Assessment methods | homework help

Self-Monitoring: Influencing Effective Behavior Change in Your Clients,” article below
  Select a health behavior other than exercise.
Write a 1,200 word paper including the following:

Develop your own self-monitoring scale for this health behavior.
Explain how you would use this scale as an assessment tool in a behavioral health intervention.
Summarize three current behavioral assessment techniques.

 Include a minimum of three scholarly references. Use article below
 Format your paper consistent with APA guidelines.
Self-Monitoring: Influencing
 
 
 
Effective Behavior Change
 
in Your Clients
 
 
by Melissa Burgard, B.S., and Kara I. Gallagher, Ph.D., FACSM
Learning Objective
To understand how to effectively use self-monitoring to
 
assist clients with behavior change and improve client
 
outcomes.
 
 
Key words: Behavior Change, Self-Monitoring, Weight
 
 
 
Loss, Feedback, Clients.
 
 
Behavior change is a difficult process. As a health/
 
 
 
fitness professional, assisting clients with behavior
 
change can be particularly challenging because client
 
interaction is often limited. Many times, these meetings
 
are not sufficient to target both eating and exercise behaviors
 
and address the many barriers clients face. Because many
 
health behaviors need to be targeted outside of these
 
meetings, finding ways to track progress also is necessary
 
to successfully provide clients with appropriate feedback
 
and direction. Thus, teaching clients to self-monitor is
 
an effective strategy for targeting both eating and exercise
 
behavior change. Self-monitoring allows you to review
 
your clients’ current eating and exercise behaviors, identify
 
what needs to be modified so clients can reach their personal
 
health/fitness goals, and provide feedback.
 
By definition, self-monitoring is ‘‘the systematic
 
observation and recording of target behavior’’ (1) and
 
has been described as the most effective technique and
 
the ‘‘cornerstone’’ of behavioral treatments for weight loss
 
(2). Self-monitoring increases a client’s self-awareness, and
 
this has been shown to positively influence eating and
 
exercise behaviors (3). Several weight loss studies have
 
shown that the more consistent participants were at
 
self-monitoring and the more self-monitoring diaries were
 
completed, the greater was the weight loss (4–6). In a
 
review of studies, D.S. Kirschenbaum, Ph.D., determined
 
that consistency is best defined as recording at least 75%
 
of eating and exercise behaviors (7). This relationship
 
also has been found in high-risk situations. In a study
 
examining weight change during the holiday season, only
 
the most consistent self-monitors lost weight (8). Although
 
self-monitoring is considered to be a valuable tool for
 
behavior change, it does require the consideration of
 
several factors to be applied and used appropriately with
 
your clients.
 
Teaching your client to effectively and consistently
 
self-monitor is a process that is dependent upon the client’s
 
personality, goals, and knowledge regarding his or her
 
behavior. Taking individual differences into account, your
 
goal as the health/fitness professional should be to ‘‘help
 
clients be the best self-monitors they can be’’ (8). As a guide,
 
you can use the following ‘‘Four Ps of Self-Monitoring’’
 
to determine the best self-monitoring fit for your clients.
 
 
Purpose of Self-Monitoring
 
 
 
It is helpful to explain the benefits of self-monitoring to your
 
clients so they understand the value and importance it has
 
in promoting behavior change. Self-monitoring can lead to
 
self-awareness regarding behaviors and can help the client
 
regulate behavior more effectively by avoiding and coping
 
with situations that often lead to failure. Self-monitoring
 
records can help identify the specific nature of these situations
 
by answering questions of how, what, when, where, and why.
 
For example, self-monitoring can provide information
 
regarding specific details of client behavior such as:
 
 
How many calories do they eat?
 
How much activity do they perform?
 
 
 
Photo courtesy of Christopher R. Mohr
 
 
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JANUARY/FEBRUARY 2006 VOL. 10, NO. 1
 
 
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What type of foods do they eat?
 
What foods do they tend to overeat?
 
What time of day are they most likely to exercise?
 
What types of exercise do they enjoy?
 
