Scandinavian Journal of Psychology, 2014

DOI: 10.1111/sjop.12159

Health and Disability A qualitative study of citizens’ experience of participating in health counseling LOTTE NYGAARD ANDERSEN,1 STINNE SONNE ANDERSEN,1 BRITT MUURHOLM2 and KIRSTEN KAYA ROESSLER3 1

University of Southern Denmark, Institute of Sport Science and Clinical Biomechanics, Odense M, Denmark The Health Care Center, Sønderborg, Denmark 3 University of Southern Denmark, Institute of Psychology, Odense M, Denmark 2

Andersen, L. N., Andersen, S. S., Muurholm, B. & Roessler, K. K. (2014). A qualitative study of citizens’ experience of participating in health counseling. Scandinavian Journal of Psychology. Individual health counseling is a form of intervention designed to minimize the effects of chronic health disease and to offer a path towards good health practices. The aim of the present study was to explore the experiences of those persons who participated in health counseling in order to assess the psychosocial significance of the counseling upon their health behavior. In addition the study was concerned with the factors which underlay peoples’ decision to sign up for health counseling. The research involved 11 semi-structured interviews with individuals who had participated in a municipality based health counseling program. Data was analyzed using Malterud’s systemic text condensation and a theoretical framework around Bandura’s social cognitive theory. Analysis revealed that an approach tailored to each individual with minor short-term goals accompanied by feeling supported by the counselor produced the greatest impact on behavior. Receiving feedback from the counselor and feeling positive about the relationship were seen as essential. These aspects were also crucial in the decision to undertake health counseling. The study indicates that whether individual’s sign up on their own initiative or conversely are invited to join the program has no influence upon their motivation to change their behavior. Overall the respondents demonstrated improvement in their behavior and attitudes towards their health. However, the study also indicates that this form of intervention is less or even ineffective without the support of the individual’s immediate family. Key words: Counseling, qualitative research, behavior change, health promotion, social cognitive theory. Lotte Nygaard Andersen, University of Southern Denmark, Institute of Sport Science and Clinical Biomechanics, Campusvej 55, 5230 Odense M, Denmark. Tel: +45 23 61 25 53; e-mail: [email protected]

INTRODUCTION According to the World Health Organization, 36 million people died from chronic diseases such as cardiovascular diseases, cancer, diabetes and chronic lung diseases in 2008 (Alwan, 2011). Unhealthy diet and physical inactivity are among the leading causes for chronic diseases (Waxman, 2004). In Denmark alone, the consequence of physical inactivity adds an additional annual cost of 2,883 billion DKK to the health care system (Juel, Sørensen & Brønnum-Hansen, 2006). Besides socioeconomic consequences, chronic diseases affect the person and are associated with reduced quality of life (Jia, Zack & Thompson, 2013; Rubin & Peyrot, 1999). Due to the extent of the problem, there is much research in this area and several studies support the impact of physical activity and dietary interventions in relation to minimizing chronic diseases and preventing the occurrence of these (He, Nowson & MacGregor, 2006; Kesaniemi, Riddoch, Reeder, Blair & Sorensen, 2010; Ma, Zhou, Zhou & Huang, 2014; Waxman, 2004). In Denmark, the Health Law states that municipalities have the primary responsibility for creating healthy environments and preventive services for their citizens (Hanak, Falk, Størup & Bruun, 2007). Individual health counseling is one of the ways in which the municipalities meet their legal requirements. Motivational interviewing is a commonly used technique in health counseling (Miller & Rollnick, 2012; Noordman, de Vet, van der Weijden & van Dulmen, 2013). The effect of motivational interviewing is found to be good and is supported by a meta-analysis, which concluded © 2014 Scandinavian Psychological Associations and John Wiley & Sons Ltd

