/bmjopen-2011-000381
To test a group educational intervention called Controlling Hypertension (HTN): Education and Empowerment Renal Study (CHEERS) to improve self-management of blood pressure in people with chronic kidney disease (CKD). Exploring the acceptability of the intervention.
Patients with early CKD and HTN.
There were 81 people enrolled in the study 30% of the 267 patients approached.
Random controlled trial.
Patients recruited from nephrology outpatient clinic.
Control group received standard clinical management of HTN.
Intervention group received routine standard care plus structured CHEERS patient education intervention.
Measured: recruitment, retention, patient demographics, self-efficacy, and patient satisfaction.
Lack of time 48% and lack of interest 44% were the main reasons for non-participation.
37.5% of the intervention group failed to attend. These patients were older and had lower self-efficacy.
The intervention was rated enjoyable and useful by 100% of participants.
None of those who attended the education sessions accessed the additional support offered.
Carr, L. J., Dunsiger, S. I., Lewis, B., Ciccolo, J. T., Hartman, S., Bock, B., & Marcus, B. H. (2013). Randomized controlled trial testing an internet physical activity intervention for sedentary adults. Health Psychology, 32(3), 328-336. doi:10.1037/a0028962
To test the efficacy of a newly enhanced internet (EI) intervention in relation to six standard internet (SI) intervention websites that are publicly available to promote physical activity (PA), for improving PA behavior in previously sedentary adults.
Healthy sedentary (achieving less than 60 minutes of moderate-to-vigorous physical activity per week) men and women between ages 18 and 65 years of age.
66 participants were enrolled.
25 were randomly assigned to the EI group.
28 were randomly assigned to the SI group.
More than half were college educated.
More than 80% reported being non-Hispanic white.
Both groups used an internet website to monitor and improve physical activity.
Website use, physical activity, and patient satisfaction were measured.
The EI included five SCT-influenced internet features including, physical activity tracking & goal-setting calendar, regular peer activity updates, ask the expert Q&A forum, exercise videos, and geographic mapping function.
At 3 months EI participants averaged 180.4 weekly minutes of PA compared to 46.3 minutes by SI participants.
At 6 months EI participants averaged 171.4 weekly minutes of PA compared to 121.8 minutes by SI participants.
The EI intervention facilitated quicker increases in PA behavior than the SI comparison group.
An improvement in PA behavior was associated with improvements in various SCT constructs including social support, self-efficacy, outcome expectations, and self-regulation.
Dorough, A. E., Winett, R. A., Anderson, E. S., Davy, B. M., Martin, E. C., & Hedrick, V. (2012). DASH to Wellness: Emphasizing Self-Regulation Through E-Health in Adults With Prehypertension. Health Psychology, doi: 10.1037/a0030483
To assess the initial efficacy of an electronically delivered, lifestyle intervention for treating prehypertension (PHT) by increasing fruit and vegetable consumption, reducing dietary sodium through the adaption of the DASH eating plan, increasing physical activity, promoting use of home blood pressure monitoring, reducing weight, and decreasing BP thereby reducing risk of movement to stage I hypertension in middle-aged adults with PHT.
27 participants with a mean age of 54.3, mean weight of 87.8 kg, mean BMI of 31.5, were 69.5% female, 95% Caucasian, 5% Mexican American, were well educated with 52% reporting 4-year or postgraduate degrees, and 60.8% reported a household annual income above $60,000.
Participants were randomly assigned a group. The standard-of-care condition, DASH 2 wellness (D2W) only, or the intervention-treatment group, DASH 2 wellness plus (D2WP).
At baseline both groups completed a 4-day food intake record and a 7-day step log. Baseline height, weight, and BMI were also recorded. This data was gathered again after the 10-week intervention.
D2W group was provided the DASH eating plan guide, walking and weight program, a scale, and a pedometer.
D2WP group was provided everything listed above along with an automatic blood pressure monitor, weekly electronic feedback in planning, goal setting, and tracking of intake, weight, exercise, and self-monitored blood pressure readings.
D2WP had a large increase in average daily steps 2,900 vs. 636.
D2WP had a larger decrease in systolic BP 15.14 mmHg vs. 4.61 mmHg.
D2WP had a larger decrease in weight 10.54 lbs. vs. 3.23 lbs.
Outcomes suggest the primarily electronically delivered approach was more effective than the standard of care in changing some health behaviors related to nutrition and physical activity, reducing body weight, and systolic blood pressure. All D2WP participants moved from the PHT category to a normal, even optimal BP except for one.
Fjeldsoe, B. S., Miller, Y. D., & Marshall, A. L. (2013). Social cognitive mediators of the effect of the MobileMums intervention on physical activity. Health Psychology, 32(7), 729-738. Doi: 10.1037/a0027548
To explore whether improvements in physical activity (PA) following the MobileMums intervention were facilitated by changes in Social Cognitive Theory (SCT) constructs targeted in the intervention.
Women less than 12-months postpartum were recruited from a database of women that agreed to be contacted for health-related research projects.
Eligibility criteria included English comprehension, ownership of a mobile phone, engaged in less than five days per week of 30-minutes of moderate-to-vigorous physical activity, and intention to increase PA.
88 participants completed the baseline assessment and were randomized to either the intervention group, n=45, or control group, n=43. Seventy-seven percent of participants were reassessed at 6-weeks and 69% at 13-weeks.
There were no meaningful or statistically significant differences between group demographic characteristics.
Participants were randomly assigned to the control or intervention group.
