This document discusses 10 elements of behavioral modification for cardiovascular risk factor reduction. It outlines strategies for facilitating behavior change, including tailoring education to individual patient needs and characteristics, recognizing that knowledge alone is insufficient for change, promoting self-efficacy and control, assessing readiness to change, setting SMART goals, promoting independence through self-monitoring, providing feedback and rewards, creating environmental cues, engaging social support, and serving as a role model. The goal is to design sustainable programs that meet patients where they are and empower them to successfully adopt and maintain new health behaviors.

1. CENTER FOR PHYSIOTHERAPYAND REHABILITATION SCIENCE
JAMIA MILLIA ISLAMIA
Topic: Elements of behavioural modification for cardiovascular risk factor reduction
Shagufa Amber
MPT-3rd Semester
Roll no.- 19MPC0006

2. Elements of behavioural modification for cardiovascular risk factor reduction
-The primary goal of patient education is to facilitate behavior change to improve health
outcomes.
-Changing health behaviors involves a process that alters how people think (cognitive factors such
as knowledge, attitudes, and beliefs related to the behavior) and feel (such as emotions, anxiety, or
depression).
-To promote long-term and sustainable behavior change, health professionals must be aware of
the meaning a target behavior has to a patient, the patient’s understanding of the benefits and
consequences of specific health-related activities, and how the patient evaluates the outcomes in
association with a change (socially, emotionally, physically, financially).

3. -The patients may be influenced by emotions that are associated with surviving a cardiac event
(depressive mood, anxiety, anger, fear), which may bias their ability to process information and to
successfully implement a behavior change program.
-It is critical that health professionals design risk factor modification programs to meet the cognitive
abilities and well-being of the patient, including an understanding of how patients view their behavior
as a part of their overall recovery and their role as an active participant in a CR program and the
behavior change process.
-The summary of principles and related practices integrate cross-cutting themes and concepts that
have been developed and tested extensively by health behavior scholars.
-The Transtheoretical Model (TTM), also known as Stages of Change, Protection Motivation Theory,
the Health Belief Model and the Theory of Reasoned Action Behaviour.

4. 1: Tailored and Individualized Approach
One size does not fit all when it comes to designing new educational or behavioral change programs
or selecting prepackaged materials that are well suited to individuals or groups. Risk reduction
strategies work best when key characteristics are relevant to readiness and change.
These characteristics include the following:
• Cognitive characteristics- existing knowledge of the disease process, ability to learn and the presence of
distractions to cognitive processing (such as fear, anxiety, hostility, and depressive symptoms).
• Behavioral characteristics- identifying risk behaviors to target, with consideration of the complexity and an
understanding of the consequences and outcomes associated with success and failure.
• Psychosocial characteristics- consider the sense of self-confidence to perform the behavior, including prior
experiences with the behavior and related successes or failures; readiness to change; limitations imposed by
illness such as functioning at work, at home, and in recreational activities; priorities; and values.
• Demographic characteristics- the influence of age, gender, education and literacy level, race-ethnicity,
culture, and linguistic differences.
• Environmental characteristics- these include the support of family, friends, social networks, and powerful
others; the involvement of health professionals and CR professional staff; and access to a quality risk factor
management program.

5. An optimal program of education and behavior modification is based on the following:
• Allocate resources for all modifiable risk factors.
• Develop plans for risk factor modification using current clinical practice methodologies.
• Train staff in health counseling skills.
• Employ a variety of strategies and materials that take into account the individual patient and family needs and
preferences, culture, and spiritual beliefs.
• Foster patient independence.
• Allocate resources to facilitate transition to full independence postdischarge.
• Evaluate the potential for social isolation prior to discharge from the hospital.
• Include written teaching plans and documentation of progress toward goals.
• Address smoking cessation immediately on an inpatient basis.
• Address all risk factors, disease processes, management of cardiac emergencies, maintenance of psychosocial
health, and adaptation to limitations on an outpatient basis.