on a significant and clinically relevant decrease in both body mass index and systolic blood pressure for people who received motivational interviewing (Rubak, Sandbæk, Lauritzen & Christensen, 2005). A cross-sectional survey based on 7,947 Europeans, concluded that 43% think that they have to improve their eating habits and 48% think that they need to do more physical activity (Brotons, Drenthen, Durrer & Moral, 2012). Although the motivation to change health behavior exists, changing lifestyle habits is often a difficult process involving both behavioral and cognitive change, and it is well known that it is difficult for people to maintain new health habits (Hill, 2009; Roessler, 2011; Tuah, Amiel, Qureshi, Car, Kaur & Majeed, 2011). The Danish Health and Medicines Authority has produced material on the Small Steps concept, which is used in the municipalities. Small Steps recommend people to make small changes in their current behavior that can subsequently lead to a sustainable lifestyle change (Mikkelsen, Hejgaard & Dansgaard, 2012). Few studies have examined how people experience health counseling (Chan, Fam & Ng, 2009; Dellasega, Anel-Tiangco & Gabbay, 2012; Hardcastle & Hagger, 2011; O’Sullivan, Fortier, Faubert et al., 2010; Walseth, Abildsnes & Schei, 2011), but none of these focus on health counseling for the general population wanting to change health behavior. In order to investigate why people sign up for health counseling, and in order to gain a deeper understanding of which aspects of health counseling are of greatest importance to the health behavior of the person, more studies are needed.

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The aims of the present study are twofold: (1) to explore the experiences of the persons who participated in health counseling, in order to assess psychosocial aspects of health counseling’s significance for citizens’ health behavior and (2) to understand the decision making process that made the participating citizens sign up for health counseling. The findings of this study may support health professionals and municipal decision makers, in their work to organize and regulate future health promotion activities in their work against chronic diseases.

experiences, vicarious experiences, social persuasion and physiological and affective states (Bandura, 1997). A meta-analysis of physical activity interventions concludes that feedback on previous performance or feedback on others’ performance is associated with higher levels of selfefficacy (Ashford, Edmunds & French, 2010). Based on the theoretical framework, it was hypothesized that the citizens would be motivated to change health behavior and that they would have a certain degree of self-efficacy, because they have agreed to sign up for the intervention. It was assumed that the concept of Small Steps, which include short goal setting, would promote the citizens’ mastery experience and strengthen the citizens’ self-efficacy through successful experiences in achieving short term goals.

METHODS Interview guide Health Counseling The individual health counseling examined throughout this study, is a free municipality-based service for all citizens and employees in a municipality in Southern Denmark. Persons can be referred to health counseling by various entities in the municipality, by their general practitioner or they can sign up themselves after having been made aware of health counseling by, for example, local newspapers or on the municipal website. The health counseling is conducted by health professionals trained in physiotherapy, occupational therapy or health and nutrition, and is based on motivational interviewing and the Small Steps concept. The goal of the service is to work towards a healthy and sustainable lifestyle and to provide behavioral change in diet, physical activity, smoking, alcohol and well-being. It takes place at the local health center and the duration of the intervention and the frequency of counseling are agreed between the service-taker and the health supervisor.

An interview guide containing relevant themes and related interview questions formulated in everyday-language was developed (Kvale & Brinkmann, 2009). To gain knowledge of the area, relevant literature was analyzed, observations were made at the local health center and an evaluation report of the specific health counseling was studied, before the interview guide was designed. The interview guide was inspired by Banduras theory and contained themes concerning motivation to sign up for health counseling, outcome expectations and goal setting. It contained questions such as Could you try to explain to me what health counseling is and how you experienced it? and What made you sign up for this particular effort? Open-ended questions and reflexive listening was used to gain in-depth and nuanced descriptions from the informants. The interview guide was continuously modified as new themes emerged from obtained data. One example of this was increasingly detailed questions about Small Steps (see Appendix).

Study design and theoretical framework

Informants and data collection

A qualitative approach using semi-structured interviews was chosen as the method to obtain a complete and in-depth understanding of citizens’ experiences of health counseling. The framework of the study is phenomenological-hermeneutic and the method is based on a combination of description and interpretation of informants’ experiences (Malterud, 2011). Bandura’s (1997) social cognitive theory (SCT) was applied as a theoretical framework to assess the psychosocial aspects of health counseling’s significance for citizens’ health behavior. The theory describes the ongoing dynamic relationship between behavior, environment and personal factors, which include cognitive, affective and biological events. Self-efficacy refers to ones belief in ones capability to organize and execute the courses of action required to produce a given task. The level of self-efficacy is fundamental for human motivation and action in adopting new lifestyle habits or pursuing rehabilitative activities (Bandura, 1997). Self-efficacy interacts with goals, outcome expectations and perceived impediments (Bandura, 2004). According to Social cognitive theory, there are four sources that influence a person’s self–efficacy: Mastery

