Elsevier

Social Science & Medicine

Volume 60, Issue 4, February 2005, Pages 859-875
Social Science & Medicine

Habitual self-control and the management of health behavior among heart patients

https://doi.org/10.1016/j.socscimed.2004.06.028Get rights and content

Abstract

This study examined the predictive power of habitual self-control on health behaviors among 381 heart surgery patients in Germany. Habitual self-control and other trait predictors (dispositional optimism, generalized self-efficacy beliefs, health locus of control beliefs) were assessed before and six months after surgery. Social-cognitive predictors of health behavior (behavior-specific self-efficacy and outcome beliefs, intentions) were assessed only before surgery. Outcomes were dieting, physical exercise, and smoker status before and after surgery. Compared to other trait variables, habitual self-control emerged as a superior predictor of the behavioral outcomes. Further, habitual self-control explained unique variance in dieting and physical exercise beyond proximal behavior-specific predictors (i.e., self-efficacy beliefs, intentions) that are supposed to display direct effects on behavior. Results of hierarchical linear regressions provided partial support for the assumption that habitual self-control strengthens the intention–behavior congruence. In prospective analyses predicting dieting at the 6-month follow-up an interaction between habitual self-control and dieting intentions emerged indicating that self-control supported dieting among patients with imperfect (moderate) dieting intentions only. In sum, the results suggest that habitual self-control may be a useful construct in research on health behavior management, in particular when long-term maintenance of health behavior is the target.

Introduction

Coronary heart disease is the primary cause of death in developed countries (AHA, 2002; Sans, Kesteloot, & Kromhout, 1997). According to statistics of the American Heart Association, more than 60 million Americans suffer from one or more forms of cardiovascular disease (CVD), which is responsible for approximately 40% of all deaths. In 1999, CVD claimed nearly 1 million lives in the United States. Similar alarming numbers are reported from Europe (Sans et al., 1997). In 2001, 1.1 million Americans experienced a new or recurrent myocardial infarct, and about 40% of them were likely to die as a consequence of a coronary attack.

Prevalence and impact rates of well-known, controllable risk factors such as smoking, obesity, hypercholesterolemia, and a sedentary lifestyle identify the control of health behavior as the prime target of prevention and intervention programs aiming at a reduction of CVD. About 24% of the US Americans are smokers and have a two to fourfold risk of heart attack and sudden death. Studies indicate that between 28% and 50% of the US population aged 18 and older lead a sedentary lifestyle, doubling the risk of coronary heart disease (CHD) compared to physically active adults. Estimates from the AHA indicate that about 40 million American adults have an increased blood cholesterol level of 240 mg/dL or higher (AHA, 2002), and about one third of the US population is obese (AHA, 1997); both of these factors increase the risk of high blood pressure and CHD but are controllable by a healthy diet (AHA, 1998). Further, there is evidence that multiple risk factors not only accumulate, but also interact in increasing the risk of CHD (AHA, 2002). In sum, the evidence suggests that the control of smoking, dieting, and physical exercise would lead to a marked reduction in CVD development, cardiac events, and sudden cardiac death, and thus to a considerable prolongation of life (AHA, 1999).

In consequence of cardiovascular diseases, between 500,000 and 600,000 coronary artery bypass surgeries are performed each year in the United States. Patients suffering from severe CHD most likely have a history of unhealthy habits. However, the long-term success of open-heart surgery, the recurrence of vessel occlusion, the likelihood of recurring infarcts, and overall post-surgical gains in cardiac functioning may depend on patients’ ability to adopt a healthy lifestyle. As a preventative measure, similar lifestyle changes are requested from patients with severe heart diseases other than CHD, such as heart valve malfunction, because of their increased risk and reduced tolerance for additional constraints on cardiac functioning.

Despite the increased vulnerability of cardiac surgery patients to the harmful effects of health risk behaviors, little research has focused on the predictive and explanatory power of theoretical models of health behavior within this particular risk population. The fact that many cardiac patients—who are usually well informed about the effects of lifestyle on cardiac health—proceed with an unhealthy lifestyle until they have clear evidence that their lives are at risk indicates that many of them experience difficulty in the voluntary control of unhealthy consummatory and sedentary behaviors.

