Self-Management: A Key Component of Behavior Change

“Several years ago, I went to my PCP for a routine physical exam. I showed up ten minutes early for my appointment, waited twenty minutes in the waiting room, and finished my visit in under 20 minutes. A nursing assistant guided me to my room and began assessing my vitals, then asked me a few questions about my medical history while typing away on the computer. The assistant left the room while I waited, reading about the next best diet on the cover of some magazine. Ten minutes later, a NP (nurse practitioner), whom I’ve never met, came into the room, introduced herself, and began my assessment and physical exam. While reviewing my test results, she stated my blood pressure was elevated in addition to my triglycerides, and “bad cholesterol”. She stated I was considered overweight according to the BMI chart, that I should lose 10-15 pounds, and exercise more. But, overall, I was in “good health” and needed to “eat better and exercise”. I went home with a few printouts from the administrator’s desk on “blood pressure and cholesterol management”, and no real sense of urgency to do anything about it. Days later, the printouts were no longer to be found, and I went on with my usual daily activities.”

You may have heard of a similar story, or maybe you’ve been in a similar situation at some point in your life. Nowadays, I continue to notice similar situations and patterns while visiting specialists and doctors. Several years later, I began to realize that there have been a few patient care gaps embedded within my visits over the years. There was one specifically on that day that stood out to me: self-management and prevention. For purposes of this blog, I’m going to unpackage the strategy of self-management, in the treatment and prevention of common health conditions, and discuss how behavior analysts could make an impact on the health and well-being of others by bringing our science, knowledge, and skills into our healthcare systems and helping to bridge the gaps between healthcare providers (HCPs), patients, and other preventive healthcare programs.

Self-Management Defined. While researching self-management, I came across a few conceptualizations and definitions across resources and journal articles, and here’s what I found:

“Self-management is the personal application of behavior change tactics that produces a desired change in behavior” (Cooper, Heron, & Heward, 2007, p. 578)

“Management of or by oneself; the taking of responsibility for one's own behavior and well-being.” (Oxford Dictionary Online)

“An individual’s ability to manage the symptoms, treatment, physical and psychosocial consequences and lifestyle changes inherent with living with a chronic condition” (Sadler, Wolfe, & McKevitt, 2014)

“Self-management is defined as the day-to-day management of chronic conditions by individuals over the course of an illness” (Clark, Becker, Janz, Lorig, Rakaowski, & Anderson, 1991)

“Self-management has been described and considered for more than 40 years with the term first used by Thomas Creer to suggest that patients are active participants in their own treatments” (Lorig & Holman, 2003)

In summary, self-management is a skill or behavior that is carried out; in order to change a specific behavior and, achieve a specific goal or outcome. Self-management includes observing and recording one’s own behavior. A few examples of this strategy as it relates to my story above include:

1. Planning healthy meals for the week. This reduces temptation of going out to eat several times per week and/or eating foods that may not contain proper nutrition.
2. Setting alarms on my phone every hour to take a 10 to 15-minute walk. This increases the amount of physical movement I engage in throughout the day and reduces sedentary behavior.
3. Blocking out 3 to 5 hours a week to focus on resistance training. This allows me to prioritize a specific exercise regime, that helps me maintain muscle mass.

Below are three graphs displaying self-management behaviors I’ve tracked and integrated over the course of July and August, and over several months, including: sleeping at least 8 hours per night, achieving movement/exercise/stand goals, and logging food and weight trends. All data were gathered from my smartphone and MyFitnessPal app.

Below is a bar graph exhibiting my powerlifting meet results and 1 rep maxes over the course of 2 years with no formal programming and with formal programming.

Below is a line graph illustrating personal blood lipid panels while incorporating self-management of health behaviors over an eight-year span:

Below are other examples of health behaviors targeted for change and examples of corresponding self-management behaviors:

While some individuals experience serious and chronic health conditions, there may be opportunities to self-manage at least some aspect of their well-being. For example, if an individual is suffering from early onset dementia, that individual could self-manage by seeking outside support from a home health aide or writing a daily “to-do” checklist that needs to be accomplished each day or joining a local gym to incorporate exercise as a daily therapeutic activity. A second example could be someone who is suffering from a chronic disease or cancer. This individual, or their caregiver, could seek out support from the community, church, or hospital. They could also self-manage some negative side effects by engaging in activities that have purpose and meaning to them if they are able to do so.