Control group participants received one face-to-face consultation with a behavioral counselor and given a PA information pack.
MobileMum intervention group participants had two PA consultations with a behavioral counselor and one telephone consultation at 6-weeks. Counselor helped to set goals and plan exercise activities. Participants were also given weekly activity planning magnets to help self-monitor. Participants nominated a social support person. They also received 42 individualized phone messages providing strategies for behavior change and 11 goal check messages. Support person also received messages.
Frequency of walking for exercise and the amount of moderate-to-vigorous PA was measured. Barrier self-efficacy, goal setting skills, outcome expectancy, social support, and perceived environmental opportunity were also measured.
The MobileMum program increased the amount of walking for exercise and moderate-to-vigorous physical activity among postnatal women.
An increase in physical activity was mediated in the short-term (6-weeks), by improvements in barrier self-efficacy and goal setting skills.
Social support did not significantly mediate the intervention effects on physical activity.
The intervention did not have a significant impact on outcome expectancy or perceived environmental opportunities for PA.
Pilutti, L., Dlugonski, D., Sandroff, B., Klaren, R., Motl, R. (2013). Randomized controlled trial of a behavioral intervention targeting symptoms and physical activity in multiple sclerosis. Multiple Sclerosis Journal, doi: 10.1177/1352458513503391
To examine the efficacy of an internet delivered behavioral intervention for improving outcomes of fatigue, depression, anxiety, pain, sleep quality, and health related quality of life (HRQOL) in ambulatory persons with MS. This intervention has previously been tested to increase lifestyle physical activity among persons with MS. The second aim of this study is to replicate those results regarding change in physical activity.
Sample consisted of 82 participants who were randomized into a control group, n=41, and an intervention group, n=41.
Participant inclusion criteria: 18-64 years, diagnosis of MS, relapse-free for the past 30-days, internet access, ability to walk with or without an assistive device, physician approval, not maintaining > 30 minutes of moderate-to-vigorous physical activity a day for more than 2 days.
Sample was primarily female (76%). The level of disability of the sample was moderate and most participants (74%) did not use an assistive device.
There were no statistically significant differences between groups in demographic or clinical characteristics, physical activity, or symptomatic and HRQOL outcomes pre-trial.
Random controlled trial.
The intervention group was provided a study website with information about becoming more physically active based on principles of SCT, self-monitoring, and goal-setting using a pedometer and activity logs, and one-on-one video coaching sessions for 6 months.
Data measures included physical activity, fatigue, depression, anxiety, pain, quality of sleep, HRQOL, and disability.
These measures were recorded at baseline and 6 months post intervention.
Participants in the intervention group participated in significantly more self-reported physical activity compared to control group. They also spent more time in moderate-to-vigorous physical activity compared to the control group although not a significant difference.
Symptoms of depression and anxiety were significantly lower in the intervention group.
There was a favorable effects of the intervention on symptoms of pain and sleep quality post-intervention.
Participants in the intervention group reported greater quality of life compared to control participants, although this difference did not reach statistical significance.
Overall, it can be confirmed that a lifestyle intervention delivered through the internet can be effective for increasing everyday physical activity in persons with MS, and this had a positive effect on symptomatic outcomes.
Amaya, M., & Petosa, R. (2012). An evaluation of a worksite exercise intervention using the social cognitive theory: A pilot study. Health Education Journal, 71(2), 133-143. Doi: 10.1177/0017896911409731
To increase exercise adherence among insufficiently active adult employees.
Employees (n=127) who did not meet current American College of Sports Medicine recommendations for exercise.
Majority of subjects were female (83%). A majority of subjects had obtained a bachelor’s or post bachelor’s degree (61%). Nearly all subjects were married (77%). A majority of the study sample was Caucasian (84%).
A quasi-experimental separate samples pre-test-post-test group design was used to compare treatment and comparison group.
Intervention: An eight-week educational program targeting the social cognitive theory constructs. There were 6 one-hour classroom-based sessions and multiple meetings with a trainer. The intervention taught subjects self-regulation skills, including focusing on self-monitoring, goal setting, and time management. Taught self-efficacy skills, overcoming barriers and exercise preferences. Taught social support for exercise, outcome expectations and expectancies, reasons to exercise and its value.
Measures: free-living exercise, self-regulation, self-efficacy, social support, and outcome expectations and expectancies.
Measurements were taken at pre-test, post-test, one month and three months post-intervention.
There was a significant difference between groups for moderate intensity exercise and vigorous intensity exercise at post-test and follow-up.
There was a significant difference between groups for self-regulation at post-test and follow-up.
There was not a significant difference between groups for self-efficacy or outcome expectancies. Family and friend social support group differences were non-significant at post-test and at one-month follow-up, but were significant at three-month follow-up.
The educational intervention was effective in increasing the exercise rates of employees at the worksite.
Social Cognitive Theory Framework Paper
Framework Description, Components, and
Synthesis
Social Cognitive Theory (SCT) emerged primarily from the work of Albert Bandura. Social cognitive theory is a learning theory based on the idea that people learn by observing others. The theory is an expansion of the Social Learning Theory (SLT) originally proposed by Neal Miller and John Dollard and later expanded by Bandura himself. Social Learning Theory theorizes that people learn new behaviors by observing others, imitating their behavior, and then being reinforced by the observed outcomes. Bandura’s SCT differs from SLT by its emphasis on the role of self-efficacy and the concept of reciprocal triadic causation. Self-efficacy is a person’s confidence and desire to perform a behavior. It reflects not only a person’s actual know-how to perform a behavior, but also their skepticism or willingness in performing the behavior. Behavior is theorized in SCT to occur in a social context and influenced by the active shared interaction between the person, environment, and behavior, the reciprocal triadic causation. Never is a behavior not influence by all three. There are five key concepts that make up the Social Cognitive Theory, those concepts are knowledge, perceived self-efficacy, outcome expectation, goal formation, and sociostructural factors.
