1 1 National Psychology Week 2006 Health Behaviour Change survey conducted by The Australian Psychological Society The current climate in Australian health is one of increasing concern about the sedentary habits and weight problems of the general population. This is embedded in more serious concerns about epidemic rates of diabetes and obesity (Zimmet & James, 2006). In the general population these concerns have resulted in an increased awareness of the need to monitor health behaviour. Almost everyone at some point in time has wanted to change something about his or her eating habits or activity levels. Given this increased community focus on health behaviour, it is important for health professionals to have an understanding of how individuals work at changing behaviour and the challenges they face. There is relatively little known about how unhelpful health behaviours arise, become maintained, and most importantly, how they can be changed (Glass & McAtee, 2005). People are generally aware that they should eat healthier food and exercise more, but people usually find it difficult to get motivated to actively make the change, and when they do make positive changes, they find it difficult to maintain these changes over time. A number of factors have been identified that may influence people s ability to achieve successful change in health behaviour. These include features of the individual such as their belief in their ability to change, the expected outcome of making the change, and their level of persistence. In addition, aspects of the environment have been found to be important such as the culture and values of people around them, support networks, and access to resources (e.g., being able to join a gym). This year s APS survey investigated two aspects of health behaviour, eating habits and physical exercise. An online survey was developed to gain information on how people go about making changes to eating habits and physical activity, the strategies they adopt, and their perceived level of success in making and maintaining the change. Participant characteristics A total of 1,289 people completed the survey. Of these, 751 people identified themselves as female and 129 as male. A large number of participants (409) did not state their gender. Nevertheless, the participants appear to be predominately female. Participants covered a broad range of age groups from adolescents to older adults. However, just over half were in the 20 to 40 year age bracket (52%). Eight hundred and twenty four participants provided information in order for a Body Mass Index (BMI) to be calculated. A BMI is a mathematical formula using height and weight measurements that provides a general indication of whether weight falls within a
2 2 healthy range. Less than half of the participants (44%) recorded a BMI in the normal weight range. A small number of participants were underweight (2%) according to their BMI. However, a considerable number of participants had a BMI identifying them either as overweight (31%) or obese (23%). The percentage of participants falling into these groups is depicted in Figure 1. Obese, 23% Underweight, 2% Normal weight, 44% Overweight, 31% Figure 1. The percentage of participants grouped into the categories underweight, normal weight, overweight and obese based on their BMI score. Figures for overweight individuals are consistent with those released recently by the Australian Government who this year reported that 32% of adults met criteria for being overweight in the period 2004 to However, the number of individuals in the current study who were classified as obese is much higher than the 16% of the population reported by the Australian Government in the 2004 to 2005 period. The current results also show that as individuals get older they are more likely to have a weight problem as measured by their BMI. Participants were asked to state whether they currently have a problem with their health, weight, or level of fitness. Twenty-two percent of people who completed the survey reported that they believe they currently have a health problem, 30% believe they have a weight problem, and 36% believe they have a problem with their level of fitness. When looking at perceptions of health, an area of interest was the views of those whose BMI placed them in an unhealthy weight range. Because of the small numbers in the underweight group this group was excluded from all analyses. Therefore, discussion of results for the BMI groups focuses only on findings for the normal weight, overweight and obese groups. Results for these BMI categories showed that individuals whose BMI placed them in the obese group generally acknowledged their weight difficulties (89%). Results for the overweight group were not as clear, with just under half of the group (47%) reporting that they do not have a weight problem. A small, but noteworthy number of individuals whose BMI placed them in the normal
3 3 weight range reported that they have a weight problem (17%). This may have been a recognition that they had difficulty maintaining a healthy weight. A large number of individuals also reported problems in their level of fitness although they were less likely to report having a problem with their level of fitness than with their weight. Again a higher number of individuals in the obese group reported a problem with their fitness (73%) when compared to the overweight (59%) and normal weight groups (39%). Finally, when considering general health, fewer people in each of the groups acknowledged that they have a health problem (obese group = 53%; overweight = 33%; normal weight = 24%). This suggests that when considering problems with weight and fitness, individuals do not necessarily link these to health problems. Eating habits Almost all of those responding to the survey (97%) indicated that they had at some time attempted to change their eating habits. This may not reflect the percentage in the general population however as some individuals may have opted not to complete the survey if they were of the view that they had not needed to change. The main motivation for changing eating habits was to improve physical appearance (44%) followed by improving general health (31%). The main strategies for changing eating habits reported by participants were using one s own willpower (63%), or joining a gym or sports club (26%). Participants were less likely to report using educational strategies such as using the internet or magazines (18%) or through self-help books (17%). Similarly, fewer people reported using support strategies such as family support (15%), working with a friend (14%) or support groups (4%). Over half of participants (55%) did not seek any professional help to change their eating habits. Those who did seek professional help were most likely to get help from a weight loss organisation (12%), a personal trainer or gym instructor (12%) or a medical practitioner (10%). Surprisingly, fewer people sought help from professionals who are more highly trained experts in health education, such as a dietitian (7%), or in changing health behaviour, such as a psychologist (3%). Of the 97% of participants who attempted to change their eating habits, 98% reported some success in changing their behaviour. However, many of these participants failed to maintain the change over time. Figure 2 shows the level of success reported by participants who have attempted to change their eating habits. For 22% of participants the change lasted no longer than a few weeks or months before they lapsed back into old habits, while 39% said that although they generally feel they have made the change they don t always stick to it. Nevertheless, 26% of participants had maintained the change for longer than six months and 12% of participants who had only attempted to change their eating habits in the last six months have managed to maintain the change.
