"Where do I start?"
This might be a common question you ask yourself when a client acknowledges trouble beginning and sticking with healthy behavior change. Although health coaches are not like mechanics who look at a sluggish engine and know which tools they'll need, there are specific skills that can be used to help clients make sustainable lifestyle changes. The purpose of this article is to help you fill your toolbox with practical behavior change strategies. To continue with the theme of beginning, this inaugural article will cover assessment tools from a behavioral perspective. My early training as a clinical social worker provided simple wisdom for helping foster change, that is, to start where the client is. We can discover this starting point through conducting a comprehensive assessment. Client assessments help identify the scope of the problem, potential barriers, and motivation for change. The information gained directs us to the most appropriate intervention setting and strategies, measurable anchors for goals, and methods to monitor accomplishments and evaluate effectiveness.
What are the elements of a comprehensive assessment? What do you need to know to foster any health behavior change?
Start with basic objective demographic and fitness information. Sex, age, health history, race, family situation, occupation, and education give us important parameters that cannot be changed but can influence the selection of other things we need to know about the client. If a new client played contact sports in high school and college, you would follow-up with questions about athletic injuries and any enduring physical concerns or limitations. Demographic information also will direct the types of strategies and targets to support change. For example, a young mother who works from home and wants to lose weight could be assisted in identifying the walkability of her neighborhood and referred to online fitness classes and training programs.
The results from standard and appropriate fitness testing based on demographics and health history also are critical in helping establish realistic and reasonable goals and behavioral objectives. One of my first experiences with the value of fitness testing was discovering that most of the apparently healthy normal-weight college students taking an activity class could not walk a mile on a flat track without stopping to rest. Knowing their limits through assessment - and not working from assumptions - helped me adjust short-term goals to foster identifiable successes and bolster their confidence. An excellent resource for comprehensive fitness assessment is the 9th edition of ACSM's Guidelines for Exercise Testing and Prescription (1), which explains the scope of health-related fitness testing and interpretation.
Psychosocial assessments are not as objective as heart rate measured at rest or body weight, but they give us information about subjective attitudes, beliefs, and values that can play as important a role in developing a healthy lifestyle as knowing someone's 1-rep max. One of the most popular assessments to complement fitness testing is to determine someone's stage of change, or motivational readiness for the target behavior, typically followed by theoretically based strategies associated with the client's stage of change. Some excellent books include stage-based strategies as well as a variety of short self-report questionnaires to measure motivation, self-efficacy, outcome expectations, and other psychological factors included in theories of behavior and documented in research to be important in adoption and maintenance of regular physical activity (e.g., 2,3).
Understanding motivations for changing behavior is essential.
If you know why your client wants to exercise and what she expects (e.g., weight loss, increased strength, performance of activities of daily living with more ease and confidence), you can design a better program to meet her goals. Multiple motives for adopting new or revising current health behaviors are common and should be explored thoroughly in an assessment. Brainstorm with your clients to discover in more depth their reasons for seeking help to make healthy changes. You also may help them discover motives that they had not considered but realized were part of why they want to change, such as decreasing risk for certain diseases. Across time, motives will change, thus it is important to reevaluate their motives periodically and adjust the program accordingly. For example, someone can start a mall walking program to lose weight and comply with his doctor's advice, but across time, the opportunities to visit with other participants become a new and equally strong motive. Recommending other group-based physical activities or adaptable sports can be a corresponding new strategy. Getting information about past attempts to change the target behavior also enables you to explore motivations in more depth.
Clients exist in a dynamic social network that can provide motivation and support but also challenges and barriers to behavior change. No one changes health-related behavior in isolation, and efforts to modify diet and level of physical activity will have some impact on family and friends. You want to know about your clients' living situation and the family and friends who would be important to support and enable the change. Discovering who might be affected by their behavioral change should help determine additional strategies to counter resistance and recruit support. A spouse and children living at home would have to adjust to having supper later on the days a parent goes to the gym after work. This might take some negotiating on the part of your client. Identifying friends who already exercise regularly can point to sources of reinforcement and problem solving based on their own experiences tackling barriers to an active lifestyle. Likewise, your client has to implement strategies in a physical environment that will influence to what extent the change can be carried out. By discussing access to parks and recreation facilities, neighborhood safety, presence of others engaging in physical activity, sidewalks, traffic, terrain, and weather, you can pinpoint environmental influences to take into consideration in designing an appropriate program.
A comprehensive assessment that addresses personal, social, and environmental factors allows us to implement strategies at the appropriate level.
Are barriers to change at the level of the individual, the situation, or both? A motivated individual in a high-crime area would be directed to explore home-based activity options or work- out facilities within a convenient distance from school, home, or work. A reluctant client referred by her physician to start an exercise program would benefit from brainstorming all the potential benefits of becoming more active, along with convenient activities that might be enjoyable.
Assessment helps you start where the client is, but assessment is also a process.
You need to identify and measure the critical elements first, but gathering information about the client that can help you implement the best program and plan occurs across time, and assessments should be repeated as necessary to track progress. Given that you may be conducting multiple assessments, it is important that the methods are practical in terms of time, effort, and resources for you and your client and consistent with the importance of the information gathered. For example, self-monitoring might take a lot of effort and time but provides a wealth of information about the client and the target behavior. On the other hand, asking a client if she prefers to exercise with others or alone instead of having her complete a 70-item questionnaire could give you enough information to suggest workout options. Assessments also should be specific and sensitive, that is, the measurement should discriminate difference at the level needed to identify and monitor the behavior change. For example, a good benchmark for a weight management program is typically body weight, but program adherence might not show up on the scale in pounds but on the tape measure in inches. Both methods are specific to weight management, but circumference measures would be more sensitive to changes in body composition and more practical and meaningful than more complicated measures of percentage body fat.
Assessments provide you with information about the specific problem (overweight? overfat?) and thus enable you and your client to craft better goals. You also can help identify the scope of the problem and then help the client define the solution in measurable behavioral terms. With baseline assessments, your clients have benchmarks to compare across time, and progress thus becomes reinforcing. Assessment also gives you the foundation for applying other tools, such as goal setting, stimulus control, reinforcement, self-efficacy enhancement, relapse prevention, and other strategies to be covered in future columns.
1. American College of Sports Medicine. ACSM's Guidelines for Exercise Testing and Prescription. 9th ed. Baltimore (MD): Lippincott Williams & Wilkins; 2013.
2. Marcus BH, Forsyth LH. Motivating People to Be Physically Active. Champaign (IL): Human Kinetics; 2003.
3. Nigg CR. ACSM's Behavioral Aspects of Physical Activity and Exercise. Baltimore (MD): Lippincott Williams & Wilkins; 2013.
Janet Buckworth, Ph.D., FACSM, has spent more than 25 years studying exercise adherence and theory-based behavior change interventions. She has master's degrees in clinical social work and health education and a Ph.D. in exercise psychology, with work experiences in medical and college settings. Dr. Buckworth is a fellow of the American College of Sports Medicine, serving on the Behavioral Strategies Special Interest Group. Dr. Buckworth is department head in Kinesiology at the University of Georgia.
The author declares no conflict of interest and does not have any financial disclosures.
Content reprinted from ACSM's Health & Fitness Journal®.