Although self-management appears to be self-explanatory and/or a simple concept, there are several competing behaviors, motivations, beliefs, and/or environmental factors that could potentially become a barrier to the self-management of one’s own health, as shown in the Table 1 below from Green-Shulman, Jaser, Chorong, & Whittemore (2016):

An example of a barrier to self-management is our belief system. Our core values, principles, and knowledge, may need to be addressed before self-management can be implemented. For instance, an individual may have the belief that they must eat the food that is part of their culture and heritage, however, the food that the individual is consuming on a consistent basis is highly correlated with their health symptoms, such as type 2 diabetes and high blood pressure. It could be that they don’t understand or have the knowledge of their health conditions or ways to prevent them, or they’re completely unaware of the short and long-term consequences of their eating habits. The individual may think it would be too difficult to change their dietary habits because of what other people in their community might think, do, or say about them, or because their environment doesn’t support it. Another barrier could be that an individual’s home or work life isn’t conducive to their health and well-being. For instance, working long hours in a sedentary job, or having constant non-nutritious food temptations around the home or office, or not having enough time to exercise because of other priorities an individual considers to be more important.

Another example from Shulman-Green et al. (2016) is access to resources. Individuals may not have financial, social, or physical resources to support self-management of health behaviors. For example, individuals may lack access to nutritious foods or the money to afford a healthy meal, or they may not be able to afford health insurance and premiums to get access to the preventive care that they need. As you may notice, self-management of one’s health is significant, and weaves in many aspects of an individual’s life. Going back to my example in the introduction, not only was I ignoring the short and long-term consequences of my health behaviors, I also wasn’t really aware of my conditions or thought they were truly significant at the time. Nor was I even contemplating doing anything about them, as my priorities were elsewhere, and my competing behaviors were more positively reinforcing at the time. For instance, I worked many hours in restaurants and ate mostly “restaurant food”, I used to drink alcohol every weekend. I went out to eat more frequently, my social life involved a lot of drinking and smoking cigarettes, and I stayed up late to study and used food to cope with stress. At that point in time, I believed that a lot of exercise and skipping meals was going to resolve my health issues. I had a hard time accepting that I had some level of self-control with regards to managing my own health.

Where does behavior analysis fit into all this?

Imagine a world where BCBAs collaborated with all health care professionals, on which we all put our heads together to help improve the lives of others. I believe BCBAs can have a large impact on the quality of patient care. BCBAs can bring awareness and understanding of our science to other health care professionals, help problem solve patient barriers, derive potential solutions for health behavior change, and provide evidenced-based behavioral treatments or treatment packages in alliance with HCPs and other clinicians within a patient care model. BCBAs can help develop and test new behavioral theories or methodologies for treatment and/or prevention of chronic illness, or even help build new treatments models in health care prevention. BCBAs can assess the function of behaviors, assess the conditions under which behaviors occur, assess risks and benefits, identify areas of need, and develop care plans alongside individuals to teach and help them manage an independent and healthy lifestyle. The future is bright, and I know we still have a long way to go. But I truly believe we can make an impact on a granular level, and potentially, on a much larger scale down the road.

References

Clark, N.M., Becker, M.H., Janz, N.K., Lorig, K., Rakowski, W., & Anderson, L. (1991). Self- management of chronic disease by older adults: a review and questions for research. Journal of Aging and Health, 3(1):3–27. Doi: 10.1177%2F089826439100300101

Cooper, J. O, Heron, T. E, & Heward, W. L. (2007). Applied Behavior Analysis (2nd ed.) Upper Saddle River, NJ: Pearson.

Green-Schulman, D., Jaser, S., Chorong, P., & Whittemore, R. (2016). A Metasynthesis of Factors Affecting Self-Management of Chronic Illness. Journal of Advanced Nursing, 72(7): 1469-1489. doi: 10.111/jan.12902

Lorig, K.R., & Holman, H. (2003). Self-Management Education: History, Definition, Outcomes, and Mechanisms. Society of Behavioral Medicine, 26(1):1-7.

Sadler, E., Wolfe, C.DA., & McKevitt, C. (2014). Lay and health care professional understanding of self-management: A systematic review and narrative synthesis. SAGE Open Medicine, 2: 2050312114544493. doi: 10.1177/2050312114544493

https://en.oxforddictionaries.com/definition/us/self-management

AUTHOR BIO: Tanya Wareck, BCBA, LABA, CPT, Pn1 has over 7 years of experience supporting children with developmental disabilities and autism in home-based, school-based, and community-based settings. Tanya’s passion for health and wellness began as a young adult, and since then, her vision has been to help improve the lives of others through lifestyle behavior change. Tanya is currently a Behavior Coach at Transform Alliance for Health where she works in preventive care and management of metabolic diseases. Tanya is also the creator of Behavior For Change, a health and fitness coaching company.