4 Percentage of participants Did not make the change Changed for a few w eeks/months but lapsed but don't alw ays stick to it less than 6 months ago and sticking to it more than six months ago and sticking to it Level of success Figure 2. Level of success reported by participants following an attempted change of eating habits. The four to six month stage in change appears to be a critical time for strengthening a commitment to the new behaviour. Research suggests that individuals who manage to maintain behaviour change for up to six months are more likely to continue with the new behaviour (Orleans, 2000). The current results support this research. There was an increase in the number of individuals who stated that they stuck to the behaviour change once they had passed the six-month period of change. While only 12% of participants who had made the change less than six months ago were sticking to the new behaviour, over double this number (26%) are sticking to the change having made the behaviour over six months ago. Individuals who were in the 30 years and over age groups were more likely to stick to changes in eating behaviour for a period over six months than were participants who were younger than 30 years of age. While only 17% of participants aged below 30 years of age reported having changed their eating habits and maintaining these changes for over a six month period, the rate of such success increases for those aged between 30 and 50 years of age (30%) and even more so for participants aged over 50 years (35%). A number of explanations could be proposed for explaining these age differences. For example, it may be that older individuals have, over time, adopted strategies that work for them. Older individuals in this study were also found to report more health problems than did the younger participants. This suggests that they may be more focused on possible risks of not changing their eating habits, and therefore may be more motivated to see the changes through in the long term. In addition, older individuals may have more time to buy and prepare particular foods than young people who may be more likely to prepare quick meals or eat out, and thus have more difficulty focusing on particular eating habits.
5 5 Physical activity The results for attempting to change physical activity are relatively consistent with those reported for eating habits. Although fewer participants reported having attempted to change their physical activity (73%), those who had, reported similar motivation to those who had worked to change eating habits. The main reason for changing physical activity was to improve physical appearance (32%) followed more closely in this case by improvements to general health (31%). The main strategy used to change physical activity reported by participants was again using one s own willpower (49%). In a similar pattern to that reported for eating behaviour, joining a gym or sports club was the second most likely strategy used (30%). Less frequently used strategies included rewarding oneself along the way (14%), educational strategies such as the internet or magazines (11%) and self-help books (7%), and support strategies including family support (13%) and joining a support group (2%). As was the case with changing eating habits, few people who reported attempting to change physical activity sought professional help to do this. The most likely professional help sought was a personal trainer or gym instructor (17%), followed by a medical practitioner (4%) and a weight loss organisation (2%). Again few people sought help to change physical activity from specialists such as psychologists (1%), exercise physiologists (1%) and dietitians (1%). Open-ended responses identified aspects of the help they received that was most beneficial. These strategies tended to focus on assistance to achieve a general increase in daily exercise such as being challenged to work harder. Participants were slightly more likely to report success in changing physical behaviour than in changing eating habits. Thirty-three percent of participants reported having changed something about their physical activity over six months ago and have maintained that change. A smaller number (14%) changed their physical activity less than six months ago and also report maintaining the change. However, a larger group (30%) of participants made the change but don t always stick to it, 20% made the change but it lasted only a few weeks or months before they lapsed back into earlier physical activity levels. This finding is consistent with previous research and with anecdotal information showing that one of the greatest challenges is to maintain change over time. On a more positive note, only 2% of participants reported no change at all after attempting to change physical activity. The pattern of results of success in changing physical activity is presented in Figure 3. As with results for changing eating behaviour, there was an increase in the number of participants who were sticking to changes in physical behaviour once they had successfully maintained the change for a six-month period. In addition, also consistent with the results for changing eating habits, those individuals in the older age groups (over 30 years of age) were more likely to stick to changes they had made for a period over six months than were individuals in the younger age groups, with for example, 42% of those over 50 years of age and 37% of those between 30 and 50 years of age maintaining changes in physical activity longer than 12 months compared to only 25% of participants who are under 30 years of age.
