Psychological Models To Help Understand Selfmanagement

Social cognition models

The psychological literature has investigated in considerable detail the beliefs that predict a person's intention to engage in a health-enhancing behaviour. These models can help guide the clinician in terms of the most relevant topics to explore.

The Health Belief Model (Figure 5.3), proposed by Becker65, argues that people acquire beliefs about perceived disease severity, susceptibility and the perceived benefits over barriers for change; these combine to increase the 'likelihood of taking action'. The Health Belief Model has been extensively researched in diabetes, with the use of psychometric measures for each health belief dimension66. They are usually significantly associated with self-management but account for a small amount of the variance67. Consequently, they provide a relevant but insufficient explanation of the process, although they are widely referred to by clinical staff. However, the model does not cite the importance of intention as a mediating variable, and does not embrace other non-health beliefs that might determine behaviour change. It therefore needs to be integrated within a wider model.

Figure 5.3. The Health Belief Model. Based on reference 65

Some psychological models assume that self-management behaviours are under volitional control, and therefore the single best determinant of future behaviour is a person's reasoned 'intention to change'68. The Theory of Reasoned Action69 predicted that an intention to behave results from two variables: (a) a favourable attitude towards the behaviour, and (b) from norms that suggest that valued others would approve of the individual engaging in the behaviour. A third variable, namely self-efficacy, or the person's belief in his/her ability to carry out the behaviour was added and the model then became known as the Theory of Planned Behaviour70.

The Health Action Process model71 (Figure 5.4) attempts to combine research findings and serves as the best summary to date of the relevant variables. It emphasizes the importance of outcome expectancy (^What's in it for me?') and self-efficacy ('Can I do it?'). It adds an important further predictor of behaviour, namely cognitions that result in plans about initiating the behaviour, e.g. 'I will start going for a walk on Monday with my friend' (i.e. action plan) and thoughts that predict difficulties in maintaining the behaviour and develop appropriate coping strategies, such as distraction or focusing upon the gains of change (i.e. action control). The model emphasizes a set of beliefs that can in part determine and motivate towards an intention to behave, but then need to be translated into cognitive plans for action and maintenance. They provide a checklist of beliefs to explore with

Figure 5.4. The Health Action Process Approach71 (Schwarzer 1992)

the patient and thus influence the likelihood of self-management. These attitudes and beliefs are evident initially during the precontemplative stage of readiness, but are most important during the contemplative stage. The action plan and action control of the Health Action Process model are relevant in the determination and action stages.

Behavioural processes

Behavioural theory argues that actions are shaped by their antecedents and consequences. If a behaviour is positively reinforced, by either a pleasant sensation, praise or the cessation of something unpleasant, then individuals are more likely to engage in that behaviour again. If adverse consequences follow behaviour, then it is less likely to occur again. Crucially, it is the immediate consequences that shape behaviour, not long-term gains. In diabetes self-management this is problematic, as the immediate consequences of some elements of the regimen are not instantly reinforcing and the gains are only evident in the long term.

Reinforced behaviour that is preceded by a cue, or trigger (known as a stimulus), will then be initiated by the presentation of the 'stimulus' alone, and will seem automatic. Improving self-management may involve disrupting the cues that trigger unhelpful behaviour, or deliberately introducing new triggers that will initiate the new behaviour. Shillitoe72 describes the use of these behavioural principles to improve self-management in diabetes care and these techniques have proved to be beneficial in obesity29 and diet73. They involve manipulation of the stimuli and the inclusion of more immediate positive reinforcers.

For new behaviours to become automatic, they would need to be followed by positive reinforcers and preceded by strong triggers or cues. This is the ideal, as the new behaviour would not have to be consciously thought about in order to be maintained. Unfortunately, most lifestyle changes in diabetes self-management have no immediate reinforcers, the cues for the new behaviour are subtle, and the cues for old behaviours are very strong. If the behaviour is to be maintained, it will have to be consciously thought about each time and reinforced. For patients with diabetes, health issues may not be given highest priority when other life events or needs demand conscious attention. Behavioural principles generate strategies for increasing success during the action and maintenance stages74.