Knowledge is often the starting point for most health promotion programs. Many people will obtain knowledge through observation, verbal or written description, video or audio recordings, and other forms of knowledge delivery (DiClemente, 2013). The DARE program is a good example of a program that delivers knowledge to kids about the risks of alcohol and drugs to hopefully prevent their use and abuse. However, behavior change after obtaining knowledge is often dependent on four inner-related processes involving attention, retention, production, and motivation. Regardless of having the knowledge there must be underlining drives to commit to a behavior change. Building off the last example if a kid were to be a valued member of a sports team they may be move motivated to abstain from alcohol and drugs to avoid a decline in performance. Since knowledge alone may not initiate a behavior change all of the study articles listed above provided education for all participants at baseline. The Baptist study provided asthma education on how to administer medication, asthma triggers, control, and signs of exacerbation. The Pilutti study provided online material on becoming more physically active and healthy.
Perceived self-efficacy can be explained as a person’s inner confidence in performing a task. This inner confidence has been influenced by past performances, the observation and verbal persuasion of others, and their physiological state (Bandura, 2004). Low self-efficacy can be caused by fear and can defeat any effort to perform a given task. Having a high level of self-efficacy will increase a person’s initiation and drive for a particular task. There are four methods to improve self-efficacy; learn to reduce the fear and other negative emotions that may be associated with the task, verbal persuasion, watch others perform the task successfully, and be physically guided or coached through the task (DiClemente, 2013). Many of these methods were used in the study articles listed above. By providing education, participant knowledge is increased, which helps to improve self-efficacy. The Carr study provided online exercise videos. In the Fjeldsoe study participants were assigned a counselor and a support person to provide encouragement. Participants in the Amaya study met for one-hour classroom sessions and had group discussions discussing fears, barriers, and exercise technique.
Outcome expectations are individual beliefs about what consequences are most likely to occur if a particular behavior is performed. People anticipate the consequences of their actions before engaging in a behavior, and these anticipated consequences could influence the successful completion of the behavior (Bandura, 2004). The benefit of the behavior is the driving force for action. Educators, trainers, and counselors work well to help people recognize the possible positive outcomes. The Baptist, Amaya, and Fjeldsoe studies all used a person as part of their intervention to help participants visualize the possible outcomes of their efforts. Outcome expectations can also include negative perceptions or costs. For example a person thinking about going back to school may see the benefit in an advanced degree and pay raise or the negative outcome of tuition costs and time spent.
Goal setting is an important aspect of SCT. Setting small achievable goals that progress to the final goal is an effective way to keep focused and maintain spirit throughout the process. With the attainment of small sub goals self-efficacy perceptions are likely to increase and the experience of positive outcomes will increase and improve change efforts (DiClemente, 2013). Further, goals are an important prerequisite for self-regulation because they provide objectives to strive towards and are levels against which to judge progress (Bandura, 2004). Participants of the Fjeldsoe study carried mobile devices that monitored progress and sent individualized messages with strategies to meet goals. Those participants also receive goal check messages and depending on participant responses they either received more advice or applause and encouragement to keep up the good work.
Lastly, sociostructural factors are important as they can strongly impact self-efficacy and consequently behavior. Sociostructural factors are any actual or perceived external factor that influences for better or for worse the likelihood of a behavior (DiClemente, 2013). For example, a positive sociostructural factor for an individual trying to loose weight and eat healthy would be a number of local gym options. A negative factor may be the lack of grocery stores that offer organic food options. The Carr study, which investigated the effectiveness of an Internet site to improve physical activity, had a geographic mapping function to help participants locate resources and plan outdoor activity.
Major Research and Practice Areas
Based on the journal articles above much of the research is on the effectiveness of interventions that target the patient SCT constructs to improve illness management and physical activity. These interventions mostly focus on all five of the SCT concepts. The programs typically provided education, group, online, technical, and personal support, help with goal formation and strategic planning, and also coaching and counseling. The research is looking for interventions to improve self-management, quality of life, and the increase of health promoting behaviors such as blood pressure monitoring, eating healthy, and being physical activity. Social Cognitive Theory interventions can be used in practice to improve the management of chronic illnesses such as asthma, chronic kidney disease, and hypertension. It can be used to improve health-promoting behaviors such as increasing exercise, dieting and weight loss, and monitoring blood pressure or blood sugars.
Framework Population
The populations of the studies found above using SCT involved older adults over the age of 65, patients with multiple diagnoses, adults with borderline diagnoses, sedentary adults, postpartum women, and adults managing disability related to an illness. All of the listed populations are at risk for low levels of self-efficacy, which can inhibit change. Therefore, these populations may require extra support and motivation, which can be provided by interventions using SCT to support change.
Framework and Risk Factor
In the Dorough study the population of focus was adults with prehypertension and their risk factor was physical inactivity and poor diet and nutrition. The study aimed to use an intervention influenced by SCT to promote physical activity and reduce hypertension. Features of the intervention that were SCT based were the nutrition and exercise education, the nutrition guide an outlined exercise program, and lastly the electronic resource provided for logging progress, goal setting, and goal attainment advice. The results of the intervention included a significant increase in daily steps, decrease in blood pressure, and weight loss. All but one participant moved from prehypertension to normal even optimal blood pressure.