6. 2: Recognize That Knowledge Is Necessary but Not Sufficient for Behavior Change
-It is critical for CR professionals to ensure that patients have the knowledge of behavioral factors
that increase their risk of a secondary event or procedure and ways to effectively prevent or reduce
that risk.
-Knowledge gain is a component of many health behavior change models. Patients must have
sufficient knowledge of health risks and benefits of different health practices.
Health professionals should prepare patients for outcomes associated with behavior change,
including:
• The physical effects a behavior is likely to produce (e.g., weight loss, functional improvements,
muscle soreness due to exertion)
• Social effects (approval or disapproval of significant or powerful others)
• Self-evaluative effects (self-satisfaction, selfesteem)

7. 3: Promote a Positive Sense of Self and the Personal Relevance of Risk Reduction
-The self-esteem and risk perception literature suggests that people tend to protect self-esteem under
conditions in which a negative outcome is regarded as controllable.
Acknowledgment of the role of high-risk behavior (e.g., smoking) in an adverse occurrence (e.g., a
heart attack) may threaten self-esteem.
-Attributing a negative outcome to a factor beyond personal control (e.g., heredity, age) poses no
threat to sense of self.
-Patients who undergo a surgical intervention, such as cardiovascular bypass graft surgery, may
believe that risk factor modification is not relevant to them because "the surgeon fixed me.
-During counseling patients about behavioral risk factors, it is advisable to avoid strategies that
threaten self-esteem; instead, emphasize the link between behavior and the personal relevance of risk
factor reduction and provide consistent, repeated verbal instructions and reinforcements of the need
for specific behavior changes.

8. 4: Promote Self-Efficacy and the Power of Control
It is critical to assess and to promote self-efficacy for successful behavior change.
Self-efficacy is the belief in one’s ability to exercise control
“Efficacy belief is the foundation of human motivation and action. Unless people believe they can
produce desired effects by their actions they have little incentive to act or to persevere in the face of
difficulties.”
-Patients must be encouraged to believe that changes in one or more behaviors will achieve the
desired outcomes and that they are able to implement the changes successfully. Experiencing success
in performing a particular behavior makes that behavior much easier to perform at a future time.
-Conversely, failures, can be barriers to beginning a behavior change program. It is crucial that CR
professionals inquire about previous experiences with specific behavior changes and address the
issues that led to past failures so that patients are guided through a problem-solving process.

9. 5: Promote Readiness to Change
The five categories are referred to as the stages of change and assessed in order to match a patient to stage-
appropriate behavior modification strategies:
• Precontemplation stage: There is no intention to change the behavior in the near future (usually defined as
within the next 6 months). Patients in this stage may believe that they do not have a problem or that the behavior
is not serious enough to warrant attention. They may lack understanding of the potential consequences of not
changing
• Contemplation stage: Patients are giving serious consideration to changing the health behavior within the
next 6 months. They are thinking but are indecisive and lack commitment to make a plan of action. In the
contemplation stage, interventions should be aimed at providing information in the form of written materials,
videotapes, and persuasive role models (such as graduates of the program, ideally of similar gender and age) that
can demonstrate the benefits of change (outweighing the costs). examples include a desire to engage in a
favorite recreational activity or to return to work, family, or social activities. In addition, at this stage a cost–
benefit analysis is often quite useful.
• Preparation stage: The person intends to act on the health behavior change in the immediate future, usually
within the next 30 days. Patients in this stage may make a plan of action and take small steps toward action, such
as talking to health professionals and seeking advice and trying out the new behavior (e.g., such as acquiring
low-fat diet recipes, joining a health club, quitting smoking for a day).

10. • Action stage: The patient has a plan and is in the act of changing the health behavior or has made specific
changes within the last 6 months or less. In order to qualify as action, the behavior must occur at a level that is
acceptable for optimal health benefits according to current knowledge and standards.
• Maintenance stage: The health behavior has been successfully maintained continuously for more than 6
months. For some behaviors, the maintenance stage is a lifelong struggle and not a discrete period of time.
• Lapse and relapse: It is important for health professionals to counsel their patients that experiencing a lapse (a
temporary slip, such as a discontinuation of a behavior) is a common and normal part of behavior change.
Lapsed behavior does not necessarily lead to relapse (a long-term discontinuation of the behavior). Patients who
lapse or relapse should be encouraged not to view this as a failure but rather as an opportunity to learn and try
new strategies.
One example is providing a telephone number to call, or a card with positive affirmation statements to read, that
prompts the patient not to let the lapse become a relapse. Stress is a common reason for lapse and relapse.
Finally, the patient should be encouraged to take ownership of and responsibility for his actions to promote the
maintenance of behavior change after program discharge and the ability to sustain it indefinitely. Family and
friends should be enlisted to provide social support outside the program to facilitate long-term adherence to
desired behavior changes.