During the period October 2012 to March 2013, 48 citizens had their final health counseling session at the health center. During their final health counseling session, all individuals aged 18 to 65 were asked by their health supervisor if they wanted to participate in the study. Written information about the study was provided and the potential informants were subsequently contacted by the researcher. Eleven citizens responded positively to the request for participating in the study. The reasons why citizens refused to participate were lack of time and interest. With the aim to achieve maximum variation and thereby gain a broad understanding of the field, the researcher chose to include both genders, a wide age range and informants with both short and long courses with health counseling. The researcher conducted 11 semi structured face-to-face interviews (Duration: 38–87 min.). The interview took place in an undisturbed room at the local health center. The sample comprised five females and six males (see Table 1). No reward was given for participation. Approval by the Regional Ethic Committee was not required, but informed consent

Table 1. Demographic characteristics of informants Informant

Gender

Age

Duration of HC

Frequency of HC

Working status

1 2 3 4

Female Female Male Male

56 45 58 49

2 years 9 months 4 months 3–4 months

12 weeks 4–5 weeks 2 weeks 3–4 weeks

5 6 7 8 9 10 11

Female Male Male Male Female Male Female

59 44 51 47 62 45 64

2.5 years 2 years 1 years 2 years 1 months 1 years 3 months

8–16 weeks 4–12 weeks 4 weeks 2–6 weeks 3 weeks 3–6 weeks 4 weeks

Teacher Social worker Reported sick from flex job. Has a porter education Early retirement Has worked in a brickyard Teacher and special advisor Self-employed handyman Special worker but long term unemployed Janitor Early retirement Social and health assistent Janitor Teacher

© 2014 Scandinavian Psychological Associations and John Wiley & Sons Ltd

Scand J Psychol (2014) was obtained from all informants at the day of the interview. Confidentiality and anonymity was maintained throughout the research via the use of identification codes.

Data analysis The audio-taped interviews were transcribed verbatim and the transcripts were reviewed twice in order to check the accuracy of transcription. All transcripts were read carefully before analysis and the process and outcome of analysis were discussed and negotiated continuously among the authors. The following steps were conducted: (1) total impression of the transcripts to get a general sense of the whole statement; (2) identifying and sorting meaning units, this coding process was supported by the software program NVivo 10 (QSR International, Burlington, MA); (3) condensation of content and meaning; (4) synthesizing – from condensation to descriptions and concepts, and a coherent story grounded in empirical data about the phenomenon is told. Meaning the participants’ experiences with and descriptions of health counseling. The final step included a discussion of the results in relation to the theoretical framework (SCT) and to existing literature. This step produced an extended understanding and interpretation that went beyond the informants’ self-understanding (Malterud, 2012). Danish quotes were selected to validate the results and were translated into English.

RESULTS The data offered one understanding of how citizens experienced health counseling. The analysis identified five main themes: (1) I wish to change my life; (2) Getting my own tailored approach; (3) Small steps fit my life; (4) It’s all about getting a response and (5) I try to treat my body properly.

Citizens experience of health counseling 3 Well, I just said yes because I got the offer. I didn’t expect that they would be able to help (Male, 51). The reasons for signing up for health counseling varied among the informants, but they all wanted to change eating and physical activity behavior and they all had a goal containing a loss of weight. Some informants had set a specific target for how much weight they would like to lose, while others simply desired a non-specific loss of weight. The informants’ motivation for weight loss varied significantly, but what was clear from most of their descriptions was that they wanted to improve the condition of an already diagnosed lifestyle disease or wanted to prevent a lifestyle disease from occurring. Diabetes, high blood sugar and high cholesterol were mentioned by several informants. The risk of Diabetes 2 and all the lifestyle diseases and knowing how obese persons die faster and, well, so many things, you are not very mobile (Male, 45). For about half of the informants, it had a great significance that lifestyle changes could help influence their physical appearance positively. The desire for a better appearance was linked to both a desire for greater self-fulfillment and to being easier socially accepted as slim. But to me it might have been just as much the visual and the appearance going to stores and really fancy clothes, and I didn’t really think that any of it would fit me. And I constantly had to go one size up and one size up again and it didn’t really fit and then on (Female, 45).

