An Information—Motivation—Behavioral Skills Analysis of Diet and Exercise Behavior in Puerto Ricans with Diabetes
Chandra Y. Osborn, PhD, MPH,1,2,3 K. Rivet Amico, PhD,3,4 William A. Fisher, PhD,3,5 Leonard E. Egede, MD,6,7,8 and Jeffrey D. Fisher, PhD3,4
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Abstract
Frameworks are needed to inform diabetes self-care programs for diverse populations. We tested the Information-Motivation-Behavioral Skills (IMB) model among Puerto Ricans with Type 2 diabetes (N=118). Structural equation models evaluated model fit and interrelations among constructs. For diet behavior, information and motivation related to behavioral skills (r=0.19, p<0.05 and r=0.39, p<0.01, respectively); behavioral skills related to behavior (r=0.42, p<0.01 and r=0.32, p<0.05); and behavior was related to glycemic control (r=−0.26, p<0.05). For exercise, personal motivation related to behavioral skills (r=0.53, p<0.001), and behavioral skills related to behavior (r=0.45, p<0.001). The IMB model could inform interventions targeting these behaviors in diabetes.
Keywords: Information, motivation, behavioral skills (IMB) model, glycemic control, Puerto Rican, diabetes, behavior
Diabetes is a chronic debilitating condition worldwide that is associated with increased complications, mortality, and health utilization and cost (Bonow & Gheorghiade, 2004). Puerto Rican Americans have a significantly high rate of diabetes (Melnik et al., 2004; Whitman, Silva, & Shah, 2006); and those with diabetes have low rates of adherence to self-care behaviors (Gollenberg, Pekow, Markenson, Tucker, & Chasan-Taber, 2008), and experience high rates of diabetes-related complications (Lipton et al., 1996) and mortality (Smith & Barnett, 2005). Despite the obvious need for diabetes self-care programs for this population, to our knowledge only a few interventions been developed and published (Cleghorn et al., 2004; Vazquez, Millen, Bissett, Levenson, & Chipkin, 1998). Because self-care behaviors such as diet and exercise are critical for glycemic control, increased efforts are needed to identify what elements should be included in interventions to promote these behaviors in this and other high risk populations.
Several conceptual models of health behavior change describe the factors influencing behavioral performance across disease contexts, with the ultimate goal of informing health promotion interventions (Elder, Ayala, & Harris, 1999). Many models have informed diabetes educational efforts (Whittemore, 2000). However, in a recent review of 185 diabetes education programs, no single conceptual framework to date was comprehensive enough to link attributes of high quality diabetes care to self-care processes and, ultimately, diabetes outcomes (Borgermans et al., 2008). The authors of that review further call on researchers “to develop a standardized framework on high quality diabetes care that is complemented by a practical tool to provide guidance to the design, implementation and evaluation of diabetes care programs.”
In an effort to address this call to action, the current research applies a comprehensive, theoretical model of health behavior change, known as the Information--Motivation--Behavioral Skills (IMB) model (J. D. Fisher & Fisher, 1992), to two critical diabetes self-care behaviors: diet and exercise. Although the basic tenants of the IMB model (J. D. Fisher & Fisher, 1992) have been empirically validated across a number of diverse populations and health promotion behaviors (Amico, Toro-Alfonso, & Fisher, 2005; J. D. Fisher, Amico, Fisher, & Harman, 2008; J. D. Fisher et al., 2004; J. D. Fisher, Fisher, Amico, & Harman, 2006), the model’s application to diabetes has been limited to one study (Osborn & Egede, 2009). In addition, while interventions based on the model have successfully promoted a range of health behaviors (W. A. Fisher, Fisher, & Harman, 2003), to our knowledge, no published diabetes intervention has used the IMB model to inform its design, content, delivery of content, implementation and evaluation of intervention efficacy. More importantly, no study has examined the utility of the model in designing intervention content for ethnic minorities.
