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                                 February 2010
    Examining Behaviour Change Interventions
The World Health Organisation states that an unhealthy diet and physical inactivity are two of the main
preventable risk factors for the major chronic diseases such as cardiovascular diseases, cancer, and

The 2008 inaugural Zurich Heart Foundation Heart Health Index compares the heart health behaviours
of Australians with their perceptions of whether they meet recommended guidelines. Results indicated
that sixty per cent of Australians are not meeting Australian Physical Activity Guidelines, ninety-one per
cent of Australians are not eating enough vegetables and forty-seven per cent do not eat enough fruit.

Research on physical activity and dietary behaviour interventions demonstrates that such interventions
have been effective in increasing physical activity levels and nutrition intake.

The Biomedical Journal, 2008 published ‘Exercise on prescription for women aged 40-74 recruited
through primary care: two year randomised controlled trial.’ This study included 1089 women aged 40-74
who did not undertake 30 minutes of moderate intensity physical activity on at least five days of the week.
Participants were recruited through a primary care setting and a randomised control trial was conducted.
The intervention used the green prescription model, in which General Practitioners or Practice Nurses
briefly counsel (7-13 minutes) patients using motivational interviewing techniques to increase physical
activity. A six month follow-up visit was included and monthly telephone support was provided over a
nine month period. This program of exercise on prescription increased physical activity and quality of life
over a two year period, although falls and injuries increased. These findings support the use of exercise
on prescription programs as part of population strategies to reduce physical inactivity 1.

‘The Logan Healthy Living Program,’ published in the Science Direct Journal in 2007 highlighted the
results of a similar program. This trial compared a 12-month telephone and print-delivered physical
activity and diet intervention against usual care, for patients with type 2 diabetes or hypertension. The
484 participants were recruited from the general practice setting in a socially disadvantaged community.
A cluster randomised design was used. The underlying theoretical perspective used to guide the
telephone intervention was derived from Social Cognitive Theory (SCT) and the Social-Ecological Model.
Eighteen telephone calls were conducted over the 12 month period. Calls were delivered weekly for the
first three weeks, fortnightly until four months, and monthly for the final eight months. The study targeted
a challenging primary care patient sample and, using a telephone-delivered intervention, demonstrated
modest improvements in diet and in physical activity. Results suggest that telephone counselling is a
feasible means of delivering lifestyle intervention to primary care patients with chronic conditions—
patients whose need for ongoing support for lifestyle change is often beyond the capacity of primary
healthcare practitioners. 2

The Nutrition Journal published the ‘Weight, physical activity and dietary behaviour change in young
mothers: short term results of the HeLP-her cluster randomised controlled trial’, in 2009. The aim of this

study was to evaluate the short term effect of a community-based self-management intervention to
prevent weight gain. Two hundred and fifty mothers of young children (mean age 40) were recruited from
the community in Melbourne, Australia. The intervention group (n = 127) attended four interactive group
sessions over 4 months held in 12 local primary schools in 2006, and was compared to a group (n = 123)
receiving a single, non-interactive, health education session. Data collection included self-reported
weight (both groups), measured weight (intervention groups only), self-efficacy, dietary intake and
physical activity. Both interventions resulted in similar weight loss in the short term, however more
participants in the intervention group lost or maintained weight. There were small non-significant
changes to physical activity and changes to fat intake specifically replacing high fat foods with low fat
alternatives such as fruit and vegetables 3.

Health Coaching Australia (HCA) trains health practitioners with a structured system of evidence-based
behaviour change protocols that assist patients or clients to adhere to medical and lifestyle
recommendations. The HCA model is a practitioner model that has been shaped by thousands of health
professionals who have provided feedback and input to the model, its processes and techniques.

The HCA model is a structured approach to working with clients (or patients) that enables health
practitioners to undertake three critical tasks to empower clients to engage in their own health
management. These tasks work on increasing or reinforcing the client’s readiness, importance and
confidence in engaging in health behaviour change. They are: 1) providing treatment recommendations
and health education in a way that doesn’t inadvertently create resistance, 2) assisting clients to decide
that it is in their interests to engage in health behaviour change for their own personally motivating
reasons, and 3) increasing clients’ chances of success by identifying and addressing barriers to change
and building self-efficacy.

Although successful in all aspects of health and lifestyle management, health coaching is proving to be
particularly successful in the area of chronic disease prevention and self-management. The following
case study illustrates how health coaching and the Health Coaching Australia model can be used to
assist people to make changes to their health.

A 50 year old male has a history of morbid obesity and back pain and limited enjoyment of daily living
and life. His previous occupation involved standing (Chef), then he moved to seated work (Taxi). His
debilitating pain caused him to cease all work. His wife also has health issues and receives a Carer’s
Pension for her husband. He spent 6-7 hours per day watching TV and DVDs which he described as
one of his few enjoyments in life.

