Behavior Modification - Lessons from Bandura and a Soccer Coach!


  1. Fun Theory
  2. Abstract - such interventions don't produce lasting impact
  3. Problem of Chronic Disease
  4. Bandura's self efficacy model
  5. Wisdom from a soccer coach
  6. My Take Aways
  7. Example of a Google Form (try it out and see summary responses)

Fun and Behavior change:
This is a great video about how making something fun and arousing curiosity can lead to change in behavior.

Can it really be this easy?  Will it lead to a sustained behavior change?

Recently read an abstract on use of information technology to motivate our youths to increase their physical exercise.
Computer- and web-based interventions to increase preadolescent and adolescent physical activity: a systematic review. Journal of Advanced Nursing 67(2), 251-268.  Although most interventions demonstrated statistically significant increases in physical activity or positive health changes related to physical activity, findings were small or short-lived .Conclusion.  Computer- and web-based interventions can promote physical activity among preadolescents and adolescents, particularly in schools. However, further efforts are needed to sustain positive changes.

Chronic disease and behavior change:
Majority of the chronic disease burden in the US (and elsewhere) can be attributed to our lifestyles.  What we eat and how much we exercise (or don't exercise) affects our bodies, leading to obesity, diabetes, high cholesterol and heart disease.

Most of our patients know this quite well but both we and our patients find it difficult to change our lifestyles.  The question is why?  There are many possible reasons, some of them being:

  1. We don't believe these bad things will happen to us, even though they happen to everyone else.
  2. But even after we get one of these conditions, we find it difficult to change our lifestyles. This may be due to:
    • Difficulty in changing our environment - when we change our lifestyle it impacts our families
    • Depression or other mental states
    • Lack of good information on what we have to do
    • The required change is too boring, repetitive etc.
    • Lack of motivation
    • Lack of self-efficacy (our personal belief that we can attain a goal)

These last 2 points are closely linked together.  Take a person who needs to lose weight to improve his diabetes control.  He is motivated to lose weight, but does not take the necessary steps because he perceives them as too difficult and the goal seems unachievable.  If all it took to lose weight was to push a button, everyone would do it.  Thus lack of motivation really is a lack of self-efficacy, the feeling that it is pointless to start something as it is bound to lead to failure.

Lessons from Bandura
Albert Bandura in 1977 wrote the seminal paper on Self-Efficacy; "Self-efficacy: toward a unifying theory of behavioral change".  He describes the relationship of one's beliefs to one's expectations and describes 2 types of expectations that impact behavior change.  Going back to our patient with diabetes, he may believe that he can walk for 20 minutes every day but he may not believe that this will lead to his sugar control getting much better (his glycosylated hemoglobin will not come down from 9.0 to 7.0 by doing this).  This belief model will prevent him from starting to exercise.

We tell our patients, "Your HbA1c should be less than 7.0, your LDL should be less than 100, your systolic blood pressure should be less than 130.  If you get down to your ideal body weight and stop eating all the bad things you eat, and start exercising 40 minutes 3-4 times a week, you will get there.  Otherwise we will need to start medications". They return in 3-4 months and have not made any progress.

As physicians we see this all the time and get frustrated when our patients (some of whom are also physicians) do not "comply" with our recommendations.  So what can we do?  Are we fighting a losing battle?  Have we already lost the war?

Lessons from a soccer coach
I got some hope recently talking to my daughter's soccer coach.  One of the drills that all aspiring soccer players need to do is juggling the soccer ball.  This essentially means being able to move the ball from one foot to the other without letting it touch the floor/ground.  Good players should be able to do this over 100 times quite easily.  For a young player new to the sport this is a daunting task.  Doing it even 5 times is an achievement.  Progress is very slow and it can take months to years before a player can juggle 50-100 times.  As one can imagine, young players would get quite frustrated and give up.  So I asked my daughter's coach how he motivates his players to do this.