6 Percentage of participants Did not make the change Changed for a few w eeks/months but lapsed but don't alw ays stick to it less than 6 months ago and sticking to it more than six months ago and sticking to it Level of success Figure 3. Level of success reported by participants following an attempted change of physical activity. Maintaining behaviour change Research in behaviour change suggests that after six months of sticking to a new behaviour there is a move into a maintenance stage. In this stage the person wants to make the change a permanent part of their life, and work at not falling back into old habits. At this stage it is important not to assume that the new behaviour is now permanent and that it no longer requires effort and attention. Individuals in the current survey indicated that they did not draw heavily on support type strategies, such as working with a friend, or seeking family support, to assist them to change their behaviour. Moreover, while people who reported to be in the earlier stages of behaviour change were found to draw on support strategies, individuals who had made the change, or continued to maintain the change, were less likely to report using support strategies. It could be that they believed that once the change had been made they no longer needed to rely on others. Given the high relapse rates found for people who have changed eating behaviour and the evidence in past research of the positive effects of support strategies during the active change stage, the current findings appears to suggest that individuals should be encouraged to continue to seek support from others in the ongoing maintenance of the healthy behaviours. Responses to open-ended questions about changing eating habits and physical activity Participants who used professional help to change provided a range of open-ended responses identifying the approaches used by professionals that were most helpful. Although a small proportion of participants reported that they received information about useful strategies and techniques to change health behaviours, the majority of the responses identified that they received nutrition or physical activity-specific information but no useful tips about how to implement these recommendations. That is, they often
7 7 received information about what it is they should be doing, with little or no information on how to put these recommendations into practice. Coping and emotional responses In addition to the general survey questions that were developed, the online survey included the administration of a standardised scale of coping ability, the Health Assertiveness Scale. The scale evaluates the level at which people perceive their ability to deal with health issues and to communicate their health concerns to others. A significant relationship was found between respondents level of coping and their success in changing both eating habits and physical exercise. Those individuals scoring higher on the Health Assertiveness Scale were more likely to demonstrate a successful outcome when attempting to change health behaviour around eating and physical activity. While these results cannot be seen as causal, they do emphasise the need to further explore the importance of the development of specific coping skills to successful behaviour change. Measures of emotional reactions such as anxiety, helplessness, anger, self-esteem, expected outcomes from making changes in health behaviour and perceptions of risk associated with not changing health behaviour were also collected. Results on coping and emotional responses were analysed using statistical procedures, and showed that: As a whole, the obese category demonstrated lower coping ability when compared to the normal and overweight groups. The obese group reported significantly higher levels of negative emotions when attempting to change eating habits than the other groups. The second highest level of negative emotion was for the overweight group, followed by the normal weight group. The obese group reported the lowest level of self-esteem of all groups when attempting to change both eating behaviour and physical activity. The obese group perceived the highest level of health risk if they did not change their eating habits, suggesting that his group of individuals is realistic about the problems associated with their weight. However, perceptions of health risk linked to not changing physical activity was perceived as highest by individuals whose weight placed them in the normal range, followed by the overweight group. The obese group also reported the lowest perceived level of risk to health associated with not changing physical activity. Those classified as obese were most likely to report expected negative outcomes from their attempt to change, followed by the overweight group, and then the normal weight group. There was a significant difference between the BMI weight groups on the reported level of success in changing both eating habits and physical activity. The obese group reported the lowest level of success in changing eating habits and physical activity. Reported success in changing eating habits was second lowest for the overweight group. The normal weight category reported the highest level of success at changing eating habits. For changing physical activity, after considering the obese group, the lowest reported success level was from the overweight group, followed by the normal weight group. To summarise this section, the results demonstrate the negative impact of obesity and being overweight on mental health. Individuals in the current study who were found to