When do they eat the majority of their calories?
 
When are they most likely to miss a planned exercise
 
 
 
session?
 
 
Where do they make poor food choices?
 
Where do they have opportunities for exercise?
 
Why do they miss exercise sessions?
 
Why do they want to lose weight or begin an exercise
 
 
 
program?
 
By addressing the specific details of clients’ behaviors
 
that occur outside of in-person sessions, you can better assist
 
them with recognizing patterns of behavior that may
 
impact progress.
 
 
Personalized Approach
 
 
 
What to Monitor
 
 
Once you have explained to the client the underlying
 
purpose and benefits of self-monitoring, the next step is
 
to decide with the client what behaviors to monitor in
 
order to best reach their health/fitness goals. It is essential
 
to keep in mind that this should not be a one-size-fits-all
 
approach. Take a personalized approach to tracking
 
client behavior that is based upon personality, environment,
 
and individual characteristics and goals. For example, for
 
clients who wish to lose weight, monitoring both eating
 
and exercise information is the best way to determine
 
if they are on track. For other clients, eating behaviors may
 
be related to stressful situations, and thus, feelings of
 
stress may be an additional variable you may want to
 
monitor to assist with weight loss.
 
Collecting baseline data is an important component
 
of self-monitoring because it provides you with an
 
understanding of what your clients are currently doing,
 
which behaviors require minor modification, and which
 
behaviors you may need to target more heavily. More
 
information is helpful, but it is not necessary to have clients
 
heavily self-monitor at the beginning of a program. Rather,
 
collecting a typical weekday and a typical weekend day of
 
information may be sufficient to capture a snapshot of
 
current behaviors. Once this information is collected, it is
 
beneficial to discuss these initial self-monitoring records with
 
your clients. This will allow you to identify what areas or
 
behaviors they find to be most troublesome and to gain
 
greater insight into how they believe these behaviors can
 
be changed.
 
 
Amount of Detail
 
 
Some clients may prefer to keep highly detailed
 
self-monitoring records that include, for example, date,
 
time, place, mood, description of food, quantity of food,
 
calories, grams of fat, and hunger level (Figure 1). Others
 
will simply want to record whether they made healthy
 
eating choices at each meal. In determining the amount of
 
detail your clients should use, pay careful attention to
 
clients’ attitudes regarding monitoring, personalities, and
 
time constraints. For some, more will be better, and this
 
will provide you with ample information to offer feedback
 
and direction; others may become overwhelmed and
 
disheartened by trying to attend to too many variables.
 
There are pros and cons to having clients provide a large
 
amount of detail regarding behaviors. For example, although
 
measuring body weight can tell you whether a client is on
 
track, it does not provide you with any information on eating
 
and exercise behaviors. This type of self-monitoring may
 
work for an individual who is successfully losing weight. On
 
the other hand, for the individual who is struggling with
 
changing his or her body weight, you have very little
 
information to determine what is impacting weight loss and
 
will be limited in the amount of feedback you can provide.
 
 
Figure 1. Example of detailed self-monitoring.
 
 
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Thus, you need to discuss the optimal approach that allows
 
them to easily self-monitor, while still adequately describing
 
the behaviors at hand.
 
Regardless of the amount of detail provided, the
 
variables being monitored should be closely tied to the target
 
behavior of interest. For clients interested in weight loss, these
 
variables would include total food intake (including type,
 
calories, and quantity), fat intake, and amount of exercise
 
performed (5). If a client is unable or unwilling to provide
 
this amount of detail, monitoring fewer variables will still
 
increase awareness and serve to direct his or her attention
 
toward the targeted behavior. Abbreviated measures still
 
allow the client to track the behaviors he or she is interested in
 
changing. In addition, it also allows the client to modify the
 
type of recording to suit his or her personality and lifestyle.
 
Figure 2 provides examples of abbreviated types of selfmonitoring
 
that are based upon individual likes and needs.
 