Application of Framework
Stroke survivors can have a low perceived level of self-efficacy and this puts them at an increased risk for not meeting their rehabilitation goals for recovery. Stroke survivors want to return to the varied roles they had before their stroke. However, commonly these survivors become victim to themselves as they begin to lose interest, become unmotivated, and become difficult to get going. Depression and apathy are common consequences of stroke with the sudden loss of independence and self-reliance. An intervention that aims to change patient SCT constructs to improve physical activity in rehab may work to improve the patient’s self-efficacy and their progression in rehabilitation. The desired outcome is increased participation in physical rehabilitation. The factor that is limiting that outcome is the patient’s low level of perceived self-efficacy. One study revealed that the functional level at 6 months post stroke could predict long-term survival and disability (Jones, 2010). Therefore, an intervention that promotes a positive spirit, provides support, and creates an environment that facilitates goal attainment is absolutely necessary for these patients to increase their functional ability and decrease their level of dependency, which is of utmost importance.
An ideal SCT intervention for this population would begin with an educational session on stroke covering topics such as common side effects, medications, needs and goals of rehabilitation. The recovery process is long and therefore multiple small goals should be set weekly to help maintain motivation and recognize progression however small. Therapy should be conducted in groups to allow patients to motivate each other, witness each other’s progression, and support one another through the recovery process. Nurses, and physical, speech, and occupational therapist should help the patients monitor and log their progress, coach exercises, and motivate. To measure the effectiveness of the program therapy participations may be measure based on time, patient exertion and attitude. The level of self-efficacy before and after would be a good measure along with patient’s outlook on current progression and further progress.
References
Amaya, M., & Petosa, R. (2012). An evaluation of a worksite exercise intervention using the social cognitive theory: A pilot study. Health Education Journal, 71(2), 133-143. Doi: 10.1177/0017896911409731
Bandura, A. (2004). Health promotion by social cognitive means. Health Education & Behavior, 31(2), 143-164. doi:10.1177/1090198104263660
Baptist, A. P., Ross, J. A., Yang, U., Song, P.X., & Clark, N. M. (2013). A randomized controlled trial of a self-regulation intervention for older adults with asthma. Journal of the American Geriatrics Society, 61(5), 747-753. Doi:10.1111/jgs.12218
Byrne, J., Khunti, K., Stone, M., Farooqi, A., & Carr, S. (2011). Feasibility of a structured group education session to improve self-management of blood pressure in people with chronic kidney disease: An open randomized pilot trial. BMJ Open, doi:10.1136/bmjopen-2011-000381
Carr, L. J., Dunsiger, S. I., Lewis, B., Ciccolo, J. T., Hartman, S., Bock, B., & Marcus, B. H. (2013). Randomized controlled trial testing an internet physical activity intervention for sedentary adults. Health Psychology, 32(3), 328-336. doi:10.1037/a0028962
DiClemente, R. J., Salazar, L. F., & Crosby, R. A. (2013). Health behavior theory for public health: Principles, foundations and applications (13th ed.). Burlington, MA: Jones & Bartlett.
Dorough, A. E., Winett, R. A., Anderson, E. S., Davy, B. M., Martin, E. C., & Hedrick, V. (2012). DASH to Wellness: Emphasizing Self-Regulation Through E-Health in Adults With Prehypertension. Health Psychology, doi: 10.1037/a0030483
Fjeldsoe, B. S., Miller, Y. D., & Marshall, A. L. (2013). Social cognitive mediators of the effect of the MobileMums intervention on physical activity. Health Psychology, 32(7), 729-738. Doi: 10.1037/a0027548
Jones, F., & Riazi, A. (2011). Self-efficacy and self-management after stroke: A systematic review. Disability & Rehabilitation, 33(10), 797-810. doi:10.3109/09638288.2010.511415
Pilutti, L., Dlugonski, D., Sandroff, B., Klaren, R., Motl, R. (2013). Randomized controlled trial of a behavioral intervention targeting symptoms and physical activity in multiple sclerosis. Multiple Sclerosis Journal, doi: 10.1177/1352458513503391
Marie Wilcox
Rush University
Reference Citation
Study Purpose
Sample Characteristics
Methods
Findings
Baptist, A. P., Ross, J. A., Yang, U., Song, P.X., & Clark, N. M. (2013). A randomized controlled trial of a self-regulation intervention for older adults with asthma. Journal of the American Geriatrics Society, 61(5), 747-753. Doi:10.1111/jgs.12218
To evaluate an asthma self-regulation intervention for older adults, specifically observing the effects on asthma quality of life and asthma control.
Participants were outpatients aged 65 and older with asthma who were currently taking daily medications to control their asthma.
There were 70 patients enrolled.
The average age was 73.3 years old.
Women made up 27% of the enrolled population.
The mean number of years diagnoses with asthma was 27.3 years.
Caucasians made up 28% of the enrolled population.
Randomized, double-blind, controlled trial.
Patients assigned randomly to control or intervention group.
Control group (n=35) participants received standard asthma education administered by a health educator. …show more content…
Topics included proper inhaler technique, asthma triggers, asthma control, and signs of exacerbation.
Intervention group (n=35) participants received standard care and participated in a six-session program conducted over the telephone and group sessions. Participants selected an asthma-specific goal, identified problems, and addressed potential barriers.