I wish to change my life The analysis shows three different ways in which citizens were referred to health counseling. Two informants had heard about health counseling at work, four informants had contacted health counseling after viewing an ad at the municipality’s website, in the local newspaper or after having heard about it from friends. The remaining five informants had heard about health counseling through their general practitioner or in connection with following other courses at the health center. 10 out of 11 informants described that they were motivated for the intervention. There was no tendency that informants who had signed up for health counseling on their own initiative were more motivated for making behavioral changes than those who had been invited to health counseling, for example, through their general practitioner or through their workplace. For example, a man in his 40s who was referred to health counseling because his general practitioner thought it would improve his diabetes 2, was very motivated and experienced a weight loss of 16 kg in 4 months. But it is all about wanting it in order to. I had made up my mind, I wanted to lose weight (Male, 49). One participant had joined the health counseling because she felt a compulsion to attend when the municipality offered such a course through her workplace. For her, the feeling of compulsion was motivating. A man in his 50s signed up because of lack of better health services. He was unemployed and the only thing he believed would help against his overweight was to get a job. © 2014 Scandinavian Psychological Associations and John Wiley & Sons Ltd

Getting my own tailored approach Several informants expressed the importance of health counseling being specifically tailored to their everyday life. They explained that they did not lack knowledge about health, rather they lacked the tools to make a healthier lifestyle fit into their daily lives. A woman in her 50s describes how the health supervisor helped her figure out how to practically implement the new habits into her everyday life: Here you have to say, OK what are you going to do instead and where do you do something that comes easy, so it doesn’t turn into a huge change. For example, it’s like wanting to go for a walk, when do we do it then. Is it right after work. Is it before dinner, is it after dinner. How do we make it fit practically into our everyday life (Female, 59). For seven of the informants, it had been a decisive factor that the health counseling was individual. They found the topic of their own health behavior personal and several informants describe that they would not have liked to sit in a group and talk about themselves. They describe that they would not have signed up if the intervention had been based on group sessions. The setting of health counseling was closely associated with the tailored approach. The duration of the health counseling intervention varied a lot between the informants and they explained that it was an advantage that it was not a given course

4 L. N. Andersen et al. they had to go through. Some informants preferred to have conversations bi-weekly, while others found it appropriate with longer intervals between the conversations. Some informants felt good about their health counseling process only lasting a few months, while others felt good about stretching the process across years. If it had been a course with a duration of three months then it would have been a big change . . . Now the course has had a duration of two years . . . and because it has been equalized over such a long period, I don’t think that it has been a big change. You have learned and you have taken it in and you have seen it from a completely different point of view and over time you have gotten rid of the old bad habits (Male, 44). For three of the informants, the tailored approach through health conversations was not sufficient and they decided to leave the health counseling intervention because it did not live up to their expectations. They would have preferred a health care service with, for example, fitness training, kitchen training and grocery shopping. Two of them expressed that it would have been motivating for them if the intervention had been based on group sessions which would allowed for sharing of similar challenges and experiences. The motivation becomes much larger if you are in a group. You talk to the others and you don’t think as much about it when others are also exercising, and you don’t think as much about the pain (Male, 51).

Small steps fit my life The tailored approach was associated with learning how to make small changes fit into one’s everyday life. One informant describes how the most important thing she learned during the process was to think in short sequences. It is the small steps. It is accepting that the small steps make a difference. I actually think that has been a crucial factor. Of course you can make some large changes to your lifestyle, but if you want it to last, then it cannot be too far from your everyday life (Female, 56). One informant had set a target that he would lose 5 kg each year, until he at some point in the future would weigh 100 kg. He was disappointed with intensive diets that failed. Several informants described that despite the fact that the changes were small, it required hard work to implement them in everyday life and it was difficult to accept that changing lifestyle was a long lasting process. One informant explained that when implementing several changes into everyday life, it was important to build up slowly, otherwise he would simply forget the initial changes. On the other hand, he describes that the small steps sometimes were too small. This made him ride 15 km on his bike instead of the 5 km he had agreed with the health supervisor, which in turn resulted in decreased motivation. Another informant describes that when he experienced success with smaller changes, he began to believe that he was also capable of changing other things. © 2014 Scandinavian Psychological Associations and John Wiley & Sons Ltd

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Well, now I have actually managed to get to where I wanted to go, but then these last couple of weeks, I found out that I actually want to go even further. It’s like a new box opening up (Male, 47).