The IMB model identifies three core determinants of the initiation and maintenance of health behaviors: accurate information that can be readily translated into health behavior performance; personal and social motivation to act on such information; and behavioral skills to confidently and effectively implement the health behavior (J. D. Fisher, Fisher, Cornman et al., 2006; S. J. Misovich, Martinez, Fisher, Bryan, & Catapano, 2003; Murray, 2001; Starace et al., 2006). At a general level, the IMB model posits that performing a health behavior is a function of the extent to which someone is well-informed about the behavior, motivated to perform the behavior (e.g., has positive personal beliefs and attitudes towards the behavior or outcome, and social support for the behavior), and has the requisite skills to execute the behavior and confidence in their ability to do so across various situations. For complex behaviors, information and motivation are believed to work largely through the activation of relevant behavioral skills to bring about the initiation and maintenance of the behavior at focus. Information and motivation may also have direct effects on behavior when performance does not require complicated or novel behavioral skills.
According to the IMB model, information relevant to the performance of a behavior is a necessary but insufficient prerequisite to its enactment. Articulated to diabetes self-care behavior, the information construct would arguably include accurate information about specific diabetes self-care behaviors (e.g., exercise is important for managing diabetes). It would also include information concerning any health behavior performance required or recommended (e.g., knowledge of one’s daily recommended carbohydrate intake, and exercise requirements for glycemic control). Finally, it would also include heuristics and implicit theories that house misinformation about the behavior (e.g., “only sweet tasting foods raise blood glucose levels,” or “diet without exercise is enough to manage diabetes”) or heuristic decision rules which are actually accurate (e.g., “foods with carbohydrates raise blood glucose levels,” and “exercise and insulin lower blood glucose levels”).
In addition to behaviorally relevant information, the IMB model specifies that motivation is a critical determinant of whether or not even well-informed individuals will be inclined to enact a specific health behavior. The motivation construct of the IMB model is comprised of two components -- personal and social motivation (Amico et al., 2009; J. D. Fisher & Fisher, 1992; J. D. Fisher, Fisher, Amico et al., 2006). Following Fishbein & Ajzen (1975), personal motivation is a function of beliefs about the consequences of a behavior and evaluations of these consequences. Social motivation involves perceiving that there is normative support for a health behavior (e.g., that significant others, such as family, friends, and health care providers support its performance) and being motivated to comply with these referent others’ wishes (Fishbein & Ajzen, 1975; Pender & Pender, 1986). Articulated to diabetes self-care behavior, personal motivation would include one’s beliefs about the consequences of a diabetes self-care behavior (e.g., believing that monitoring carbohydrate intake and exercising every day would improve glycemic control; or, alternatively, would be intrusive and time consuming), and one’s evaluation of these consequences (e.g., monitoring carbohydrate intake and exercising every day would be a good or a bad thing to do). Social motivation for diabetes self-care would include one’s perceptions of significant others’ support for performing a specific diabetes self-care behavior (e.g., perceiving that important others believe one should monitor carbohydrate intake and exercise every day to manage diabetes), and one’s motivation to comply with these others’ wishes (e.g., “I want to do what my parent/doctor/spouse/friend/co-worker thinks I should do”) (Fishbein & Ajzen, 1975; Pender & Pender, 1986).
Finally, the IMB model identifies behavioral skills as a critical core determinant of complex health behaviors, which influences whether well-informed and well-motivated individuals will be capable of carrying out the health behavior effectively (Bandura, 1986). Behavioral skills include objective and perceived skills for performing the behavior (i.e., being able to enact the potentially complex and novel steps involved in its performance) and a sense of self-efficacy for doing so (i.e., one’s confidence in implementing the behavior in a variety of settings). Articulated to diabetes self-care behavior, behavioral skills may involve the ability to adequately perform a specific diabetes self-care behavior (e.g., one’s ability and confidence in monitoring carbohydrates - by identifying carbohydrate and serving size information on food labels, accurately calculating carbohydrate grams per serving of food, and estimating the appropriate serving size based on this amount; and the ability and confidence in exercising in different commonly occurring challenging situations - when the weather is bad, identifying a convenient time to exercise, after a long break in activity).
The goals of the current research are three-fold: (1) to articulate and validate the IMB model as initially described by Fisher and Fisher (1992) with two diabetes self-care behaviors: diet and exercise; (2) showcase the IMB model’s value across populations by sampling from a high ris
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