Looking at the examples, ‘‘Sarah’’ prefers to keep track of
 
total calories but does not want to do so in an obvious way;
 
she simply tallies calories consumed throughout the day in
 
the margin of her day planner. ‘‘Jim,’’ on the other hand,
 
prefers to have an overall picture of how well he is doing; he
 
keeps track of his behaviors on a monthly calendar he posts
 
above his desk. Allowing your clients to determine the
 
optimal way they would like to monitor their eating
 
and exercise behaviors will improve compliance to the
 
self-monitoring process.
 
 
Frequency of Monitoring
 
 
Another factor that requires a personalized approach
 
when prescribing self-monitoring is how frequently
 
clients should record behavior. Unfortunately, there is no
 
clear formula for the optimal frequency of self-monitoring;
 
this will depend upon the client’s schedule and ability to
 
monitor, as well as the targeted behavior, how frequently
 
it occurs, and the degree of difficulty the client has
 
experienced while trying to change the behavior in the past.
 
For example, eating behaviors are best monitored every
 
time they occur. A client who chooses to self-monitor his
 
or her eating behaviors only at night will likely underestimate
 
this information because it is difficult to remember exactly
 
what and how much was eaten throughout the day. In
 
addition, the self-awareness that occurs at such a late hour
 
will do little good because the client cannot modify the
 
eating plan for that day if needed.
 
In general, the more frequently your clients monitor
 
behavior, the better. Frequency of monitoring, however,
 
should also be determined by how frequently the behavior
 
may change. For someone interested in weight loss,
 
weighing more than once per week is not necessary. In fact,
 
frequent weighing throughout the day or week may lead
 
to unrealistic expectations about how quickly weight loss
 
should occur and can ultimately lead to frustration and
 
disappointment. By selecting an appropriate frequency
 
of monitoring for the behavior at hand and discussing
 
individual preferences with your clients, you can maximize
 
the consistency and effectiveness of self-monitoring.
 
 
Pinpoint Method of Monitoring
 
 
 
Once you have discussed which behaviors to monitor,
 
the degree of detail, and monitoring frequency, the final
 
step is determining how the client should monitor his or
 
her behavior. With the increasing availability of health/
 
fitness information to the consumer, there are a number
 
of self-monitoring methods from which you can choose.
 
These vary from basic pen and paper methods such as
 
sticky notes, diaries, or calendars to more advanced
 
technologies such as pedometers, personal desk assistants
 
(PDAs), MP3 players, cell phones, and the Internet.
 
The most important determinant in which self-monitoring
 
method to recommend is that it is one the client is
 
willing and able to use.
 
The Internet is one avenue of self-monitoring that
 
is becoming increasingly popular and may be a viable
 
option for many clients. Many commercial Web sites offer
 
some form of self-monitoring for eating and exercise
 
behaviors, and many of these are free of charge. Using the
 
Internet for self-monitoring will depend upon the
 
 
Figure 2. Examples of abbreviated self-monitoring.
 
 
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availability and technologic expertise of your clients, but it
 
does allow for frequent and relatively easy monitoring of
 
eating and exercise behaviors. You also can have clients send
 
you electronic copies of these records and easily track
 
individual progress over time.
 
Not all clients will prefer to use technology. Some
 
individuals prefer to use a small notebook specifically for their
 
self-monitoring or will simply check off their behaviors as
 
they have met their goals (Figure 2). Whichever method is
 
decided upon should be matched to the client’s preference
 
for recording to enhance self-monitoring consistency.
 
To further determine which method is most
 
appropriate for your client, consider the following
 
questions:
 
 
1. Does monitoring the target behavior require
 
subjective or objective information? If you would
 
 
 
like your client to monitor moods, feelings, or ratings
 
of hunger or fatigue, then having the ability to record
 
more detailed information is important. Thus pen
 
and paper, e-mail, or a PDA may be good choices.
 
On the other hand, if you are only interested in objective
 
measures such as steps taken each day, a pedometer
 
can sufficiently provide the client with the information
 
he or she needs.
 