He said,"I don't tell them to try and get to a hundred.  I ask them to count the number of times it takes to get to a hundred.  Then I ask them to keep a log of this number".  This made intuitive sense and then I realized what he was doing.  He was changing the goal.  He was taking away the unrealistic (outcome) expectations of  reaching a goal of 100 without dropping the ball.  There was no risk of failure.  The goal was "can you juggle the ball and keep track of a number" not "can you juggle the ball 100 times".  Inherent in this model, is the knowledge that if the player keeps juggling, he will get better and will see that progress on his log.  This will serve as a self-motivator.
Another concept that is built into this is what my chairman always likes to say, "Don't let perfect be the enemy of the good".

So what are the lessons for us when helping our patients and ourselves?  Let me list these again with the example of our sedentary friend with diabetes in mind:

  • Make the goal a process not an outcome.  Tell our patient to keep track of how many days he actually spends time walking for exercise.  Don't tell him that the goal is to lose 12 pounds in the next 3 months.
  • Next ask him to calculate how many weeks it takes him to achieve 15 days of walking e.g. if he walks every other day, it will take him 30 days to reach this goal.  
  • Next ask him to wear a pedometer and see how many days it takes to reach 50,000 steps.  Don't tell him to walk 10,000 steps a day.  
  • Make the walking more fun or interesting (if possible).  On a treadmill, get an iPad and watch Ted Talks while walking with some Pandora to break up the monotony.  
  • Have the patient create a Google spreadsheet and a form what he can enter this data from any computer.  It would look something like the one below.  The patient can share the spreadsheet with you (the physician) and send you an email every time he gets to 10 days of walking or 50 K steps.  
  • After an appropriate period of using this, you could go up one level e.g. # of days in a month that you walked more than 3 miles or # of days you walked more than 5,000 steps.  
  • When it seems like there has been a substantial consistent change in behavior check some parameters that will provide feedback to patient that he is making progress with his diabetes and obesity.  This will serve to improve the chance of sustaining the behavior modification.

My love-hate relationship with the iPad

I have had the iPad for over 6 months now and have given it sufficient time to get over any preconceived notions.  I really had some pretty strong feelings about the iPad after I had used it for about 24 hours. I have used it a lot more since then, and here I some impressions:

Top 5 things I love about the iPad

  1. It is the perfect size to watch Ted Talks while walking on the treadmill.  
  2. Its instant start and screen size make it perfect to check (and READ) e-mail or Facebook - the pinch/zoom function helps for small print
  3. Its brightness makes it easy to read an e-book or catch up on the news at night without a night light
  4. Don't have to worry about finding a movie that both my wife and I would like.  She can watch one on the TV and I can watch one on NetFlix (with ear plugs) on the iPad sitting side by side!
  5. When turned off, the super reflective screen serves a double purpose as a mirror.  Of course that assumes you wiped off your grimy fingerprints first.  But if it is squeaky clean, it will cause blinding reflections from every light source.  So you have to learn to get it just right!
Top 5 things I hate about the iPad
  1. The on screen keyboard does make typing a pain.  This is particularly a problem when writing a lot of text e.g. OK for Twitter but not for blogs.  Also having to put the device so it is comfortable to type with both hands means you have to crane your neck to read what you are typing - definitely not ergonomic.
  2. The lack of support for multiple user accounts makes it difficult to share the device.  Typing in passwords into multiple sites is a pain especially if you use complex passwords.  So you would set the iPad to remember your passwords.  You would set the device to prompt you for a password on start up.  So if a friend wants to play with your iPad you have to wipe out all your passwords.  
  3. The lack of flash support is a disaster - recently watching the state of the union address, I wanted to check out the viewer reactions to the speech in realtime on CNN.  Had to use my laptop as the CNN polling app is Flash.  Wanted to check Google analytics - I could not change the date range or view the graphs as that is in Flash.  Wanted to use Scottrade - same problem. 
  4. The failure to provide any SD card or USB ports is a mistake - does not need any explanation. 
  5. The lack of a built in handwriting/stylus tool and handwriting recognition.  The device is perfect for jotting down notes with some diagrams, for brainstorming, for thinking "aloud".  Need a OneNote for the iPad and stylus support.