The current study aimed at an investigation of habitual self-control in the prediction of health behaviors among cardiac surgery patients. Habitual self-control is defined as a latent trait that is activated when an intention has been formed whose enactment is effortful and involves non-hedonistic behavior. Theoretically, self-control is assumed to support the enactment of an intention, thus enhancing the intention–behavior consistency. The goals of this study were fourfold. First, the predictive power of habitual self-control on health behavior management was tested and compared to similar trait predictors. Second, the contribution of habitual self-control to the prediction of health behavior was tested in the context of proximal behavior-specific predictors as specified by theoretical models of health behavior (e.g., dieting self-efficacy beliefs, dieting intentions). Third, interactions between behavioral intentions and habitual self-control were examined in order to test the hypothesis that habitual self-control strengthens the intention–behavior congruence. Fourth, differential effects of habitual self-control in diverse patient populations were tested.

Most models of health behavior focus on the processes in the pre-intentional stage of the action process, in which motivation is aroused and/or an intention is formed. Well-known examples are the health belief model (Becker, 1974; Rosenstock, 1966), the protection motivation theory (Rogers, 1983), the theory of reasoned action (Ajzen & Fishbein, 1980) and the theory of planned behavior (Ajzen, 1991). These models explain behavior as a consequence of cognitive-motivational processes such as perceived threat, cost-benefit analyses, and the formation of a behavioral intention. According to a meta-analysis (Godin & Kok, 1996) that integrated 56 studies on the theory of planned behavior, intentions and perceived control explain, on average, about 34% of the variance in health behaviors. This finding indicates that there is ample room for additional predictors to account for differences in health behavior management (Bagozzi, 1992; Conner & Armitage, 1998; Perugini & Bagozzi, 2001).

One shortcoming of intention-based models of health behavior is that they do not account for discrepancies between intentions and behaviors. Intentions are not always performed, specifically if they involve non-hedonistic behaviors. Theories of action control suggest a distinction between motivational processes of intention formation and volitional processes of action initiation and maintenance (Bagozzi, 1992; Gollwitzer, 1993; Heckhausen, 1991; Kuhl, 1985). The intention–behavior congruence can be weakened by unforeseen obstacles or costs, emotional resistance, temptation, time delays between decision-making and action initiation, and insufficient elaboration of goal-oriented action plans. Action control processes such as planning, self-control of action, and resistance to temptation can explain why some people are able to realize their goals while others fail. Several recent reviews of health behavior models converge in their conclusion that motivational models need to integrate a volitional stage in order to better explain individual differences in health behavior and health behavior change (Armitage & Conner, 2000; Bagozzi & Edwards, 2000; Conner & Armitage, 1998; Gollwitzer & Brandstaetter, 1997; Sheeran & Abraham, 1996; Sutton, 1998).

In response to these considerations, Schwarzer (1992) developed the health action process approach, which integrates volition theory into health behavior models, specifying a two-stage process of health behavior management (see Fig. 1). Similar to the Theory of Planned Behavior, the health action process approach model assumes that intentions and self-efficacy beliefs are the proximal motivational precursors of health behavior. In the post-intentional action stage, volitional processes intervene between intentions and behavior. Although activated only after an intention has been formed, volitional control of action is supposed to display unique effects on behavior; otherwise the construct of volition would be redundant in the explanation of health behavior (Gollwitzer, 1993; Heckhausen, 1991; Kuhl, 1985). The health action process approach model is unique in specifying volitional control of action as an additional predictor of health behavior. It specifies the proximal predictors of intention and behavior that were used in the present study to test the effects of habitual self-control on behavior. However, the health action process approach refers primarily to a sequence of processes and not to structural (causal) paths. Thus, in order to test a causal model, the predictors specified in that model had to be reorganized into a structural model, in which the paths indicate causal influence rather than a sequence of processes and stages on a timeline. The causal model tested in the present study is shown in Fig. 2. Outcome beliefs and self-efficacy beliefs were specified as the proximal predictors of intentions. Health behavior was modeled as a function of intentions, self-efficacy beliefs, and volitional control of action. Further, the path model specified two major assumptions of volition theory (Heckhausen, 1991; Kuhl, 1985), namely that (1) self-control adds uniquely to the prediction and explanation of behavior beyond the motivational processes involving intentions and self-efficacy beliefs, and (2) self-control interacts with intentions in predicting behavior.

The core of volition theory is the assumption that volitional control of action moderates the intention–behavior relationship. Difficult (non-hedonistic) intentions will only be performed if action control is applied. However, long-term behavior change requires more than the current control of behavior. Permanent self-control, and thus, a disposition to enact control over one's behavior is needed to explain the adoption and long-term maintenance of a healthy lifestyle. According to results of Baumeister and his colleagues, self-control is a limited resource comparable to a muscle whose performance is and likely to deplete under conditions of repeated or constant activation (Baumeister, Bratlavsky, Muraven, & Tice, 1999; Baumeister, Heatherton, & Tice, 1994). Further, the authors assume that self-control ability is a durable and central aspect of personality, which seems to develop early in life (Mischel, Shoda, & Peake, 1988) but can be enhanced by repeated training of self-control techniques (Muraven, Baumeister, & Tice, 1999).

