| HOME | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|---|
| ||||||||||||||||||||||||||||||||
Correspondence: Address correspondence to David Haber, Ball State University, Fisher Institute for Wellness and Gerontology, Muncie, IN 47306. E-mail: dhaber{at}bsu.edu
 |
Abstract |
|---|
 TOP Abstract MethodsFive ComponentsResultsDiscussionReferences |
|---|
Key Words: Exercise promotion; Social • behavioral • and cognitive management; Health educators
The health-contract technique is guided by social cognitive theory (Bandura, 1986; 1997; Glanz, Lewis, & Rimer, 1997), which attempts to explain why people will behave in a certain way. This theory has evolved over several decades (Bandura, 1977; Miller & Dollard, 1941; Rodin, 1986; Rotter, 1954) and now incorporates a broad array of behavioral, cognitive, social, and environmental components of behavior change. Social cognitive theory is frequently applied to interventions aimed at behavior change. Examples of behavior-change strategies that emanate from this theory are (a) helping clients set gradated goals in order to develop skill mastery; (b) empowering clients to choose from among several practicable options; and (c) encouraging clients to monitor their progress through record keeping. These and other techniques are designed to help clients increase their self-efficacy, that is, their confidence to perform a recommended behavior. The multiple strategies elicited by social cognitive theory can be incorporated into the single technique referred to as a health contract.
There have been multiple versions of health contracts, and they have focused on an array of health behaviors, such as exercise, nutrition, smoking cessation, and drug and alcohol addiction (Clark, Leukefeld, & Godlaski, 1999; Cupples & Steslow, 2001; Jette et al., 1999; Johnson, Nicklas, Arbeit, Webber, & Berenson, 1992; Leslie & Schuster, 1991; Moore, Von Korff, Cherkin, Saunders, & Lorig, 2000; Neale, 1991; Schlenk & Boehm, 1998; Swinburn, Walter, Arroll, Tilyard, & Russell, 1998). One version of this technique—a health contract and calendar—has been refined over several years. This type of contract includes an accompanying calendar on which contracted health behaviors are recorded on specific days of the week and are then compared with behaviors actually performed in order to produce a success rate at the end of a month.
Previous evaluations of the health contract and calendar technique (Haber, 1993; 2001; Haber & Looney, 2000) did not examine which components of the health contract and calendar contributed to client success. In this article we focus on the latest version of the health contract and calendar, and its five main components: motivation, goal setting, social support, memory techniques, and problem solving. Our primary goals in this pilot study are to (a) report on the success rate of 25 sedentary older adults seeking to improve their physical activity or exercise level, and (b) examine the responses of these older adults to questions about how each of the five components of the health contract and calendar might have been helpful to them.
|
Methods |
|---|
|
TOPAbstractMethodsFive ComponentsResultsDiscussionReferences |
|---|
The eligible older adults who participated in this project received a health contract and calendar (Figures 1 and 2) that focused on increasing their physical activity or exercise. The older adults were guided through the completion of the health contract and calendar process by health educators who recorded the appropriate information in the different sections of the contract and the calendar.
|
|
Success was noted by the client on the health calendar with a checkmark on each day that a scheduled exercise behavior was performed in its entirety. The client added up checkmarks at the end of the week. The health educator calculated the percentage of success by dividing the number of exercise behaviors that the client reported he or she performed (the number to the left of the diagonal lines that the client recorded on the health calendar) by the number of exercise behaviors that were scheduled to be performed (recorded by the health educator at the beginning of the month to the right of the diagonal lines). If clients had aerobic and strength-building goals, they were asked at the beginning of the month to choose one goal on which to be evaluated.
Safety
Health educators administered exercise screening questions to each individual prior to his or her participation in this project. Examples of these questions are as follows: Has a doctor ever said that you have a heart condition, or a bone or joint problem, that could be made worse by physical activity? Do you know of any other reason, such as an injury, a balance problem, or any other medical condition that might prevent your participation in this program? Although medical consent by a personal physician was not required prior to participation, it was encouraged. Informed-consent forms were completed by the participants.
Health educators implemented additional safety procedures as follows.
Training and Implementation
The first author (D. Haber) created written materials that summarized each component of the health contract and calendar in order to guide a health educator who would be helping a client. For the training period for this project, the two health educators (the authors) used the health education materials to conduct three practice health contracts each. Each of the interviews was observed by the other health educator and discussed afterward to develop a standard protocol that both educators would follow. After the training interviews were completed, the two health educators divided the subsequent 25 interviews on a roughly equal basis (13 and 12). After one of the health educators completed the initial interview, the other health educator completed the follow-up evaluations with that same client. The purpose of switching health educators was to minimize socially desirable responses on the part of the clients. The rationale was that clients might be more willing to reveal failure to a health educator who did not help them with the health contract.
