Introduction
This behavior change intervention will focus on the lifestyle alterations needed for patients with cardiovascular disease that will be examined in this review is the dietary change. Although there are several factors that impact the risk of developing cardiovascular disease, including smoking, insufficient physical activity, and poor eating habits, the latter is the focus of this review since dietary changes are also linked to other conditions and help address factors such as patient’s weight. Hence, the target behavior for cardiovascular disease is a proper diet with the inclusion of vegetables and fruits. Under the Transtheoretical Model, behavior change occurs in stages, and individuals may not be able to assess the benefits of their actions during the initial stages of the intervention. This paper will present the literature review on dietary change intervention using the transtheoretical model and discuss the potential barriers and strategies for addressing them.
Critical Review
People’s health state continuously changes in the spectrum from health to disease, which defines their perceptions of their wellbeing. Sarafino and Smith (2019) define health as the continuum of illness and wellness today and in the past. The end of this continuum is death, a terminal condition that no one can escape, while the other side of the spectrum is optimal health. Therefore, health is a positive state where a person feels good both physically and mentally (Sarafino & Smith, 2019). To maintain an optimal state of health, one has to lead a specific lifestyle, avoiding the risk behaviors that may subject them to the development of disease, such as smoking, lacking physical activity, having an unhealthy diet, and others.
There are several approaches to addressing the health and illness of the individual, one of which is the transtheoretical model. According to Liu et al. (2018), it is “aimed at understanding individuals’ behavioral changes and describing how people move dynamically through five different stages of behavioral changes” (p. 50). This model is commonly applied by healthcare practitioners and scholars to address the behavior changes related to physical activity, which is relevant for cardiovascular disease as well. Moreover, this model is also referred to as the stages model because its underlying principle of it is the understanding of the different stages of change that an individual goes through when introducing a new behavior (Winter et al., 2017). Winter et al. (2017) note that this model, together with the Social Cognitive Theory and the Theory of Planned Behavior, is the most commonly used in the studies relating to behavior changes for cardiovascular disease.
In contrast to the Transtheoretical Model, the Social Cognitive Theory is based on the idea that the person’s environment and the internal and external reinforcers allow facilitating behavioral changes (Schunk & DiBenedetto, 2020). Control and reinforcement, as well as the person’s experience and expectations, are the core elements in this theory that allow achieving long-term changes in one’s wellbeing, which is the true goal of behavioral change. In comparison, the Transtheoretical Model is more focused on the process of change and the different steps one takes toward implementing these long-term health habits (Winter et al., 2017). The reason why this model was not used for cardiovascular disease intervention is that it relies on external factors and the environment, which suggest that external stimuli matter more when compared to the individual’s own intentions.
The Theory of Planner Behavior is based on the assumption that the individual’s expectations and attitudes toward an action affect the likelihood of the person executing this behavior (Ajzen, 2020). A change in behavior occurs as a result of motivation and the capabilities of a person to exert the change. Although this theory sufficiently describes the factors required for a proper behavioral change, it does not allow to structure of an intervention as opposed to the Transtheoretical Model.
The use of a model for the behavioral intervention helps structure the steps required to achieve success and therefore is more effective for addressing the risk behaviors. Shakiba et al. (2018) studied a behavioral intervention using the transtheoretical model using a sample of 1230 individuals from Iran aged between 30 and 50 and concluded that a model-based intervention has been highly effective for addressing the health-related behaviors of the participants. In this study, the authors included health education regarding the diet changes, such as the value of fruits and vegetables for one’s nutrition. At the end of the intervention, the participants showed better knowledge of healthy dietary habits and reported higher consumption of healthy foods (Shakiba et al., 2018).
First and foremost, to identify the changes needed to decrease the risks associated with cardiovascular disease. According to Winter et al. (2017), most studies addressing behavior changes relating to cardiovascular disease focus on healthy eating, smoking, and monitoring of glucose levels. The target of interventions introduced by Raeside et al. (2019) and Miranda et al. (2019) is weight loss, which mitigates the risks of cardiovascular disease achieved through healthy eating and frequent physical activity. The latter, in particular, is an issue for the modern-day population as the majority of people lack physical activities in their daily lives and require additional interventions. Moreover, the abundance of food that contains large quantities of sugar and increases blood glucose levels is another significant problem.
Evidently, to change risk behaviors, one has to comprehend the underlying psychology of such habits. According to Verplanken (2018), people often use habits as an excuse for adverse behaviors, while individuals with strong habits have a higher level of certainty that their actions are a result of their intent. Moreover, habitual behaviors account for a large proportion of everyday actions, and they are a result of the complex interconnection between personal and environmental factors. This reason explains why changing risk behaviors is difficult since people often excuse these actions using habits as reasoning and because there is no one factor that can be addressed in order to change these habits for the better. Another factor in transforming the risk behaviors is the person’s reaction to pain and wellness, as well as their perceptions of these factors. The reaction to pain, medication, illness and treatment differs among individuals and is linked to cultural, social, and personal factors. The potential barriers to change are linked to the nature of human behavior and the tendency of people to stick to their old habits despite them understanding the unproductiveness of these strategies.