8 8 have a BMI in the obese range reported lower levels of coping ability, more negative emotions, lower self-esteem, and higher levels of perceived risk and negative expectations of outcome following their attempted behaviour change when compared to individuals in the overweight and normal weight categories. While all individuals are likely to benefit from professional assistance to change health behaviour, the findings suggest that individuals who are obese are likely to be most in need of professional assistance such as that offered by psychologists who are trained experts in both health behaviour change and in mental health. Individual style The attached table outlines the characteristics of each of three thinking styles. It includes a set of tips to help individuals who have identified themselves as predominately using one of these thinking styles to adopt strategies that are most likely to fit into their way of thinking and lead to successful behaviour change. Each individual has beliefs and thoughts about events or situations, such as their health, and these beliefs and thoughts can influence their behaviours and emotions. Ellis (2004) identified three categories or content areas of beliefs: approval, achievement, and comfort. Understanding each of these content areas helps to understand peoples thinking style and their motivation to change health behaviour. Approval beliefs focus on the social interaction component of events, tend to be focused on short-term goals or the here and now, and typically avoid focusing on the long-term consequences of actions. Achievement beliefs tend to be task focused, and beliefs are around successfully implementing a solution to complete the task. Comfort beliefs are focused on the multiple options available, and tend to consider the consequences of any event within a framework of fairness and harmony (Bond & Dryden, 2000; Campbell, 1985). When considering these three styles of thinking the results of the survey indicated that those individuals who had successfully changed tended to place less emphasis on social support and specific instructions or goals, than those individuals who reported unsuccessful health behaviour change. That is, they reported less use of approval and achievement types of thinking than individuals who reported unsuccessful health behaviour changes in eating and physical activity. Specifically, it was found that as an individual adopted changes in eating and physical activity behaviours on a long-term basis, they used less short-term goals and comparison to others. People who did not successfully change physical activity tended to use more approval beliefs than those who did change. Successful long-term changes in eating habits were related to lower social factors, such as being influenced by friends or working at changing eating habits with a friend, than non-successful changes in eating habits. For changes in eating habits, successful changes were also linked to lower reports of a focus on specific goals, in comparison to unsuccessful eating changes. Although these findings appear counter-intuitive, they could reflect two situations. First, it could reflect the use of social and goal setting strategies in the early process of change, where the individual is more aware of social influences, and using specific approaches to change behaviour. These strategies are well-known positive coping responses used in psychology for behaviour change. Second, the findings could reflect that individuals who report health behaviour change for at least six months either tend to not typically have high levels of approval or
9 achievement thinking or that they tend to under-utilise these patterns of thinking as they have maintained behaviour change over a period of time. As it is theoretically proposed that everyone uses all styles of thinking, it is probably the reduction of approval or achievement thoughts that is reflected in the survey results. Considering the high rate of inconsistency or relapse of changes in the health area that has been reported, these results could be indicating a factor related to relapse prevention. The encouragement of individuals to continue to use social and professional help intermittently, even when they have made substantial changes, could help maintain health eating and physical activity behaviours. 9
11 11 References Australian Government (2006). Overweight and obesity in Australia E-Brief: Online Only issued 5 October Retrieved 23 October 2006 from Bond, F. W., & Dryden, W. (2000). How rational beliefs and irrational beliefs affect people s inferences: An experimental investigation. Behavioural and Cognitive Psychotherapy, 28, Campbell, I. (1985). The psychology of homosexuality. In A. Ellis & M. Bernard (Eds.), Clinical applications of rational-emotive therapy (pp ). New York: Plenum Press. Ellis, A. (2004). Why Rational Emotive Behavior Therapy is the most comprehensive and effective form of behavior therapy. Journal of Rational-Emotive & Cognitive- Behavior Therapy, 22, Glass, T. A., & McAtee, M. J. (2006). Behavioral science at the crossroads in public health: Extending horizons, envisioning the future. Social Science and Medicine, 62, Orleans, C. T. (2000). Promoting maintenance of health behaviour change: Recommendations for the next generation of research and practice. Health Psychology, 19, Prochaska, J. 0., & DiClemente, C. C. (1986). Toward a comprehensive model of change. In W. R. Miller & N. Heather (Eds.), Treating addictive behaviors: Processes of change (pp. 3-27). New York: Plenum Press. Zimmet, P. Z., & James, W. P. T. (2006). The unstoppable Australian obesity and diabetes juggernaut. What should politicians do? The Medical Journal of Australia, 185,