The client was referred from a General Practitioner to the Exercise Physiologist (trained in health
coaching, the “health coach”) in May 2007. The client’s current medical conditions include osteoarthritis
in his knee (bilateral), back pain, morbid obesity (currently 159 kg), waist 152 cm, hypertension, snoring,
Gastro-Oesophageal Reflux Disease (GORD), and depression. The client had Gastric Stapling in early
2005, that was unsuccessful.

The health coach was very concerned about the client’s family history of diabetes and lack of ability to
play with his young children. The client stated he often attends his children’s primary school to assist
with reading and other tasks and this outlet makes him feel useful. His children also enjoy it.

The client tried 5-6 various diets but was unsuccessful. Exercise suggestions by GP’s and Specialists
were unappealing and unrealistic, including swimming and hydrotherapy. The client was self conscious
of his body, and walking caused him too much discomfort. The client understood that his weight was
impacting negatively on his health and was fed up with the experts’ advice and being told what to do.
The client mentioned that “no one is really able to help him”. The health coach and client discussed the
need to develop a strategy that might work long-term and as long as the client continued to maintain
hope, the client could move forward. The health coach mentioned that there was no such thing as a

failure, just the wrong strategy. The client felt pleased. The health coach’s primary goal was to build
rapport with the client and to build his self efficacy.

The health coach used the GROW model, to apply the health coaching principles. This includes:
G= General Goal, what does the client want to achieve? The general goal is an overall goal which the
client wants to focus on. In order to achieve the general goal more specific goals are set in the action
R=Reality, what is the current/past/ future situation? How likely is the client to achieve the goal?
O= Options, what are all the possible solutions? Are there barriers preventing the client from achieving
the goal?
W=Written Goals and Action Plan, the course of action. Written specific goals and a step-by-step action
plan to achieve the general goal.

General Goal
The client set a general goal to weigh 140 kg by Christmas (from 159- 140kg over 7 months) but to
eventually weigh 110 kg.

The client was high in readiness to lose weight and it was important to the client but the client was low in
confidence to achieve the goal. The client was ready to try something new “but not dieting”. The health
coach invited the wife to come to future consultation sessions with the client.

The client agreed to explore options with the health coach by only working on one thing at a time so it
was manageable. They also discussed the possibility of using a stationary exercise bike during television
time. The health coach talked to the wife and client about energy intake by focusing on specific goal
options of a combination of better food choices (healthier take away and reduced fat intake) and finding
a suitable avenue for more movement that does not cause pain in order to burn more energy.

Written Goals and Action Plan
An action plan was constructed at the consultation. The client did not seem comfortable writing things
down so the health coach wrote the action plan using the client’s words.

The Client identified his intrinsic motivators to achieve the goal:
   1) to be a good role model for children
   2) to contribute to family life (mow lawns at home and contribute more financially)
   3) to feel good about himself, look good at the family Christmas party this year
   4) to be available for his children and not limited by pain.

Short term outcome
The client lost weight slowly. He reduced his fat intake, although he could not increase his energy
expenditure at that point in time. The client lost approximately 4.5 cm at the neck and the client reported
that he felt less ‘jowly’. Although not a traditional place of measurement, this was an important place to
gauge progress for the client and helped to build confidence as he could measure progress. The client
had lost 4 centimetres from his waist although he was far prouder of his neck girth progress because it
was more visible.

Barriers and facilitators identified during attempted goal pursuit
The barriers for the client included very limited income, reliance on others for financial support (food
parcels), thinking “all movement will cause more pain”, does not plan meals, impulse high energy food
buying, always has snack foods for the children at home (chips, twisties etc). Some factors the client

identified as facilitating change included a supportive family (wife and children), positive comments from
his family, and extra roles at school assisting the teachers with day-to-day tasks.

Five months after the client’s first health coaching session the client called the health coach and said that
he was ready to buy a stationary exercise bike. The health coach had done considerable research on
where he could purchase a bike that could accommodate his weight and methods to finance it.

The health coach asked the client what had happened to make purchasing this bike his number one
priority, his response demonstrated the power of intrinsic motivation. He had been asked by the primary
school and his children to cook sausages at the local school fund raiser and found that he had to return
home after 1.5 hours of work due to pain and pins and needles in his legs. He felt that he let his children
down as other parents were able to work for longer periods. He also felt that he let the school and
himself down and realised that he had to do something more to achieve his goal.