Three Strategies and Potential Barriers
The development of technology has made it possible to both access information about healthy behaviors and track the person’s progress as they adopt these habits. Winter et al. (2017) argue that using the technology to introduce and monitor the interventions is a method that is highly effective, both when the individuals are supervised by medical professionals and when they are self-managing the behavioral change. Hence, the first strategy when introducing the dietary change that includes the use of mobile applications for the monitoring and guidance of the patients. According to Klimis et al. (2018), mobile health is a leading strategy that researchers have used to address the behavior changes required to combat cardiovascular disease.
The benefit of the mobile health applications is that they allow for tracking multiple health factors relating to cardiovascular disease. For instance, MyFitnessPal allows to log in activities such as exercise and diet (Klimis et al., 2018). One barrier to this approach is that the majority of studies, such as a systemic review by Klimis et al. (2018), point out that these interventions have been studied only in the short term, and it is unclear how they affect people in the long term, as well as lack of clarity regarding the unknown variables relating to health and wellness. Still, mobile health applications use is consistent with the Transtheoretical Model’s concept of self-monitoring and therefore is an effective method for reducing the risks associated with cardiovascular disease.
However, with self-monitoring strategies, there is an evident barrier to motivation and adherence. For example, Du et al. (2018) state that participants’ perspective is the factor that impacts the efficiency of such interventions; for example, their technological literacy and the perceived ease of use impact the outcomes of the behavioral interventions. Hence, if a person is unfamiliar with how to use an application or if they perceive the process to be burdensome and ineffective, they are more likely to achieve worse results over the course of the intervention. Chitten et al. (2021) report a similar issue and argue that professionals should “empower patients to communicate their barriers to physicians through triadic communication models and question-prompt lists” and use empathy when working with these individuals to mitigate this barrier (p. e21183). To address this barrier, practitioners should include the perspective of the participants, for example, by assessing their options regarding the proposed intervention and by educating them on the application of mHealth and the potential benefits.
The second strategy for dietary behavioral change is the education of patients on the benefits and proper eating habits. One barrier to this approach is that education is not directly linked to the changes in one’s behavior since the target of this method is merely providing more information and enhancing a person’s understanding of their actions and their potential effects on their health. Raeside et al. (2019) argue that advocacy targeting health promotion is an effective way of addressing people’s risk behaviors, and one factor for this is the education of the individuals. The idea behind this approach is that advocacy helps raise awareness about the risk behaviors and triggers the person’s interest in improving their lifestyle and wellbeing.
From the perspective of the Transtheoretical Model, this approach helps address the first stages of pre-contemplation, contemplation, and preparation (Liu et al., 2018). During the first stage, individuals do not have a plan for changing their risk behavior, and they require a cue, such as a recommendation from a health expert or a promotional campaign that would hint at the potential problems with their current behaviors. This stage is addressed through the community advocacy that Raeside et al. (2019) discuss in their paper, as many people may be unaware of their diet being unhealthy and contributing to the deterioration of their health. Next, the pre-contemplation stage is the intent to make a change to one’s behavior; for example, after seeing the promotional campaign, a person can decide to reevaluate their approach to diet. This, however, does not necessarily result in the actual change and the contemplation stage is the one where a person decides to actually implement an intervention. Thus, the idea of the second strategy is to trigger the pre-contemplation and contemplation stages under the Transtheoretical Model to help people at risk. To address the barrier discussed above, advocacy and education efforts should explain the specific behaviors a person should adopt, such as reviewing one’s diet and including healthy foods in it.
The final strategy for facilitating behavioral change in individuals is the development of a rewards system that would promote the healthy eating habits of patients at risk of cardiovascular disease or those diagnosed with the condition. Under the Transtheoretical Model, during the first stages, individuals do not recognize the effect of their actions on their habit development. However, once implemented, the maintenance stage is where the actions become routine and where a person may see the actual changes that are a result of their efforts. During this stage, it is essential to reinforce positive behaviors, which is the basis of behavioral change psychology. According to Miranda et al. (2019), “incentives play a role in introducing health-related benefits” (p. 139). The authors’ research has shown that rewards, in this case, a cash prize and individual incentives for reaching a weight-loss objective, affect the adherence and results of the participants. Moreover, the use of rewards is an important factor in supporting the motivation of the individuals during the habit change process, as well as an essential step to ensuring that this habit becomes a long-term one.
The barrier to the application of this strategy is the difficulty of selecting an appropriate reward that would serve as a sufficient incentive for an individual. Miranda et al. (2019) used cash rewards in their study; however, for a health clinic or when working with individuals in other healthcare faculties, this approach is not feasible. Moreover, it is difficult to develop a standardized system of rewards that could be applied to multiple people since the rewards must be tailored toward the person’s taste. One way of addressing this issue is by developing a questionnaire that will help one define the reward that will be sufficient for them to initiate the behavioral change process. This can be done at the contemplation stage of the behavioral change to trigger the actual process of implementing dietary habits change.
Conclusion
In summary, this paper is a review of literature on the topic of health-related behaviors and interventions that help patients with cardiovascular disease introduce behavioral changes. Under the Transtheoretical Model, behavior changes occur in stages, and individuals see the benefits of these changes only during the later stages, while in the early ones, they may struggle to pinpoint the positive effects of their actions, which is the main barrier to the transition towards a healthy behavior. This paper offers three strategies for behavioral change, mHealth, promotion and education, and suing individualized regards.
References
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