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896 PA R T V / Health Promotion and Disease Prevention
may be more adherent with a short-term prescription. 123 More- if they are sufficiently advantageous to sustain the behavior. If the
over, medication nonadherence has been associated with the lim- person shares this perception, the decision to persist with the new
ited availability of reimbursement after exceeding the cap amount behavior depends on the person’s perceived satisfaction with the
among Medicare beneficiaries; this system-related restraint can new behaviors’ outcomes, for example, fewer symptoms due to
lead to poorer adherence. 124 improved medication adherence, being less fatigued after weight
loss. Thus, if the individual’s experiences do not meet those ex-
pectations, they will be dissatisfied and less motivated to sustain
MODELS OF BEHAVIOR CHANGE the behavior. From a practical perspective, if the person has high
expectations of the outcomes of an intervention, the person will
Improving adherence to treatment regimens remains one of the be motivated to initiate change; however, if those expected out-
greatest challenges facing health care professionals. Various mod- comes are not fulfilled, the dissatisfaction will undermine mainte-
els of behavior change have guided studies examining the factors nance of the new adherence behavior. Thus, maintenance requires
that influence adherence and also trials that have tested interven- an environment that is supportive of healthy choices. Implemen-
tions. Earlier models included operant learning, which focused on tation of several strategies can reinforce behavior change and
the environment and used stimulus control strategies to restructure maintenance.
the environment. More recently, cognitive-motivational models Based on research guided by the models of behavior change, a
have focused on beliefs, intentions, self-efficacy, self-regulation, list of strategies for use in assisting patients to improve and main-
and readiness to change. Intervention strategies used in the car- tain adherence to behavior change follows.
diac population have frequently been guided by social cognitive
theory, which is based on an underlying assumption that behav-
ior, the environment, and cognition function as interacting deter- ADHERENCE-ENHANCING
minants with a bidirectional influence on each other. 125 Using the STRATEGIES
cognitive-motivational models, studies have examined the influ-
ence of health beliefs, intentions, illness perception, and barriers Goal Setting
to adherence. Since these constructs explained little variance of
behavior change related to adherence, additional constructs such Mastery performance, the strongest source of self-efficacy, centers on
as self-efficacy were added to the models, which have increased the goal achievement. According to Kanfer’s model of self-regulation,
explained variance in behaviors. learning and maintaining the behavior are enhanced by self-control.
Self-efficacy is described as the perception of one’s abilities to Self-control is also the mechanism by which the control of behavior
mobilize the motivation, cognitive resources, and courses of action is shifted from external sources to that maintained by the individ-
required to meet given situational demands. 126 Thus, it is con- ual. 130,131 Self-control operates through self-observation, specifying
cerned not with a person’s skills, but with the person’s judgments of an unambiguous goal, criteria for performance, and a procedure
what he or she can do with those skills. Self-efficacy is behavior spe- for evaluating the performance or behavior against the criteria,
cific, that is, a person may feel highly efficacious in one behavior do- and self-reward. Goal setting appears to be the most important
main (eating healthy) but have low self-efficacy in another domain consideration in achieving self-control. Goal setting entails work-
(exercising). There are four sources of efficacy: (1) mastery per- ing with the patient in developing realistic and attainable goals
formance—the most powerful source comes from achievement of a that are specific in terms of the expected outcome and proximal in
series of subgoals, (2) modeling or vicarious learning—observing terms of achievement. Goals that are unrealistic or too difficult for
another person perform a task, (3) physiologic cues—making infer- the patient will not be tried while those that are vague or too easy
ences from autonomic arousal or other symptoms, and (4) verbal or will be ignored. The goal, which should be developed in collabo-
social persuasion—convincing others they possess the capability to ration with the provider, needs to include what will be done,
achieve their goals. 125 These sources have implications for the ap- when, and how: for example, “will walk for 15 minutes three
plication of self-efficacy based interventions. Outcome expectancy, times a week for the next 2 weeks.” As each subgoal is reached, the
one’s perception of whether actually performing the behavior will duration, frequency, or intensity of the next goal is increased, and
lead to the desired outcome, represents the second component of reinforcement is provided for the achievement, which leads to
the self-efficacy construct. 126 mastery and enhanced self-efficacy. 125 It is recommended that
Sustained adherence to medication taking and lifestyle changes goals focus on behaviors, which are under the control of the indi-
can lead to reduced morbidity and mortality; however, the rates of vidual, rather than on physiological outcomes that can be influ-
improved adherence that result from interventions are often not enced by several factors, for example, setting a goal for reducing fat
translated into maintenance. 127,128 Adoption and maintenance of in the diet by 5% rather than targeting an LDL cholesterol level.
new behaviors pose challenges for most individuals. Because the In order to change behaviors, individuals need to pay adequate at-
beneficial effects of adherence to risk reduction strategies are not tention to their own actions, as well as the conditions under which
realized immediately, long-term adherence is essential. they occur and their immediate and long-term effects. 130 There-
The psychological factors that enable individuals to adopt new fore, successful self-regulation depends in part on the fidelity, con-
behaviors are not necessarily the same as those that enable one to sistency, and temporal proximity of self-monitoring one’s behavior.
persist for the long term. 129 An individual’s assessment of the ben-
efits of initiating behavior change that would improve adherence Self-Monitoring
needs to compare favorably to their current situation; moreover, the
person needs to have favorable expectancies regarding future out- A key technique in approaches to behavioral change, self-monitor-
comes. 129 However, a person’s decision to maintain that behavior is ing requires the patient to record behavior (e.g., eating, exercise,
influenced by the outcomes associated with the new behaviors and smoking behaviors, or medication taking) and use this information