The experience of daily positive affect -- a mild, happy feeling -- and self-affirmation helps some patients with chronic diseases, including coronary artery disease, high blood pressure and asthma, make better decisions about their health.
These findings are detailed in three studies of 756 patients published online in the Jan. 23 edition of the Archives of Internal Medicine -- the first large, randomized controlled trials to show that people can use positive affect and self-affirmation to help them make and sustain behavior change. The research was funded by a $9.5 million contract from the National Heart, Lung and Blood Institute (NHLBI) of the National Institutes of Health (NIH) and led by Dr. Mary Charlson, executive director of the Center for Integrative Medicine at Weill Cornell Medical College and the William T. Foley Distinguished Professor of Medicine and professor of integrative medicine at Weill Cornell Medical College. She is also chief of the Division of Clinical Epidemiology and Evaluative Sciences Research in the Department of Medicine at Weill Cornell Medical College.
The same intervention was used in all three studies. Patients were encouraged to think of small things in their lives that make them feel good (such as seeing a beautiful sunset) when they get up in the morning and throughout their day. Patients were also asked to use self-affirmation to help them overcome obstacles to their plan by recalling moments in their lives they are proud of, such as a graduation (see script excerpt below). The script, created by Dr. Charlson, is now in the public domain and free to use.
"This simple approach gives patients the tools that help them fulfill their promise to themselves that they will do what's needed for their health," says Dr. Charlson. "For example, if it's raining and they don't feel like exercising, these strategies can help them get past this mental block and into their sneakers."
Excerpt from Positive Affect/Self-Affirmation Script:
First, when you get up in the morning, think about the small things that you said make you feel good, like __________________________ (example: babies in hats, the sunrise...). Then as you go through your day, notice those and other small things that make you feel good and take a moment to enjoy them. Second, when you encounter some difficulties or are in a situation that makes it hard for you (e.g. taking your blood pressure medications or exercising), think about things you enjoy or proud moments in your life, like __________________________ (example: a graduation, success of a child...).
The behavior changes employed in the studies are known to be beneficial -- whether it is increased physical activity for coronary artery disease or regularly taking medication for high blood pressure or asthma. "In this way, positive affect made a real difference -- patients are better able to follow through on behaviors to improve their health," Dr. Charlson adds.
Patients were randomly assigned either to the experimental "positive affect" group or to a control group. Both groups made personal contracts to adhere to their behavior plans, were given an educational guide on the importance of their intervention, and received phone calls every two months to check in on their progress. Along with daily use of positive affect, patients in the experimental group received surprise gifts like tote bags prior to the phone sessions. The monetary value of the gifts was unimportant, Dr. Charlson explains; rather, they were symbolic and served to reinforce the intervention.
Results were measured at the completion of the yearlong studies. For coronary artery disease, 55 percent of patients practicing the positive affect/self-affirmations increased their physical activity compared with 37 percent in the control group; the positive affect group walked an average of 3.4 miles a week more than the control group. For high blood pressure (the study focused on African-Americans with the disease), 42 percent of the positive affirmation group adhered to their medication plan compared with 36 percent in the control group. For asthma patients, there was no difference in energy expenditure between the two groups; however, there was some benefit for patients requiring medical care during the trial.
The design of the studies, which simultaneously tested the same intervention for different populations, was one of the first for NIH-funded research, and began with contract awarded to Weill Cornell Medical College in 2002. This intervention development approach is now being more broadly used in the obesity-related behavioral intervention trials (ORBIT) sponsored by the NIH. Dr. Charlson is a recipient of an award titled "SCALE: Small Changes and Lasting Effects" under the ORBIT trials. The findings of the three trials are the basis for "SCALE" for overweight or obese patients.
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