 
2. How does your client prefer to keep track of tasks?
 
 
 
Does your client prefer technology and the ease of modifying
 
entries by cutting, copying, and pasting, or does he or
 
she prefer writing things down using pen and paper?
 
 
3. What is the client’s technologic experience? Does
 
 
 
your client own a PDA or cellular telephone or have
 
Internet access? Do they have Internet access throughout
 
the day or only at limited times?
 
 
4. How frequently is your client willing to monitor?
 
 
 
If the behavior requires frequent monitoring, it is
 
important to find a tool that is readily available. If
 
your client does not have the self-monitoring tool
 
available at all times to record behaviors, determine a
 
method that is more appropriate.
 
 
Provide Feedback
 
 
 
Perhaps the biggest advantage of self-monitoring is that
 
it serves as an avenue for providing feedback to clients on
 
the behaviors they are attempting to change. Therefore, the
 
type and style of feedback you provide to clients is critical
 
for appropriately directing and supporting positive
 
behavior change. The feedback you provide will depend
 
upon the amount of detail the client has reported in his or
 
her self-monitoring records. For example, it is easier to
 
respond to clients if you have a clear and detailed
 
picture of the behaviors and choices they have made.
 
Nevertheless, even less detailed accounts can give you an
 
adequate indication of whether the client is on track.
 
When reviewing self-monitoring records, you should ask
 
the following questions:
 
 
What is the overall picture? If a goal was predetermined,
 
 
 
did the client meet his or her goal for the week?
 
 
What are some positive behaviors or changes the client
 
 
 
has made?
 
 
Are there any patterns of behavior? Do these patterns
 
 
 
support or interfere with the behavior change the client
 
would like to make?
 
 
Are there any additional factors to consider such as
 
 
 
vacation, family emergency, or odd work hours?
 
Once you have assessed the self-monitoring records,
 
you are then able to provide feedback to the client based
 
upon the previously outlined questions. Table 1 provides
 
step-by-step tips for providing feedback. In addition,
 
you also should consider the following strategies:
 
 
1. Use positive reinforcement. Positive reinforcement
 
 
 
refers to any factor that increases the probability that the
 
behavior will be repeated and can include encouraging
 
statements, recognition of progress, and celebration of
 
small yet meaningful changes. For example, if a client has
 
struggled with an afternoon snacking habit that has
 
 
ASCM Photo/Lori Tish
 
 
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interfered with her weight loss, switching from cookies to
 
fruit is a meaningful change that should be encouraged
 
and rewarded.
 
 
2. Provide prompts for engaging in additional positive
 
behaviors and modifying negative behaviors. It is
 
 
 
important to try to determine challenging areas for
 
clients. This information can be learned from studying
 
patterns within self-monitoring records. Focus upon one
 
or two areas that the client can modify each week.
 
 
3. Modify the type of self-monitoring. Periodically,
 
 
 
you should modify self-monitoring assignments for
 
your clients based upon their progress, life events, and
 
personal health/fitness interests. As a client begins to
 
lose weight, for example, you may consider asking him
 
to record less information as he may already have a
 
certain amount of self-awareness regarding portion
 
sizes and calorie content. Other examples of situations
 
that require altering the type of self-monitoring
 
include a client who has decided to focus upon a
 
different health/fitness goal, a client whose schedule
 
will change drastically because of work schedule or
 
travel, or a client who begins to keep inconsistent
 
self-monitoring records.
 
Providing feedback to your clients allows you to extend
 
your personal interactions with them. As the client
 
begins to make (or not make) the necessary changes and
 
you begin to have a better understanding of the individual
 
personality type, you should modify your approach to
 
feedback so that it continues to remain interesting and
 
meaningful. Some clients will be driven by your feedback
 
to make the positive changes needed to be successful
 
and will enjoy receiving your comments. Others may
 
be more rebellious and will decide not to heed your
 
recommendations. By making proper adjustments to
 
monitoring assignments and the feedback you provide, you
 
can make self-monitoring a positive, effective tool to
 
promote the accomplishment of clients’ targeted goals.
 