Completion of the health contract and calendar was done in person by the health educator; on average, it took the educator 70 min to complete both documents. The telephone call at the end of 1 week took about 5 min; the evaluation at the end of the month, which was done in person, about 50 min; and a follow-up interview by telephone 6 weeks later, about 10 min.
Evaluation Questions
The 1-month evaluation consisted of structured and open-ended questions about each component of the health contract. In addition, the health educators added up the checkmarks on the health calendar, and they calculated and discussed a percentage of success. At the 6-week telephone follow-up, they made an inquiry about the frequency, duration, and intensity level of exercise over the past week. Clients were then reminded about their exercise achievements during the final week of the first month of the health contract, and they were asked to comment on changes in their exercise routines over the past 6 weeks. Clients were then asked why they thought their exercise routines had stayed the same, decreased, or increased.
|
Five Components |
|---|
|
TOPAbstractMethodsFive ComponentsResultsDiscussionReferences |
|---|
Motivation
Participants were presented with a list of diseases (e.g., heart disease, stroke, osteoporosis, depression, diabetes, and colon cancer) and conditions (e.g., constipation, weight gain, low energy, insomnia, and weakness) that were positively affected by exercise (Haber, 2003) and that could be identified as possible sources of motivation for the older participant. Up to three sources of motivation that were most salient to the participant were identified through discussion and then listed on the health contract. Clients were encouraged, and given techniques, to bring the identified motivations into their consciousness on a daily basis.
Another technique to maximize motivation was to empower the client to choose the most desirable option from among six exercise and physical activity goals. First, a home-based aerobic exercise routine was adapted to the individual's physical capacity. The aerobic routine consisted of easy-to-remember movements that mimicked sports such as hiking, boxing, or swimming, or musical movements such as playing an instrument, leading a band, or doing dance steps. Participants typically had music playing in the background, and they exercised at a light to medium intensity level.
Second, a brisk walking routine was completed in the individual's neighborhood, with indoor community locations identified as backup locations during inclement weather.
Third, a strength-building routine used rubber exercise bands and an illustrated guide adapted to the individual's physical capacity, with exercises designed to avoid pain and discomfort. The intensity level was typically light for the first week or two, followed by a gradual increase in intensity level.
Fourth, a referral to a community exercise program was an option for those who wanted the support of a class and instructor and who were not impeded by cost or travel.
Fifth, other exercise options were considered if they were available to a participant. For instance, a person might have access to a stationary bicycle or to a swimming pool.
Sixth, a physical activity option was offered to those who did not like formal exercise. It consisted of identifying additional physical activity (e.g., extra walking or climbing steps) that could be incorporated into the daily routine.
Goal Setting
By empowering the client to choose an exercise priority from among several options, the health educators made goal setting part of the process of fostering motivation. However, it was also important that the goal that was set was modest and measurable. Given the sedentary lifestyle required for this project, the educators based the frequency, duration, and intensity level on the exercise pattern reported by the client over the previous week. For the most physically inactive people, a modest duration as brief as 10 min was recommended by the health educator, along with a light intensity level for the first week or two of the health contract.
To further encourage a modest goal among clients, the health educator set limits on the exercise goals in terms of frequency, duration, and intensity, even during the final week of the contract month. The health educator never set an exercise goal for more than 5 days per week, a half-hour per session, or a medium level of intensity. Although clients might have exceeded their exercise goal during a particular week, they were discouraged from expecting to exceed it or from becoming too ambitious and jeopardizing their safety.
The exercise goal of the client was also measurable, with specific guidelines for each client set by the health educator within a range of options: frequency (between 3 and 5 days of aerobics per week; 2–3 days of strength building); duration (10–30 min of aerobics per day; one to two sets, 10 to 15 repetitions, and four to eight strength-building exercises); and intensity (light to medium level). The exercise goal was gradated over the month, with an increase in intensity level and duration, but not necessarily frequency.
Social Support
In order to identify potentially supportive people, the health educators presented a list of categories to the client: spouse, child, sibling, parent, extended family member, pastor, friend, co-worker, neighbor, and teacher or instructor. If the client was willing, a support person(s) was chosen, along with the specific desired method of providing support, such as participating along with the client, providing reminders, or offering encouragement, praise, or advice. The client also established how often support was needed from the individual(s), and whether it was to be planned or spontaneous.