Outcomes were assessed at 1, 6, and 12 months and included the mini-Asthma Quality of Life Questionnaire (mAQLQ), Asthma Control Questionnaire (ACQ), healthcare utilization, fraction of exhaled nitric oxide level (FENO), and percentage of predicted forced expiratory volume in 1 second (FEV1%).
The mean mAQLQ score was significantly higher in the intervention group than in the control group at 1, 6, and 12 months. Higher scores indicated greater quality of life.
Mean ACQ score was significantly lower at 1 month for the intervention group than the control group and was lower at the 6 and 12-month time points as well. Lower scores indicated greater asthma control.
Lung function was evaluated at 6 and 12 months. No difference was seen in FENO, but predicted FEV1% favored the intervention group.
There was no significant difference found for hospitalizations or ED visits between the intervention and control groups, although both favored the intervention group. For a composite healthcare utilization index (hospitalization, ED, or unscheduled visit) the intervention group had significantly fewer visits than the control.
A self-regulation intervention is effective for improving asthma quality of life, asthma control, and healthcare utilization in older adults.
Byrne, J., Khunti, K., Stone, M., Farooqi, A., & Carr, S. (2011). Feasibility of a structured group education session to improve self-management of blood pressure in people with chronic kidney disease: An open randomized pilot trial. BMJ Open, doi:10.1136/bmjopen-2011-000381
To test a group educational intervention called Controlling Hypertension (HTN): Education and Empowerment Renal Study (CHEERS) to improve self-management of blood pressure in people with chronic kidney disease (CKD). Exploring the acceptability of the intervention.
Patients with early CKD and HTN.
There were 81 people enrolled in the study 30% of the 267 patients approached.
Random controlled trial.
Patients recruited from nephrology outpatient clinic.
Control group received standard clinical management of HTN.
Intervention group received routine standard care plus structured CHEERS patient education intervention.
Measured: recruitment, retention, patient demographics, self-efficacy, and patient satisfaction.
Lack of time 48% and lack of interest 44% were the main reasons for non-participation.
37.5% of the intervention group failed to attend. These patients were older and had lower self-efficacy.
The intervention was rated enjoyable and useful by 100% of participants.
None of those who attended the education sessions accessed the additional support offered.
Carr, L. J., Dunsiger, S. I., Lewis, B., Ciccolo, J. T., Hartman, S., Bock, B., & Marcus, B. H. (2013). Randomized controlled trial testing an internet physical activity intervention for sedentary adults. Health Psychology, 32(3), 328-336. doi:10.1037/a0028962
To test the efficacy of a newly enhanced internet (EI) intervention in relation to six standard internet (SI) intervention websites that are publicly available to promote physical activity (PA), for improving PA behavior in previously sedentary adults.
Healthy sedentary (achieving less than 60 minutes of moderate-to-vigorous physical activity per week) men and women between ages 18 and 65 years of age.
66 participants were enrolled.
25 were randomly assigned to the EI group.
28 were randomly assigned to the SI group.
More than half were college educated.
More than 80% reported being non-Hispanic white.
Both groups used an internet website to monitor and improve physical activity.
Website use, physical activity, and patient satisfaction were measured.
The EI included five SCT-influenced internet features including, physical activity tracking & goal-setting calendar, regular peer activity updates, ask the expert Q&A forum, exercise videos, and geographic mapping function.
At 3 months EI participants averaged 180.4 weekly minutes of PA compared to 46.3 minutes by SI participants.
At 6 months EI participants averaged 171.4 weekly minutes of PA compared to 121.8 minutes by SI participants.
The EI intervention facilitated quicker increases in PA behavior than the SI comparison group.
An improvement in PA behavior was associated with improvements in various SCT constructs including social support, self-efficacy, outcome expectations, and self-regulation.
Dorough, A. E., Winett, R. A., Anderson, E. S., Davy, B. M., Martin, E. C., & Hedrick, V. (2012). DASH to Wellness: Emphasizing Self-Regulation Through E-Health in Adults With Prehypertension. Health Psychology, doi: 10.1037/a0030483
To assess the initial efficacy of an electronically delivered, lifestyle intervention for treating prehypertension (PHT) by increasing fruit and vegetable consumption, reducing dietary sodium through the adaption of the DASH eating plan, increasing physical activity, promoting use of home blood pressure monitoring, reducing weight, and decreasing BP thereby reducing risk of movement to stage I hypertension in middle-aged adults with PHT.
27 participants with a mean age of 54.3, mean weight of 87.8 kg, mean BMI of 31.5, were 69.5% female, 95% Caucasian, 5% Mexican American, were well educated with 52% reporting 4-year or postgraduate degrees, and 60.8% reported a household annual income above $60,000.
Participants were randomly assigned a group. The standard-of-care condition, DASH 2 wellness (D2W) only, or the intervention-treatment group, DASH 2 wellness plus (D2WP).
At baseline both groups completed a 4-day food intake record and a 7-day step log. Baseline height, weight, and BMI were also recorded. This data was gathered again after the 10-week intervention.
D2W group was provided the DASH eating plan guide, walking and weight program, a scale, and a pedometer.
D2WP group was provided everything listed above along with an automatic blood pressure monitor, weekly electronic feedback in planning, goal setting, and tracking of intake, weight, exercise, and self-monitored blood pressure readings.
D2WP had a large increase in average daily steps 2,900 vs. 636.
D2WP had a larger decrease in systolic BP 15.14 mmHg vs. 4.61 mmHg.
D2WP had a larger decrease in weight 10.54 lbs. vs. 3.23 lbs.