Currently the client is cycling 2-3 times per day at low intensity for 5 minutes and will build up by 1
minute per week. The stationary exercise bike also measures energy expended (calories). It also helped
reinforce the concept that more daily movement would increase circulation, mobility and manage pain.

The ‘Go for your life’ Infoline Telephone Health Coaching Program also utilises the Health Coaching
Australia model. All of the health coaches have been trained in the model. Clients are referred from
General Practitioners and Allied Health Professionals. Upon referral, the health coach works with the
client over the phone for 6 months. Follow up calls are scheduled 1, 2, 4 and 6 months after the initial
call. A report is sent to the referrer after 2 months and 6 months. The support of the health coaches has
resulted in client progress in the areas of; decreased portion sizes, increased water intake, increased
energy levels, reduction of sedentary behaviour and reduced energy consumption.

The Health Coaching Australia principles can be used in a variety of different settings. The effectiveness
of individuals changing their behaviour is very dependent on the readiness of the client, barriers, the
clients’ thought processes, confidence, and the reality of changing the behaviour. The health coaching
principles focus on goal setting and behaviour strategies for behaviour change to occur. The health
coach does not tell the client how to change their behaviour- it is about the client adopting the principles
to make the changes themselves.

1. Beverley A Lawton, Sally B Rose, C Raina Elley, Anthony C Dowell, Anna Fenton, Simon A Moyes.
Exercise on prescription for women aged 40-74 recruited through primary care: two year randomised
controlled trial. Biomedical Journal December 2008.

2. Elizabeth G. Eakin a, Marina M. Reeves a, Sheleigh P. Lawler a, Brian Oldenburg b,
Chris Del Mar c, Ken Wilkie d, Adele Spencer a, Diana Battistutta e, Nicholas Graves. The Logan
Healthy Living Program: A cluster randomized trial of a telephone-delivered physical activity and dietary
behavior intervention for primary care patients with type 2 diabetes or hypertension from a socially
disadvantaged community—Rationale, design and recruitment. Science Direct October 2007.

3. Catherine B Lombard, Amanda A Deeks, Kylie Ball, Damien Jolley and Helena J Teede. Weight,
physical activity and dietary behavior change in young mothers: short term results of the HeLP-her
cluster randomized controlled trial. Nutrition Journal May 2009.

Zurich Heart Foundation Heart Health Index, Meida release 15 October, 2008. Available from:

Health behaviour change: Eating habits and physical activity, The Australian
Psychological Society, 2007

National Psychology Week (NPW) survey investigated two aspects of health behaviour: eating habits
and physical exercise. An online survey was developed to gain information on the process individuals
undertake when making changes to eating habits and physical activity, their level of success in making
and maintaining changes and the strategies they adopt. The survey results highlight the difficulties
individuals experience in making and maintaining behaviour change. The findings also demonstrate the
under-utilisation of psychologists to assist in this process. The important contribution that psychologists
can make in lifestyle change appears to be overlooked or not well understood by the community. There
is a need to promote recognition of the role of psychologists in the physical health domain.

Understanding successful behaviour change: the role of intentions, attitudes to the
target and motivations and the example of diet- OPEN ACCESS, Health Education
Research, 2007

The study aimed to assess differences between different types of changes in eating behaviour and to
evaluate the best predictors of successful behaviour change with a focus on behavioural intentions,
attitude to the target and motivations.

Stages of Change for Healthy Eating in Diabetes- Relation to demographic, eating-
related, health care utilization, and psychosocial factors- OPEN ACCESS, Epidemiology/
Health Services, Psychosocial Research, 2003

The study identified diabetes-related characteristics of individuals at different stages of readiness to
change to healthy and low-fat eating. This data validates the Transtheoretical Model, where those in the
action stages displayed healthier eating. They also indicate that demographic and psychosocial factors
may mediate readiness to change diet. Pre-contemplators were a heterogeneous group and may need
individually tailored interventions.

Low-income groups and behaviour change interventions: a review of intervention
content, effectiveness and theoretical frameworks, Epidemiology and Community Health,

Interventions to change health-related behaviours have the potential to increase health inequalities. This
review investigated the effectiveness of interventions targeting low-income groups to reduce smoking or
increase physical activity and/or healthy eating. This review shows that behaviour change interventions,
particularly those with fewer techniques, can be effective in low-income groups, but highlights the lack of
evidence to draw on in informing the design of interventions for disadvantaged groups.

The Good Life Club project, Telephone coaching for chronic disease self management,
Australian Family Physician, 2005

The Good Life Club project was a 3 year demonstration project funded by the Commonwealth
Department of Health and Ageing (DOHA). The project utilised a number of interventions to support

people with diabetes to improve self management of their condition and to effectively utilise existing local
health services. This project has given good evidence for positive outcomes for this type of intervention.