It’s all about getting a response Most of the informants found that the health supervisor was able to support them in their process towards a lifestyle change. They explain that they had a feeling of being taken seriously and listened to. The health supervisor was able to provide support by following up on the points that had been discussed at previous consultations and by giving the informants feedback on their actions. It was nice just to talk about it, I mean, constantly following up on where you stand, right, that she was following me (Female, 59). The need for monitoring and feedback was present, both for those who experienced success with health counseling and for those who did not reach their goals and fulfill their expectations. A man in his 40s explains how the monitoring motivated him: Well, it is for example having someone that I have to go to and hand over this note and talk about what happened during the week, right (Male, 47). Several informants had a sense of obligation towards the health supervisor. The obligation was a motivating element for their behavioral change. One informant asked his health supervisor to be strict with him at the bi-weekly counseling, in order to keep him on track. Most of the other informants simply felt that they wanted to show their health supervisor that they had progressed. They did not want to waste anyone’s time. When there is another human being involved, you get the feeling that it is not good enough to show up and tell that you haven’t done anything. In a way, that has also been helpful (Female, 59). Two of the informants who did not feel that the health counseling had improved their lifestyle habits in the way they had wished for, explained that they would have liked even more control and kicks by the shins from the health supervisor.

I try to treat my body properly Physical improvements described as weight loss, increased fitness and reduced joint pains were for many informants connected to increased mental strength, a better mood and a feeling of control of their own situation. I believe that I have become a more positive and happy person after having been here. And I hope that everyone could become so. Because all of a sudden you start telling yourself that you decide for yourself whether you want to live longer. I mean, by trying to treat your body properly (Male, 58). Two informants described that their diabetes through lifestyle changes, had become much better and two informants who

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tended to have high blood sugar, experienced that they were able to control their blood sugar with their new lifestyle. I was running the risk of getting diabetes and stuff like that. And I ran my way out of that (Female, 56). Five informants experienced less pain after their health counseling course. Their previous pains were generally related to the joints in the lower limb. One informant describes how he believed that the pains were diminished because his body was more satisfied, when it did not have to carry around so much weight. Another explained how participating in health counseling had made him more aware of his body’s signals. Due to this, he was able to sense when he pushed himself too hard. Several informants describe how the physical improvements and a higher mental surplus made it easier to cope with work and daily activities such as climbing stairs, lacing shoes and gardening. For some informants, the increased mental strength resulted in succeeding with more things. You are stronger when you are in the middle of the choice right. That you know that if you do something one day which is not the optimal solution, then there is no reason to thump yourself in the forehead about it. Instead you just make the right choice the following day, right. So there’s a greater confidence that you know what to do (Female, 56). Several informants experienced health counseling as a process with personal development, where underlying causes of the unhealthy lifestyle emerged. For example, an informant described that he had realized that his eating habits were connected with him feeling sad. Informant 7 realized that he is the only one who can help himself through the long process of losing weight, while informant 9 considered whether changing her lifestyle was worth all the hard work if she could not be certain that there would be a reward in the end. Most informants experienced positive reactions and interest from family, friends and neighbors towards their lifestyle changes and weight loss. This support gave some informants the courage to maintain the lifestyle change and they felt that the support enhanced their confidence. One informant explained that the positive reactions to his weight loss, was not enough to motivate him to continue with the changed lifestyle. He would have liked his family to be part of the project and involved in the health counseling in order to support him. Four informants explained that it was difficult to introduce new eating habits because of lack of support from their families: And at home I have put my foot down and told my husband, but every time we go grocery shopping, he loves liver pate with red cabbage and he loves sausage and he continues to buy the same (Female, 62).

DISCUSSION From the study, it is clear that wishes to changing one’s life varies a lot. According to Bandura (1997), peoples’ belief in their ability to motivate themselves and regulate their own behavior, has a great influence on whether they consider changing their © 2014 Scandinavian Psychological Associations and John Wiley & Sons Ltd