Clients who were willing to seek support from a second individual were encouraged to do so, and all individuals were encouraged to seek support from their physicians during their next scheduled visit. This support information was recorded on the health contract.
Memory Techniques
Clients reviewed a list of memory-enhancing techniques and selected strategies perceived to be helpful. Examples of such techniques were as follows: (a) attaching a health calendar to the refrigerator with a magnet that was provided to the clients; (b) leaving walking shoes in a visible place by the front door; (c) associating a new exercise behavior with an established activity, such as just before breakfast; (d) leaving the exercise rubber band on the coffee table or another highly visible location; or (e) creating other supportive environmental structures or memory cues. The selected technique(s) was recorded on the health contract.
Problem Solving
The client was asked to review additional potential sources of problems, such as negative thoughts, insufficient motivation, stress, pain, and fatigue. The participant identified additional obstacles by reviewing past attempts at behavior change, or by speculating on what might interfere with his or her effort over the coming month. Problem-solving strategies were then examined, and up to three sets of problems and solutions were recorded on the health contract.
|
Results |
|---|
|
TOPAbstractMethodsFive ComponentsResultsDiscussionReferences |
|---|
The remaining evaluation is focused on the health contract and the responses of the participants to questions about whether they found each of the five components to be helpful. A summary of responses to a few additional questions about the health contract or calendar are reported at the end of this section.
Motivation
In response to the question about whether the identification of at least one motivation—functional or disease oriented—on the health contract was helpful to them, 15 people reported that it was helpful to them in achieving their health goals. Regarding functional motivation, 18 people identified at least one motivation on their health contract. The most frequently identified functional motivation was a desire for increased energy (n = 9), followed by weight maintenance (n = 5), improved strength (n = 4), better balance (n = 3), and ability to be more active or independent (n = 3). Eleven of the 18 participants (61%) reported that the identification of a functional motivation was helpful. The individuals who stated that it was helpful also reported thinking about their motivation often or sometimes. The 7 people who did not find this technique helpful reported that they either did not think about their motivation or, if they did, it was not a factor in whether they followed through on their health goal. Regarding disease motivation, 13 people identified at least one motivation, with 7 participants (54%) reporting that the identification was helpful and the remainder stating that it was not. The most frequently identified disease motivations were heart disease (n = 6), arthritis (n = 5), blood pressure (n = 3), cholesterol or triglycerides (n = 3), and colon cancer (n = 3).
In addition to identifying motivations and recording them on the health contract, another way to maximize the motivation of clients was to give them an opportunity to choose from among several exercise and physical-activity options. The original intent of the health educators was to encourage the selection of one exercise goal from among several choices. However, a slight majority of individuals (n = 13) chose two exercise goals, with 9 individuals selecting both aerobic and strength-building goals. The most popular exercise selection was brisk walking in the neighborhood (n = 12). During inclement weather or for the purpose of variety, several participants reported that they did some of their walking in a shopping mall that encouraged mall walking by older adults. One person reported that she went to a nearby Wal-Mart.
Eight participants selected an individualized aerobic routine for inside the home. Six of these individuals reported that this remained their first choice for aerobic activity, but 2 participants wound up using this exercise modality as a backup to brisk walking when the weather was inclement.
Ten participants engaged in a strength-building routine by using the rubber exercise bands that were provided to them. The other exercise options that were selected were the use of a stationary bicycle in the home (n = 2), attending a community yoga class (n = 2), attending a community aerobic class (n = 1), swimming at a YMCA (n = 1), and riding a bicycle outdoors (n = 1).
Several people reported that they increased their physical activity—found more walking opportunities, climbed additional steps, or did their household cleaning with more intensity—which was one of the exercise options offered by the health educators. No one, however, identified this modality as his or her primary exercise goal on their health contract.
Goal Setting
All participants agreed to the intensity, duration, and frequency guidelines recommended to them by the health educators. Six participants, including 4 of the 7 individuals aged 80 and older, agreed to goals set at the lowest level of aerobic intensity (light), duration (10 min), and frequency (four times per week). Some of these individuals, however, exceeded their goals. The remaining 19 participants had higher initial goals set for them.
All 10 individuals who selected strength building as an exercise goal began at the minimum level of frequency (two times per week) and intensity (light). Duration varied (from four to eight exercises, one to two sets).