Outcomes suggest the primarily electronically delivered approach was more effective than the standard of care in changing some health behaviors related to nutrition and physical activity, reducing body weight, and systolic blood pressure. All D2WP participants moved from the PHT category to a normal, even optimal BP except for one.
Fjeldsoe, B. S., Miller, Y. D., & Marshall, A. L. (2013). Social cognitive mediators of the effect of the MobileMums intervention on physical activity. Health Psychology, 32(7), 729-738. Doi: 10.1037/a0027548
To explore whether improvements in physical activity (PA) following the MobileMums intervention were facilitated by changes in Social Cognitive Theory (SCT) constructs targeted in the intervention.
Women less than 12-months postpartum were recruited from a database of women that agreed to be contacted for health-related research projects.
Eligibility criteria included English comprehension, ownership of a mobile phone, engaged in less than five days per week of 30-minutes of moderate-to-vigorous physical activity, and intention to increase PA.
88 participants completed the baseline assessment and were randomized to either the intervention group, n=45, or control group, n=43. Seventy-seven percent of participants were reassessed at 6-weeks and 69% at 13-weeks.
There were no meaningful or statistically significant differences between group demographic characteristics.
Participants were randomly assigned to the control or intervention group.
Control group participants received one face-to-face consultation with a behavioral counselor and given a PA information pack.
MobileMum intervention group participants had two PA consultations with a behavioral counselor and one telephone consultation at 6-weeks. Counselor helped to set goals and plan exercise activities. Participants were also given weekly activity planning magnets to help self-monitor. Participants nominated a social support person. They also received 42 individualized phone messages providing strategies for behavior change and 11 goal check messages. Support person also received messages.
Frequency of walking for exercise and the amount of moderate-to-vigorous PA was measured. Barrier self-efficacy, goal setting skills, outcome expectancy, social support, and perceived environmental opportunity were also measured.
The MobileMum program increased the amount of walking for exercise and moderate-to-vigorous physical activity among postnatal women.
An increase in physical activity was mediated in the short-term (6-weeks), by improvements in barrier self-efficacy and goal setting skills.
Social support did not significantly mediate the intervention effects on physical activity.
The intervention did not have a significant impact on outcome expectancy or perceived environmental opportunities for PA.
Pilutti, L., Dlugonski, D., Sandroff, B., Klaren, R., Motl, R. (2013). Randomized controlled trial of a behavioral intervention targeting symptoms and physical activity in multiple sclerosis. Multiple Sclerosis Journal, doi: 10.1177/1352458513503391
To examine the efficacy of an internet delivered behavioral intervention for improving outcomes of fatigue, depression, anxiety, pain, sleep quality, and health related quality of life (HRQOL) in ambulatory persons with MS. This intervention has previously been tested to increase lifestyle physical activity among persons with MS. The second aim of this study is to replicate those results regarding change in physical activity.
Sample consisted of 82 participants who were randomized into a control group, n=41, and an intervention group, n=41.
Participant inclusion criteria: 18-64 years, diagnosis of MS, relapse-free for the past 30-days, internet access, ability to walk with or without an assistive device, physician approval, not maintaining > 30 minutes of moderate-to-vigorous physical activity a day for more than 2 days.
Sample was primarily female (76%). The level of disability of the sample was moderate and most participants (74%) did not use an assistive device.
There were no statistically significant differences between groups in demographic or clinical characteristics, physical activity, or symptomatic and HRQOL outcomes pre-trial.
Random controlled trial.
The intervention group was provided a study website with information about becoming more physically active based on principles of SCT, self-monitoring, and goal-setting using a pedometer and activity logs, and one-on-one video coaching sessions for 6 months.
Data measures included physical activity, fatigue, depression, anxiety, pain, quality of sleep, HRQOL, and disability.
These measures were recorded at baseline and 6 months post intervention.
Participants in the intervention group participated in significantly more self-reported physical activity compared to control group. They also spent more time in moderate-to-vigorous physical activity compared to the control group although not a significant difference.
Symptoms of depression and anxiety were significantly lower in the intervention group.
There was a favorable effects of the intervention on symptoms of pain and sleep quality post-intervention.
Participants in the intervention group reported greater quality of life compared to control participants, although this difference did not reach statistical significance.
Overall, it can be confirmed that a lifestyle intervention delivered through the internet can be effective for increasing everyday physical activity in persons with MS, and this had a positive effect on symptomatic outcomes.
Amaya, M., & Petosa, R. (2012). An evaluation of a worksite exercise intervention using the social cognitive theory: A pilot study. Health Education Journal, 71(2), 133-143. Doi: 10.1177/0017896911409731
To increase exercise adherence among insufficiently active adult employees.
Employees (n=127) who did not meet current American College of Sports Medicine recommendations for exercise.
Majority of subjects were female (83%). A majority of subjects had obtained a bachelor’s or post bachelor’s degree (61%). Nearly all subjects were married (77%). A majority of the study sample was Caucasian (84%).
A quasi-experimental separate samples pre-test-post-test group design was used to compare treatment and comparison group.
Intervention: An eight-week educational program targeting the social cognitive theory constructs. There were 6 one-hour classroom-based sessions and multiple meetings with a trainer. The intervention taught subjects self-regulation skills, including focusing on self-monitoring, goal setting, and time management. Taught self-efficacy skills, overcoming barriers and exercise preferences. Taught social support for exercise, outcome expectations and expectancies, reasons to exercise and its value.