Emotional processes

Emotions have an impact upon the way people think and behave, and strong emotions may disrupt the cognitive and behavioural processes described so far. They may arise due to problems in adjusting to the diagnosis of fy;- rj s J rjf4 ryn diabetes , diabetes related fears of complications ' 8, negative hypogly-caemic events79, or because of external and unresolved life events. The emotional impact of an event may be amplified by individual differences in emotional lability, conditioning, coping and levels of social support80'81.

Strong emotions lead to defence mechanisms which seem to act by distorting or denying the reality of the situation which then protects the conscious mind from further distress82. This may be the underlying explanation for the theoretical model forwarded by Janis83, which predicts that high or low fear-arousing messages will not motivate healthy behaviour. Moderate levels of fear may be most useful, as they emphasize the importance of change without engaging defence mechanisms. Strong emotion may also disrupt rational thought processes, leading to more erroneous beliefs. If thinking about diabetes elicits strong negative, unpleasant emotions, behavioural principles would suggest that the individual will respond by trying to reduce the frequency of such unpleasant thoughts. The person will thus 'avoid thinking about it' and remain precontemplative.

Low or depressed mood leads to increased pessimism with respect to the perceived benefits of change and to reduced self-efficacy, which are both crucial motivating factors. Low mood may stem from the bereavement process, triggered by the diagnosis itself and the constant stream of diabetes-related losses that a person experiences84. There may be other reasons for low mood, such as negative life events, but whatever the aetiology it will have a major impact upon the person's capacity to self-manage. Screening to detect depressed mood may be helpful in patients who are attempting significant lifestyle change. A simple scale, such as the Hospital Anxiety and Depression Scale 5, can screen out patients who should either be excluded from behaviour change counselling, or need help for their problems as a precursor to work on self-management. It would then be important for the person to receive the appropriate treatment, either pharmacologically or with cognitive therapy.


Research indicates the value of combining motivational interviewing, the change cycle and an understanding of psychological processes to influence diabetes-relevant behaviours, such as taking exercise, quitting smoking and establishing a healthier diet. The Stage of Change model has not been fully evaluated by randomized control trials, but evaluations carried out in a number of areas suggest its potential efficacy86. Messages specific to a person's stage of change have been shown to increase the uptake of mammography and smoking cessation87,88. These behaviours are highly relevant to diabetes, especially type 2, where the focus is upon healthy eating, exercise and taking medication. In type 1, insulin-dependant diabetes, successful self-management is more complex, given the greater interdependency of behaviours (e.g. monitoring, diet and insulin dose adjustment). Nevertheless, similar principles should apply to complex behaviours, provided that the action plan, action control and acquisition of skill is addressed in more detail.

A pilot study supporting the use of these methods52 randomized individuals with type 2 diabetes into two groups that focused on weight reduction. One group included a motivational intervention (n = 6) and the second followed a standardized behavioural weight control programme (n = 10). Significant benefits in glycaemic control and in adherence to the weight reduction programme were reported in the motivational group. A 4 month follow-up showed that both groups had lost weight, with no significant differences but a trend in favour of the motivational group. The authors report the advantages of a motivational intervention, but note the need for further investigation with a longer follow-up period (the real test of weight reduction programmes), a larger sample size to improve the power of the study and a tighter experimental control.

In summary, empirically supported models for behaviour change have been widely used in medical settings. Counselling and motivational inter viewing largely dictate the recommended style of empowerment, but the skills are not usually taught to health care staff20. These techniques aid the development of appropriate rapport in order for the individual's readiness to change to be identified using the change cycle. The prevailing psychological models can then help to formulate which emotional, cognitive or behavioural barriers might be stopping individual progress around the cycle with the employment of appropriate specific strategies to complete the process89. Given the current level of knowledge, this represents the most logical way to understand and facilitate self-management.

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