Social Support
Of the 21 participants who identified at least one support person on the health contract, the most likely individual selected was a friend (n = 8), followed by a spouse (n = 6), or another relative (n = 5). Fourteen participants reported that social support was helpful to them in achieving their goals, either through reminders to exercise, encouragement or praise, or, for two individuals, participation in brisk walking sessions. Seven people selected a support person and did not find this option helpful. Four individuals did not select a support person.
Several people reported on the quality of the social support, and comments ranged from "it was very helpful" to "it was disappointing." A typical remark from someone who found social support helpful was "my friend called me when he was supposed to and made sure that I was progressing toward my goal." A statement from someone who was disappointed with his support reported that his spouse made several comments to him such as "exercise is important, but right now honey it is more important that you do the dishes."
Enthusiasm for having selected a support person sometimes decreased over time, as noted by the person who found his spouse to be more interested in the dishes getting done than his exercise routine. Sometimes, however, enthusiasm increased over time. One person, for instance, did not want a support person and did not identify one for her health contract. Later on, however, she discovered an individual who was quite helpful with encouraging her to exercise and offering her helpful praise.
Memory Cues
There were 16 people who reported that at least one of the memory techniques was helpful to them; 9 participants reported that attaching the health calendar to their refrigerator with a magnet was an important way for them to remember to exercise. An additional 2 individuals reported that the calendar was in another visible location that helped them to remember to exercise.
Four people reported that they left their exercise band in a highly visible location such as the coffee table in the living room, and that this reminded them to exercise. One person reported that she left her walking shoes by the front door.
Six people reported that they associated their new exercise goal with an established habit and that this was a helpful cue. Established habits were (a) before or after breakfast, (b) before dinner, (c) before doing a crossword puzzle, and (d) during a specific television program. The person who watched television while exercising commented, "I liked doing my exercise while watching Regis. It made the time pass faster, and as soon as I saw Regis I knew I needed to start my exercise routine. And my friends already knew not to call me during that time."
Several individuals reported that their support person was helpful in reminding them to exercise, but no one reported that they relied primarily on a support person to remember to exercise.
No other memory techniques were reported.
A total of 19 people found at least one of three components of the health contract—motivation, social support, or memory cues—to be helpful to them in achieving their goals, and 9 people found all three techniques to be helpful (see Table 1).
|
Two people mentioned time as a potential barrier, and one of these individuals noted that "I'm busier now than when I was working full time, but most of my activities are of the sitting variety." Both respondents successfully dealt with this barrier by realizing that time was equivalent to motivation. In other words, one finds the time for the activities that one is the most motivated to do. One person mentioned stress as a barrier and specifically noted that "my husband's health is unpredictable and it is hard to concentrate on my own exercise needs." She was given a stress management routine of deep breathing. She did not follow through on this technique, and she was also not successful with her exercise goal.
One person reported that her balance was a problem, and she was successful in doing the exercises sitting down. Two people noted that negative thinking had sabotaged past efforts, and they were offered ideas on how to promote positive thinking. Both individuals were successful with achieving their health goals.
Another person expressed dismay at the way her several medications made her feel and she was encouraged to make a visit—which she did—to her primary care physician. The physician changed her blood pressure medications, which she claimed helped her to become more enthusiastic about exercising.
Miscellaneous
Only one person reported that the health goal was too easy; no one reported that it was too hard, and the remainder of the participants reported that it was just right. Only two individuals modified their health contracts when they were called after 1 week, and both modifications were minor. No one made suggestions to improve the schedule of calling after 1 week or visiting after 1 month. Several people at the 6-week follow-up, however, reported that they would have preferred regular follow-up support by the health educators after the month-long health contract was completed.
Among the 25 participants, 16 (64%) were very satisfied with the results of their health contract, 5 were somewhat satisfied (including 1 who dropped out before completing the contract), and 4 of the 5 who did the exercises sporadically or dropped out were not satisfied with the results of their health contract.
When asked what they found to be the most helpful aspect of the health contract and calendar technique, participants gave a wide range of answers. The most frequent response was along the lines of the discipline or structure that the technique provided them. Several participants commented that the calendar made it easy for them to remember, and that the checking-off process was the most satisfying aspect of the technique.
A few people reported that they liked having someone care about them, and they would have felt guilty letting the health educator down. Others reported how much they appreciated being actively involved in the process of setting the goal and identifying what they had to do to achieve it.