Measures: free-living exercise, self-regulation, self-efficacy, social support, and outcome expectations and expectancies.
Measurements were taken at pre-test, post-test, one month and three months post-intervention.
There was a significant difference between groups for moderate intensity exercise and vigorous intensity exercise at post-test and follow-up.
There was a significant difference between groups for self-regulation at post-test and follow-up.
There was not a significant difference between groups for self-efficacy or outcome expectancies. Family and friend social support group differences were non-significant at post-test and at one-month follow-up, but were significant at three-month follow-up.
The educational intervention was effective in increasing the exercise rates of employees at the worksite.
Social Cognitive Theory Framework Paper
Framework Description, Components, and
Synthesis
Social Cognitive Theory (SCT) emerged primarily from the work of Albert Bandura. Social cognitive theory is a learning theory based on the idea that people learn by observing others. The theory is an expansion of the Social Learning Theory (SLT) originally proposed by Neal Miller and John Dollard and later expanded by Bandura himself. Social Learning Theory theorizes that people learn new behaviors by observing others, imitating their behavior, and then being reinforced by the observed outcomes. Bandura’s SCT differs from SLT by its emphasis on the role of self-efficacy and the concept of reciprocal triadic causation. Self-efficacy is a person’s confidence and desire to perform a behavior. It reflects not only a person’s actual know-how to perform a behavior, but also their skepticism or willingness in performing the behavior. Behavior is theorized in SCT to occur in a social context and influenced by the active shared interaction between the person, environment, and behavior, the reciprocal triadic causation. Never is a behavior not influence by all three. There are five key concepts that make up the Social Cognitive Theory, those concepts are knowledge, perceived self-efficacy, outcome expectation, goal formation, and sociostructural factors.
Knowledge is often the starting point for most health promotion programs. Many people will obtain knowledge through observation, verbal or written description, video or audio recordings, and other forms of knowledge delivery (DiClemente, 2013). The DARE program is a good example of a program that delivers knowledge to kids about the risks of alcohol and drugs to hopefully prevent their use and abuse. However, behavior change after obtaining knowledge is often dependent on four inner-related processes involving attention, retention, production, and motivation. Regardless of having the knowledge there must be underlining drives to commit to a behavior change. Building off the last example if a kid were to be a valued member of a sports team they may be move motivated to abstain from alcohol and drugs to avoid a decline in performance. Since knowledge alone may not initiate a behavior change all of the study articles listed above provided education for all participants at baseline. The Baptist study provided asthma education on how to administer medication, asthma triggers, control, and signs of exacerbation. The Pilutti study provided online material on becoming more physically active and healthy.
Perceived self-efficacy can be explained as a person’s inner confidence in performing a task. This inner confidence has been influenced by past performances, the observation and verbal persuasion of others, and their physiological state (Bandura, 2004). Low self-efficacy can be caused by fear and can defeat any effort to perform a given task. Having a high level of self-efficacy will increase a person’s initiation and drive for a particular task. There are four methods to improve self-efficacy; learn to reduce the fear and other negative emotions that may be associated with the task, verbal persuasion, watch others perform the task successfully, and be physically guided or coached through the task (DiClemente, 2013). Many of these methods were used in the study articles listed above. By providing education, participant knowledge is increased, which helps to improve self-efficacy. The Carr study provided online exercise videos. In the Fjeldsoe study participants were assigned a counselor and a support person to provide encouragement. Participants in the Amaya study met for one-hour classroom sessions and had group discussions discussing fears, barriers, and exercise technique.
Outcome expectations are individual beliefs about what consequences are most likely to occur if a particular behavior is performed. People anticipate the consequences of their actions before engaging in a behavior, and these anticipated consequences could influence the successful completion of the behavior (Bandura, 2004). The benefit of the behavior is the driving force for action. Educators, trainers, and counselors work well to help people recognize the possible positive outcomes. The Baptist, Amaya, and Fjeldsoe studies all used a person as part of their intervention to help participants visualize the possible outcomes of their efforts. Outcome expectations can also include negative perceptions or costs. For example a person thinking about going back to school may see the benefit in an advanced degree and pay raise or the negative outcome of tuition costs and time spent.
Goal setting is an important aspect of SCT. Setting small achievable goals that progress to the final goal is an effective way to keep focused and maintain spirit throughout the process. With the attainment of small sub goals self-efficacy perceptions are likely to increase and the experience of positive outcomes will increase and improve change efforts (DiClemente, 2013). Further, goals are an important prerequisite for self-regulation because they provide objectives to strive towards and are levels against which to judge progress (Bandura, 2004). Participants of the Fjeldsoe study carried mobile devices that monitored progress and sent individualized messages with strategies to meet goals. Those participants also receive goal check messages and depending on participant responses they either received more advice or applause and encouragement to keep up the good work.
Lastly, sociostructural factors are important as they can strongly impact self-efficacy and consequently behavior. Sociostructural factors are any actual or perceived external factor that influences for better or for worse the likelihood of a behavior (DiClemente, 2013). For example, a positive sociostructural factor for an individual trying to loose weight and eat healthy would be a number of local gym options. A negative factor may be the lack of grocery stores that offer organic food options. The Carr study, which investigated the effectiveness of an Internet site to improve physical activity, had a geographic mapping function to help participants locate resources and plan outdoor activity.