 
Limitations of Self-Monitoring
 
 
 
As with any tool used to promote behavior change,
 
self-monitoring is not without limitations. First of all,
 
self-monitoring will not be an effective tool for your clients
 
unless they record honestly, frequently, and with enough
 
detail to become more self-aware to regulate the targeted
 
behavior. In addition, the mere act of recording behaviors
 
may not be enough to bring about behavior change. If a
 
client records eating and exercise behaviors but does not
 
understand the concept of energy balance and energy deficit,
 
then self-monitoring alone will not be a sufficient stimulus
 
to promote weight loss. Therefore, work with clients to
 
discuss areas that can be modified or targeted and educate
 
 
Table. Step-by-Step Tips for Providing Feedback
 
 
1. Start Positive. Regardless of how well your client managed the targeted behavior and/or kept self-monitoring records, your
 
first comment should be a positive one. This statement could be very general, (i.e. ‘‘Great job recording this week! I can see
 
 
 
you are trying to make changes in your diet.’’) or it may specifically refer to a behavior, such as ‘‘You did a fantastic
 
job reaching 150 minutes of physical activity this week!’’
 
 
2. Identify 1-2 Areas to Target. Next, provide 1 to 2 specific and meaningful recommendations or suggestions to help the client
 
make the necessary behavior changes. For instance, based on the self-monitoring records, you might suggest the client reduce
 
 
 
high fat/high calorie foods by substituting these foods with more fruits and vegetables. Or you may highlight situations
 
during the week where poor choices could have been linked to other factors (i.e. Friday dinner with out-of-town guest,
 
baseball game, etc.). Be sure to include at least one strategy for how the client can prepare for these situations in the future.
 
 
3. Offer Encouragement. Motivate your client by offering them words of encouragement. Although behavior change is highly
 
 
 
dependent on individual personalities, goals, personal barriers, etc., in general, clients respond more favorably to positive
 
comments than negative ones. Celebrate your clients’ small successes throughout the week by recognizing small changes in
 
an encouraging way. Offering a simple, ‘‘I know you can do this,’’ or ‘‘you are worth it’’ shows the client you understand
 
that behavior change requires effort.
 
 
4. Make it Meaningful. Try to avoid offering the same feedback to all clients or the similar feedback to the same client week
 
after week. The feedback you offer should be relevant to the target behavior and should offer clear direction for change.
 
 
 
If the client is unsuccessful, modify the feedback you provide as the client may simply have misunderstood the direction
 
you provided. When possible, discuss your feedback with the client in addition to giving them a written copy.
 
 
ACSM Photo/Don Distel
 
 
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them as to why these behavior modifications are important.
 
A common criticism of self-reporting is that clients often
 
underreport calories and food intake and overreport
 
behaviors such as physical activity or calories expended
 
(10, 11). Nonetheless, self-monitoring can still be a valid
 
tool for tracking behavior change as individuals most likely
 
under- or overreport such information on a consistent basis.
 
Self-monitoring is not for every client. Some clients
 
will feel burdened by tracking behaviors, and this may lead
 
to poor compliance to exercise and eating
 
recommendations. Thus, you need to be willing to modify
 
self-monitoring assignments or eliminate it altogether if
 
it begins to decrease, rather than promote adherence.
 
 
Summary
 
 
 
While the verdict may still be out on the ‘‘optimal’’ procedure
 
for self-monitoring, research does support consistency of
 
monitoring as a critical component of weight control and the
 
adoption and adherence of an exercise regimen. There are a
 
number of self-monitoring options available to you and your
 
client. Therefore, your goal should be to individualize the
 
assigned self-monitoring tasks to determine what works best
 
for the client to enhance consistency of self-monitoring and
 
promote favorable changes.
 
 
Melissa Burgard, B.S., is a Master’s candidate
 
and graduate research assistant in exercise
 
physiology at the University of Louisville
 
where her research focuses upon the role of
 
self-monitoring, feedback, and prompting
 
upon exercise adherence and weight loss.
 