Habitual self-control, as defined in the present study, is activated when an intention has been formed whose enactment is effortful and involves non-hedonistic behavior. This implies that action control is conditional on personal goals and intentions without being enacted in a rigid way. For example, if a person were not interested in controlling her diet, an “uncontrolled” eating habit would not indicate low habitual self-control. However, if a goal has been set to control one's diet, failure to diet would indicate lack of volitional control of action. The development of the construct and its measurement was inspired by early formulations of action control theory (Kuhl, 1985). However, the current approach is distinguished by a strong emphasis of self-control in the performance of non-hedonistic behaviors that is important in health behavior applications and that is missing in Kuhl's recent theoretical formulations (Kuhl, 1992; Kuhl & Beckmann, 1994).

Habitual self-control is expected to support goal achievement with a number of action control skills such as consistent self-monitoring, translation of goal intentions into clearly defined behavioral steps, elaborated action planning and forethought, and self-rewarding skills. Habitual self-control enhances the likelihood that a person fights successfully against interfering factors such as unforeseen obstacles, temptation, social pressure, emotional states, or fatigue that render the enactment of an intention difficult.

Habitual self-control can be expected to affect behavior among patients who are well aware of the impact of health behaviors on the course of their illness and who are likely to develop the respective health behavior intentions. Further, habitual self-control should be particularly useful in the prediction of long-term, complex behavior change. Patients suffering from severe CHD are asked to adopt a healthy lifestyle for the remainder of their lives. Usually this involves multiple tasks such as smoking cessation, dieting, and physical exercise. Whether intentions will be exerted, should depend, in part, on habitual self-control.

Based on these theoretical considerations, the following hypotheses were tested.

  • 1.

    Habitual self-control is a superior predictor of health behaviors compared to other trait resources such as dispositional optimism and general self-efficacy beliefs.

  • 2.

    Habitual self-control contributes to the prediction of health behaviors beyond the effects of proximal social-cognitive predictors specified by the health action process approach model (Schwarzer, 1992) and social-cognitive theory (Bandura, 1997, Bandura, 1998), including behavior specific self-efficacy beliefs, outcome beliefs, and intentions.

  • 3.

    Habitual self-control moderates the relationship between health-behavior intentions and health behavior. Patients high in habitual self-control show a stronger concordance between health behavior intentions and behavior than patients low in habitual self-control.

  • 4.

    The effects of habitual self-control are stronger in a patient population in which a healthy lifestyle has well-documented and well-known effects on health status. Accordingly, health behavior should be more affected by habitual self-control among patients suffering from coronary artery disease compared to patients suffering from other kinds of heart failure.

  • 5.

    Habitual self-control affects health outcomes by promoting health behavior.

Section snippets

Design and setting

Patients were recruited at the heart center of the Charité hospital in Berlin, one of the two largest heart surgery centers in Germany. The study involved multiple assessment occasions: a pre-surgical questionnaire (T1), a post-surgical interview approximately one week after surgery (T2), and a weekly diary between weeks 15 and 24 following surgery, and a postal questionnaire at the six-month follow-up (T3). The schedule of assessments was selected to provide an interval of time after surgery

Predictive power of habitual self-control (HSC) compared to alternative traits

The intercorrelations between the trait predictors are presented in Table 2, and the correlations with health behaviors are shown in Table 3. HSC was significantly related to health behaviors, with the exception of physical exercise during weeks 15 and 24, which was not related to any trait measure, and smoker status at Time 1, which was negatively related to the Life Orientation Test and internal health locus of control only (r=-.14,p<.05,r=-.17,p<.05, respectively). In the following t tests,

Summary and discussion

The purpose of the present study was to test the role of habitual self-control in the prediction of health behaviors among heart surgery patients. Five hypotheses were tested. First, the predictive power of habitual self-control on smoking, physical exercise, and dieting was compared to the effects of existing trait predictors. These included generalized self-efficacy beliefs, dispositional optimism, and health locus of control beliefs as the most popular trait variables employed in health

Acknowledgements

This work was supported by a grant from the Kommission für Forschung und wissenschaftlichen Nachwuchs (FNK), Germany (l 02/524 01–1200 86) to the first author. We thank the participants and the members of the project team for their contributions to this research.

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