Citizens experience of health counseling 5 behavior and participate in rehabilitative activities. The present study indicates that even though the informants established contact with health counseling in different ways, 10 out of 11 informants felt motivated and they all had clear objectives with the course. Only a few studies have examined why persons sign up for health activities. However, the findings of the present study are supported by a study examining patients’ experiences with self-referral for in-patient rehabilitation. A study by Andreassen and Wyller (2005) find that patients are motivated and have clear objectives regardless of whether they have applied on their own initiative. Furthermore, the feeling of being forced to sign up for the health promotion efforts offered by society which was described by informant 1, is also found in a study of unemployed people by Romppainen, Salaniemi, J€ahi and Virtanen (2012). In contrast to the study by Romppainen et al., (2012), informant 1 found the feeling of compulsion motivating. It is important to note that the results of the present study regarding motivation may be explained by the fact that participation in health counseling is voluntary. It is likely that those with no interest in health counseling have simply declined the offer. There may be two possible reasons why people are motivated for health counseling regardless of how they have been referred. One possibility is that citizens are actually motivated for health counseling even before they hear about the offer. Meaning that citizens are on different stages of change and therefore also have to go through different stages to change according to The Transtheoretical Model of Health Behavior Change (Prochaska & Velicer, 1997). This is supported by Brotons et al. (2012) crosssectional study which concludes that up to 48% of the respondents in a sample believe that they have to change either physical activity or eating habits. The second possibility is that the citizens need an external motivation in order to sign up for health counseling. This is in line with the informants’ descriptions of needing to feel an obligation towards another person. The present study found that the motivation for changing health behavior was associated with positive outcome expectations related to physical health improvement and changed appearance. The informants’ expectations of improving their appearance were founded in both personal wishes of increased self-satisfaction, but also in achieving wider social acceptance. According to Bandura (1997), positive outcome expectations are essential for making a behavioral change. This might explain why informant 7 who did not expect that health counseling would help him, quit the intervention. A dominant theme that emerges from the analysis is the importance of citizens getting their own tailored approach. In previous studies, the optimal amount of health counseling has been discussed (Hardcastle & Hagger, 2011). The present study shows that there were big differences in what persons considered to be an appropriate frequency and duration of health counseling. Except from informant 9, those who had a health counseling course of less than a year commonly have very clear goals for what they wanted to achieve through health counseling. They were also very clear on what role the health supervisor should fill in the process. On the other hand, those who had a health counseling course lasting two years or more, had a more general objective of improving their health behavior. They were, however, very aware of the importance of small steps and

6 L. N. Andersen et al. emphasized that health counseling had been a process of personal development. This indicates that those with an extensive course had low self-efficacy and that it was important for them to increase their feeling of control and self-efficacy through slow individual guidance. This is consistent with Bandura’s Theory (Bandura, 1997). For seven informants, it was essential that the health counseling was individual. They explain that they needed the tailored approach in order to adapt the lifestyle changes to their specific everyday lives. This finding is consistent with other studies which have shown that the tailored approach is more effective and that people prefer this to standardized messages (O’Sullivan et al., 2010; Skinner, Strecher & Hospers, 1994). To gain a deeper understanding of why people want an individual course, two underlying reasons were found; four informants had poor previous experience with being in a group. This may have resulted in poor mastery experience and thus a low degree of self-efficacy in group contexts. Three female informants found that their health was a private matter in which they did not wish to involve others. Common to these three was that they were very aware of how their being overweight affected their appearance. This may indicate that they feel embarrassed because of their overweight and that they do not want others to see them as vulnerable individuals. Three informants would have liked the health counseling to be carried out in groups where practical activities such as cooking and exercising would have been possible. The commonality is that they all articulate barriers associated with implementing new healthy habits to their everyday family life. This indicates a need for a community where citizens can mirror themselves in others’ health behavior in order to achieve vicarious experiences. This is consistent with Bandura (1997) and Ashford et al.’s (2010) conclusions stating that vicarious experiences is an important factor in increasing a person’s self-efficacy. Short- and long-term goal setting are important elements in the process of adopting a new health behavior (Bandura, 1986). In this study, several informants praised the Small Step approach and they acknowledged that a successful lifestyle change is achieved through small changes in everyday life. Adopting the perspective of Bandura, this can be interpreted as the informants achieving positive mastery experiences through small successes which then lead to increased self-efficacy. This is consistent with a review by Hill (2009), examining the effects of large versus small changes in relation to physical activity and diet. He concludes that small steps can be a successful route to creating sustainable lifestyle changes and reducing obesity rates. On the other hand, study results show that citizens find it difficult to accept small steps when you want significant results. Combined with citizens’ general need to feel obliged, this finding indicates that it is doubtful whether citizens can continue to implement small lifestyle changes after the end of their health counseling courses. Getting a response was an important element in the informants’ process towards a healthier lifestyle. The importance of being personally supported, listened to and taken seriously, is supported by Bandura’s (1997) theory which states that social persuasion strengthens the individual’s self-efficacy. It is tempting to assume that the informants have signed up for health © 2014 Scandinavian Psychological Associations and John Wiley & Sons Ltd