11. 6: Set Goals to Promote a S.M.A.R.T.
Plan of Action Staff should encourage patients to set Specific, Measurable, Achievable, Realistic/Relevant,
and Time-framed (S.M.A.R.T.) goals for both the short-term and the long term. Risk reduction programs
should begin with goals that a patient strongly believes can (self-efficacy) and will (behavioral intent ) be put
into motion.
-As a part of this principle, it is important to assist patients to prioritize which behaviors they are willing to
change. Patients require counseling to identify and problem-solve potential obstacles and how they will cope
with temptations or make adjustments to promote the likelihood of success.
-Short-term goals focus on small incremental changes in behaviors that will break down larger skills and build
mastery for actions required to achieve the overall long-term goal.
Long-term goals are those that the immediate short-term goals are directed toward; the ultimate goal is
improvement in personal health through sustained risk factor modification and management.
-If despite achieving behavioral goals (e.g., improvement in intensity or duration of regular physical activity) a
patient continues to be unable to reach health outcomes (e.g., control of hypertension, achievement of weight
loss goal), the clinical team should work collaboratively to discuss a potential change in approach such as
adjustments in exercise prescription, pharmacotherapy, or both.

12. 7: Promote Independence Through Consciousness Raising and Self-Monitoring Skills
Skills and resources that help facilitate independence are critical to successful behavior change.
-Self-monitoring involves recording intrinsic feedback (feedback encountered as a natural consequence of
behavior) and extrinsic feedback (external feedback from health professionals and significant others) about
progress throughout the behavior change program.
Patients should be encouraged to self-monitor health behaviors with written records, logs, or diaries that record
health behaviors and feedback.
-Self monitoring can track compliance and provide feedback. Records to monitor progress should be simple to use
and readily accessible.
Encouraging patient independence during active participation in the program helps facilitate full independence from
the program after discharge.
-One way to accomplish this transition is for staff to e-mail or make telephone calls to discharged patients at
regular intervals (for example, every week for 1 month, every month for 3 months, and once at 12 months
postdischarge) to offer additional support and encouragement.

13. 8: Provide Routine Feedback and Rewards to Celebrate Success
-Provide patients with regular feedback that details progress toward goals. These progress reports
may include information related to their risk reduction goals, such as lipids, blood pressure, weight
and body composition measures, functional capacity, and other measures of cardiopulmonary
function.
-Trend graphs can be used to illustrate changes in performance over time (decrease, increase,
unchanged). Regular feedback is especially important to reinforce patients who have doubts about
self-efficacy and control over the change process, who may be at risk of lapse or relapse.
-Rewards (self-rewards as well as rewards by program staff) for achieving short- or long-term
goals are very important for reinforcing adherence to health behavior change. Rewards such as
a certificate of excellence or a T-shirt need not be expensive.

14. 9: Help Patients Create Positive Environmental Cues to Action
Cues that promote or remind patients of healthy behaviors and that reinforce healthful choices are
particularly helpful.
-Prompts can be as simple as a daily log on the refrigerator to track dietary intake, an
inspirational photograph (of a loved one such as a special family member or of the self at a
desired weight), or a motivating written expression in a place of prominence in the kitchen.
-In addition to helpful cues to prompt desired behaviors, patients may need support to (1) remove
cues for unhealthy behaviors from the environment (e.g., remove unhealthy foods from the kitchen,
throw out all tobacco products), (2) avoid challenging social situations (such as areas at work or other
gathering places where smoking is permitted), and (3) seek alternative environments that provide
support for healthy behaviors.

15. 10: Promote Helping Relationships and Engage Role Models
Staff can encourage social support by allowing spouses, other family members, or friends who are a positive
influence to participate in the program .
-Before enlisting the help of family or friends, health professionals are cautioned to take note of the relationship
between the significant others and the patient. Avoid placing patients in a situation in which reminders become
unpleasant “nagging” rather than positive reinforcement.
Developing a contract between a patient and another support person can help identify potential barriers the
patient may encounter.
-Patients learn about outcome expectations not only from personal experience but also from observation of
others, particularly those who are in a similar situation and to whom they relate. Peer role models such as guest
speakers or audiovisual recordings of patients who have been successful can be integrated into sessions
It is extremely important for program staff to model healthy behavior and to positively reinforce those behaviors
in patients.
-Staff should advise caution and should inform patients regarding websites that provide accurate patient
education information such as the American Heart Association (www.americanheart.org) and the Centers
for Disease Control and Prevention (www.cdc.gov).

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19. Thank you!