Kara Gallagher, Ph.D., FACSM, is an
 
assistant professor in Exercise Physiology at
 
the University of Louisville where her research
 
focuses upon the role of exercise and behavior
 
change in weight control. She is a member
 
 
of the editorial board for ACSM’s Health &
 
Fitness Journal.1 She is ACSM Exercise
 
Specialist 1certified, ACE Group Exercise Instructor-certified,
 
 
 
and has worked in university and health/fitness settings for the
 
last 15 years.
 
 
References
 
 
1. Kanfer, F. H. Self-Monitoring: Methodological limitations and
 
 
clinical applications. Journal of Consulting and Clinical
 
 
 
35:148–152, 1970.
 
 
2. Wadden, T. A. The treatment of obesity: An overview. In: Obesity:
 
Theory and Therapy (2nd ed.), A. J. Stunkard and T. A. Wadden (Eds.).
 
 
 
New York: Raven Press, 1993, pp. 197–218.
 
3. Heesch, K. C., L. C. Masse, A. L. Dunn, et al. Does adherence
 
to a lifestyle physical activity intervention predict changes in physical
 
 
activity? Journal of Behavioral Medicine 26(4):333–348, 2003.
 
 
 
4. Boutelle, K. N., and D. S. Kirschenbaum. Further support for
 
consistent self-monitoring as a vital component of successful weight
 
 
control. Obesity Research 6(3):219–224, 1998.
 
 
 
5. Boutelle, K. N., D. S. Kirschenbaum, R. C. Baker, et al. How can
 
obese weight controllers minimize weight gain during the high
 
 
risk holiday season? By self-monitoring very consistently. Obesity
 
Research 6(3):219–224, 1998.
 
 
 
6. Tate, D. F., R. R. Wing, and R. A. Winett. Using internet technology
 
 
to deliver a behavioral weight loss program. Journal of the American
 
Medical Association 285(9):1172–1177, 2001.
 
7. Kirschenbaum, D. S. The Nine Truths about Weight Loss. New York:
 
 
 
Henry & Holt, 2000.
 
8. Baker, R. C., and D. S. Kirschenbaum. Weight control during the
 
holidays: The potentially critical role of self-monitoring. Presented
 
at the Meeting of the Association for Advancement of Behavior
 
Therapy, New York, November 1996.
 
9. Madden, M., America’s online pursuits: The changing picture of who’s
 
 
online and what they do. December 22, 2003. Available at http://
 
www.pewinternet.org/pfds/PIP_Online_Pursuits_Final.PDF. Accessed
 
 
 
Aug 8, 2005.
 
10. Horner, N. K., R. E. Patterson, M. L. Neuhouser, et. al. Participant
 
characteristics associated with errors in self-reported energy intake
 
from the Women’s Health Initiative food-frequency questionnaire.
 
 
American Journal of Nutrition 76:766–773, 2002.
 
 
 
11. Johansson, L.,K. Solvoll, G. E. Bjorneboe, et al.Under- and over- reporting
 
of energy intake related to weight status and lifestyle in a nationwide
 
 
sample. American Journal of Clinical Nutrition 68:266–274, 1998.
 
 
 
Condensed Version and
 
Bottom Line
 
 
Interactions between health/fitness professionals
 
and clients are often limited to face-to-face meetings
 
in the gym or health club. Many clients, however,
 
struggle with maintaining consistent healthy eating
 
and exercise behaviors outside of these interactions.
 
Self-monitoring allows you to monitor client progress
 
and identify areas that may hinder client success.
 
Self-monitoring also increases self-awareness of
 
behaviors and allows the client to become familiar with
 
other factors that are linked to the behaviors he or she
 
would like to change. By incorporating self-monitoring
 
into your interactions with clients and by providing
 
meaningful, directed feedback, you can increase the
 
likelihood that clients will successfully change eating
 
and exercise behaviors.
 
 
VOL. 10, NO. 1 JANUARY/FEBRUARY 2006 ACSM’S HEALTH & FITNESS JOURNAL1 19
 
 
 
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