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counseling because of a doubt in their own ability to carry out the actions that will lead to a changed health behavior. Theoretically, this is linked to Bandura’s statement that people who have self-doubt about personal efficacy, need additional support and guidance (Bandura, 2004). Two of the informants who were not satisfied with health counseling, explained that they needed even more control and obligation towards the health supervisor. This may be interpreted as searching for external motivation because of self-doubt about personal efficacy. Also when linked to the concept of empowerment it may be interpreted that different informants have different needs. From this perspective the informants’ power to change life style can be seen as linked to informants’ actual life style and to the method used for enhancing empowerment (Smith, Tang & Nutbeam, 2006) and this may indicate that not necessarily all citizens are obvious choices for health counseling. The informants articulate the importance of receiving continuous feedback and being monitored continuously. This is consistent with a systematic review with meta-analysis examining whether increased self-efficacy results in increased physical activity, which concludes that feedback on previous performance increases self-efficacy (Ashford et al., 2010). The feeling of being obliged to comply with an agreement is also seen in a study by Walseth et al. (2011) dealing with lifestyle counseling in general practice. Walseth’s study found that feeling an obligation to follow the advice of doctors played a major role for patients. The importance of feeling responsible to someone when changing health behavior is also found in a study of health counseling for obese people by Hardcastle and Hagger (2011). The feeling of obligation and the desire to show the health supervisor that you are actively pursuing your goal can be further illuminated with the theory of gift giving by Mauss (2001). Mauss’s theory states that the fundamental and universal rule in social interaction is to give, receive and re-give. Viewed in this perspective, the fact that the citizens receive guidance and support provides them with a natural desire to deliver satisfactory results back to the health supervisor. The informant’s perceived impact of health counseling had great influence on their motivation for changing health behavior. The informants describe how changing their health behavior resulted in different reactions from their respective environments. As mentioned, perceived impediments and facilitators in the environment are important factors in the regulation of human behavior and motivation (Bandura, 2004). Some of the informants in the present study experienced difficulties in implementing new eating habits if their families did not support the project. This finding is supported by a qualitative study by Hardcastle & Hagger (2011), which shows that a lack of social support by partners presented a great barrier to the weight loss efforts of obese people. Furthermore, it is well demonstrated that family support is a key element for promoting and sustaining health behavior changes (Gruber & Haldeman, 2009). According to social cognitive theory, personal factors will influence human motivation, action and thought. In the present study, several informants experienced physical and mental improvements through the process of health counseling and regarded them as important motivators for adopting new health behavior. These experiences resulted in the informants becoming aware of their

Citizens experience of health counseling 7

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body’s signals and gave the informants a feeling of controlling, for example, pain, blood glucose and mood. This perceived control can be viewed as an increased belief in personal self-efficacy and a belief that the process of changing lifestyle can succeed. In addition, the informants experienced praise and positive feedback from their environment, which further increased the motivation of health change. Two of the three informants who were not satisfied with health counseling, felt that their efforts generated no results. This was discouraging to them and they did not get a feeling of self-control. The third informant, who was not satisfied, described that neither physical improvement nor positive feedback from the environment affected his motivation. From a psychosocial perspective, the lack of positive personal factors and the feeling of barriers in the environment had a negative impact on the self-efficacy of the three. This has a negative effect on their motivation and thoughts about a new health behavior.

treat one’s body ‘properly’, including increased self-control over body and mind. In addition feedback and feeling obliged towards the health supervisor shows to be essential aspects for citizens’ desire to change health behavior. The above aspects were also mentioned as crucial factors in signing up for health counseling. All informants who found health counseling insufficient, lacked support from immediate family in relation to implementing new healthy habits. They expressed a need for practical activities in groups and therefore individual health counseling might not be preferable for this group. A surprising finding is that the informants felt motivated and had clear objectives for health counseling, regardless of how they initially had been introduced to sign up for health counseling. This finding indicates that it may not be essential whether the initiative to a health effort stems directly from the citizen or from an externality. The authors declare that they have no competing interests.