Major Research and Practice Areas
Based on the journal articles above much of the research is on the effectiveness of interventions that target the patient SCT constructs to improve illness management and physical activity. These interventions mostly focus on all five of the SCT concepts. The programs typically provided education, group, online, technical, and personal support, help with goal formation and strategic planning, and also coaching and counseling. The research is looking for interventions to improve self-management, quality of life, and the increase of health promoting behaviors such as blood pressure monitoring, eating healthy, and being physical activity. Social Cognitive Theory interventions can be used in practice to improve the management of chronic illnesses such as asthma, chronic kidney disease, and hypertension. It can be used to improve health-promoting behaviors such as increasing exercise, dieting and weight loss, and monitoring blood pressure or blood sugars.
Framework Population
The populations of the studies found above using SCT involved older adults over the age of 65, patients with multiple diagnoses, adults with borderline diagnoses, sedentary adults, postpartum women, and adults managing disability related to an illness. All of the listed populations are at risk for low levels of self-efficacy, which can inhibit change. Therefore, these populations may require extra support and motivation, which can be provided by interventions using SCT to support change.
Framework and Risk Factor
In the Dorough study the population of focus was adults with prehypertension and their risk factor was physical inactivity and poor diet and nutrition. The study aimed to use an intervention influenced by SCT to promote physical activity and reduce hypertension. Features of the intervention that were SCT based were the nutrition and exercise education, the nutrition guide an outlined exercise program, and lastly the electronic resource provided for logging progress, goal setting, and goal attainment advice. The results of the intervention included a significant increase in daily steps, decrease in blood pressure, and weight loss. All but one participant moved from prehypertension to normal even optimal blood pressure.
Application of Framework
Stroke survivors can have a low perceived level of self-efficacy and this puts them at an increased risk for not meeting their rehabilitation goals for recovery. Stroke survivors want to return to the varied roles they had before their stroke. However, commonly these survivors become victim to themselves as they begin to lose interest, become unmotivated, and become difficult to get going. Depression and apathy are common consequences of stroke with the sudden loss of independence and self-reliance. An intervention that aims to change patient SCT constructs to improve physical activity in rehab may work to improve the patient’s self-efficacy and their progression in rehabilitation. The desired outcome is increased participation in physical rehabilitation. The factor that is limiting that outcome is the patient’s low level of perceived self-efficacy. One study revealed that the functional level at 6 months post stroke could predict long-term survival and disability (Jones, 2010). Therefore, an intervention that promotes a positive spirit, provides support, and creates an environment that facilitates goal attainment is absolutely necessary for these patients to increase their functional ability and decrease their level of dependency, which is of utmost importance.
An ideal SCT intervention for this population would begin with an educational session on stroke covering topics such as common side effects, medications, needs and goals of rehabilitation. The recovery process is long and therefore multiple small goals should be set weekly to help maintain motivation and recognize progression however small. Therapy should be conducted in groups to allow patients to motivate each other, witness each other’s progression, and support one another through the recovery process. Nurses, and physical, speech, and occupational therapist should help the patients monitor and log their progress, coach exercises, and motivate. To measure the effectiveness of the program therapy participations may be measure based on time, patient exertion and attitude. The level of self-efficacy before and after would be a good measure along with patient’s outlook on current progression and further progress.
References
Amaya, M., & Petosa, R. (2012). An evaluation of a worksite exercise intervention using the social cognitive theory: A pilot study. Health Education Journal, 71(2), 133-143. Doi: 10.1177/0017896911409731
Bandura, A. (2004). Health promotion by social cognitive means. Health Education & Behavior, 31(2), 143-164. doi:10.1177/1090198104263660
Baptist, A. P., Ross, J. A., Yang, U., Song, P.X., & Clark, N. M. (2013). A randomized controlled trial of a self-regulation intervention for older adults with asthma. Journal of the American Geriatrics Society, 61(5), 747-753. Doi:10.1111/jgs.12218
Byrne, J., Khunti, K., Stone, M., Farooqi, A., & Carr, S. (2011). Feasibility of a structured group education session to improve self-management of blood pressure in people with chronic kidney disease: An open randomized pilot trial. BMJ Open, doi:10.1136/bmjopen-2011-000381
Carr, L. J., Dunsiger, S. I., Lewis, B., Ciccolo, J. T., Hartman, S., Bock, B., & Marcus, B. H. (2013). Randomized controlled trial testing an internet physical activity intervention for sedentary adults. Health Psychology, 32(3), 328-336. doi:10.1037/a0028962
DiClemente, R. J., Salazar, L. F., & Crosby, R. A. (2013). Health behavior theory for public health: Principles, foundations and applications (13th ed.). Burlington, MA: Jones & Bartlett.
Dorough, A. E., Winett, R. A., Anderson, E. S., Davy, B. M., Martin, E. C., & Hedrick, V. (2012). DASH to Wellness: Emphasizing Self-Regulation Through E-Health in Adults With Prehypertension. Health Psychology, doi: 10.1037/a0030483
Fjeldsoe, B. S., Miller, Y. D., & Marshall, A. L. (2013). Social cognitive mediators of the effect of the MobileMums intervention on physical activity. Health Psychology, 32(7), 729-738. Doi: 10.1037/a0027548
Jones, F., & Riazi, A. (2011). Self-efficacy and self-management after stroke: A systematic review. Disability & Rehabilitation, 33(10), 797-810. doi:10.3109/09638288.2010.511415
Pilutti, L., Dlugonski, D., Sandroff, B., Klaren, R., Motl, R. (2013). Randomized controlled trial of a behavioral intervention targeting symptoms and physical activity in multiple sclerosis. Multiple Sclerosis Journal, doi: 10.1177/1352458513503391