At the follow-up telephone call, 6 weeks after the month-long calendar was completed, 11 of the 20 participants who completed the health contract reported that they continued to exercise at the same level as, or greater than, the amount they were performing during the last week of their health contract.
|
Discussion |
|---|
|
TOPAbstractMethodsFive ComponentsResultsDiscussionReferences |
|---|
This finding is congruent with the literature on social cognitive theory. Dating back to the 1940s, dozens of theorists have contributed to the theory, which is why concepts as diverse as classical behaviorism (rewards and punishments) and role modeling are comfortably incorporated into it. In parallel fashion, the techniques that emerge from these concepts are diverse as well, and some may be more salient for particular clients but not others. Thus, one support person was appreciated for having served as a role model, another for having provided a reward (praise), and yet another was consistently ignored. For health educators or clinicians who want to adopt the health contract and calendar technique, it might be helpful to consider the following.
First, if time is an issue, the health educator might want to experiment with a shorter version of this technique—perhaps even leaving out a component—and observe how this affects the success rate. Conversely, the 1-month duration appears to be inadequate for sustaining success with some clients. Follow-up between 6 months and 1 year will likely produce better results (Dishman, 1982).
Second, additional support can be given to participants on the basis of site selection. Church leaders, for instance, can promote the project and provide follow-up support to congregation members. Clinicians can promote the project—though perhaps implemented more cost effectively under the direction of a trained staff person—and follow-up can be offered at subsequent patient visits (Haber & Looney, 2000).
Third, brisk walking had the most appeal among the participants of this study, and increasing physical activity in the course of the day had the least appeal as a primary exercise goal. Both modalities, however, might be enhanced for some clients by the use of a pedometer. This step-counting device is inexpensive and appears to motivate some people to take more steps during the course of the day (Rooney, Smalley, Larson, & Havens, 2003).
Fourth, specially printed health contracts and calendars may not be necessary. For those with limited resources, health contracts may be recorded on blank paper, and most participants have their own calendars for the recording of health behaviors.
It should be noted that the results from this project were based on self-reports. No confirming strategies were used, such as using a device to measure energy expenditure. Although we felt confident that we received reasonably accurate information based on the level of detail provided to us, self-reported data are a limitation of this study. In retrospect—and based on a reviewer's suggestion—confirmation of client self-report from a family member or a support person would have been more desirable than ignoring the problem.
Another limitation of the study was the absence of a control group. It is the rare study on health contracts that uses a control group (e.g., Oldridge & Jones, 1983), and this oversight ought to be rectified.
It is likely that the lack of contact by the health educators after the health contract was completed contributed to the declining success ratio. Several people, in fact, initiated the remark that continued support for at least several more months would have been helpful to them. To sustain the effort of participants over time, a summary of research on "tailored follow-up telephone calls" concluded that this technique can be effective (Soet & Basch, 1997).
Given the 80% success rate, there was a high "floor" effect that prevented us from assessing whether there were differences in outcomes between the two interviewers. The question of how much training is needed, and the content and format of the training in order to achieve successful results, remains unanswered.
The sample was small and unrepresentative and cannot be generalized. Nonetheless, this study has shed more light on how the health contract process works, and, combined with previous studies, confidence in the health-contract technique continues to build.
Conclusions
Our purpose in this project was to increase the exercise or physical activity of older participants and to gain more understanding of the process. It is up to future researchers, however, to manipulate the specific techniques in such a way as to offer additional insight to practitioners on which components of the health contract will work best for a particular person and why.
It is not clear whether a sophisticated research design can tease out this information. In the absence of this type of research, it appears that a technique that systematically reviews several behavioral, social, and cognitive strategies with clients may be an effective compromise and one that is reasonably time efficient. Participants have an opportunity to select the combination of techniques likely to work for them. Continued guidance and support for several months is likely to be crucial with sustaining the effort of these participants.
|
Footnotes |
|---|
Decision Editor: David E. Biegel, PhD
Received for publication August 8, 2003. Accepted for publication February 24, 2004.
|
References |
|---|
|
TOPAbstractMethodsFive ComponentsResultsDiscussionReferences |
|---|
This article has been cited by other articles:
 |
|
 |
|
  A. P. C. Weintraub and T. S. Killian Intergenerational Programming: Older Persons' Perceptions of Its Impact Journal of Applied Gerontology, August 1, 2007; 26(4): 370 - 384. [Abstract] [PDF]
|
|
| ||||||||||||||||||||||||||||||||
| HOME | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|---|