Methodological considerations A critical review of the methods used in the present study indicates some limitations of the study. Forty eight citizens completed during the period, all were asked to participate in the study. Eleven wanted to participate in the study and it is reasonable to believe that those who were interviewed have had either a more positive or negative perception of the intervention than those who rejected. The number of interviews is quite small for quantitative research but relevant in this qualitative study aiming at understanding the processes operating in relation to our study aims. It is, however, assessed that the informants included in the study provided nuanced descriptions of their experience with participating in health guidance. The data collection and analysis was conducted by one researcher only, but an interrater reliability was guaranteed by feedback from other authors. The feedback was provided based on listening to one of the interviews and discussing the artificial quotes, which were created in the analysis process. In addition, the researcher was given complete knowledge of the material, which formed the basis for in-depth analysis and interpretation. In order to validate the results, the transcriptions were read and listened to several times. In between the interviews, the researcher had time to reflect on interview techniques and to discover new ways of understanding the subject. This improved the quality of the latter interviews. In order to ensure the internal validity, the researcher summarized the informants’ statements and asked clarifying questions during the interview sessions.

CONCLUSION This study provides knowledge about citizen’s experiences with participating in municipality-based health counseling. Based on the results of the study, we conclude that health counseling has the ability to promote self-efficacy in relation to health behavior. Informants who gave a positive evaluation of health counseling showed a clear tendency to change their life style. It is assessed that psychosocial aspects such as obtaining positive mastery experiences through having an individual tailored approach had a big significance for the citizens’ health behavior. The same is true, for the attempt to © 2014 Scandinavian Psychological Associations and John Wiley & Sons Ltd

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APPENDIX : INTERVIEW GUIDE Research question The project’s research questions

Themes What do I seek knowledge about?

Interview question Interview question in everyday-language

Demographic information

Age Education Work Social status Practical information regarding start and stop with HC

• How old are you? • Do you have any education? Which? • Do you work? • Do you have a family? • When did you start with HC? • How often did you attend HC? • How did you find a suitable frequency for the HC

sessions? Which factors made the citizen sign up for HC?

Motivation to sign up for HC

• Could you try to explain to me what HC is and how

you experienced it? • Where did you first hear about HC? • What made you sign up for this particular effort? • Can you describe how your environment (family,

friends, colleagues) reacted when you decided to start with HC? How did the citizen experience that HC affected his/her ability and inclination to change health behavior (self efficacy)?

Previous experiences with lifestyle changes (Mastery experiences, outcome expectations)

• What were your expectations to HC? • How did your health behavior change during the

period with HC? • Do you have previous experience with changing

health behavior? And how did it go? Goal setting and small steps

© 2014 Scandinavian Psychological Associations and John Wiley & Sons Ltd

• What was your objective with HC?

Citizens experience of health counseling 9

Scand J Psychol (2014)

Research question The project’s research questions

Themes What do I seek knowledge about?

Interview question Interview question in everyday-language

• Did you create a health plan with goals and

strategies? And what did this health plan mean to you? • Did you revise your health appointments from session to session? • Have you and your health supervisor discussed Small Steps? • Could you describe one of your small steps to me? What did you do before and what do you do now? An individual effort (vacarious experiences)

• What did it mean to you that HC was based on

Recognition and support (social persuasion)

• How did you experience the role of the health

individual sessions? supervisor? • Was it your experience that the health supervisor

was able to support you (in relation to previously mentioned items)? Perceived impact (physiological and affective changes)

• Could you try to explain what you found difficult

about changing health behavior? • Did you experience any physical and mental

differences during your HC course? If yes, how did it affect your will to keep making lifestyle changes? • Has the HC course provided you with any tools that you can make use of in the future? • Has the HC course made you think of something else? Did the citizen experience a reduction in pain during the HC course?

Pain

If the informants mentioned the topic pain during the interview, the interviewer asked further into this topic.

• Do you experience pain in your everyday life? • Could you try to describe how you experience the

pain? • How does the pain influence your everyday life

(work, spare time, sport, social life, sleep, mood)? • How did you experience the pain earlier? Before

you started with HC?

Debriefing • Is there anything I have forgotten to ask you about? Is there

anything you would like to say or ask before we stop the interview? • How did you experience participating in the interview? The interview guide has developed over time. For example, the interview guide initially contained more questions about pain. The reason why the questions regarding pain were brought

© 2014 Scandinavian Psychological Associations and John Wiley & Sons Ltd

in was that Kommunernes Landsforening has created an evaluation report of the health guidance project in Sønderborg. In this report, a questionnaire pointed towards that the citizens had experienced an improvement in their pain-levels during the HC course. On the other hand, the number of questions regarding Small Steps and the obligation towards the health supervisor increased. This was a natural development, as it turned out that these themes were of great importance to several of the citizens.