Department of Family Medicine
Health Promotion: Tool Box
Lifestyle behaviors are contributing factors in a number of chronic illnesses. Too often, however, patients do not take steps to alter unhealthy lifestyles until they are faced with a crisis or a condition that negatively impacts their lives. Even then, changing behaviors is not easy and some patients will not be willing to make any attempts. Non-adherence to medication regimens is as high as 65% while non-adherence to lifestyle behavior change recommendations is even higher.
-
How does a busy physician have time to discuss lifestyle issues with patients in a manner that will be effective?
-
How can adherence to advice to change lifestyle or medication regimens be increased?
The best predictors of adherence are the physician's interviewing skills and qualities of the provider-patient interaction. Patient demographics are not reliable predictors. Essential elements to increase adherence include establishing an atmosphere of trust and concern for the patient's well-being, and an understanding of how behavior change takes place. Provider frustration levels with non-adherent patients can be reduced with an appreciation for the role of the patient's motivational level and resultant tailored interventions.
This Tool box contains information on specific strategies to use when encouraging lifestyle change.
Getting Started
Review the Transtheoretical Model (Stages of Change) below, the basis for our intervention approach.
For Specific Interventions, select one of the following:
Tips on Counseling Patients
Fight the Addiction–Smoking Cessation
Encourage Patients to Lose Weight
Combat a Sedentary Lifestyle–Exercise
Click on Patient Education for more information.
THE TRANSTHEORETICAL MODEL
(Stages of Change)
Change is a process, not an event.
About the model:
-
Provides a framework for understanding health behavior change which spans a multitude of theoretical approaches
-
Built on five stages of change
-
Describes ten basic processes of change that occur through the series of stages, over time
-
Uses constructs such as the decisional balance, self-efficacy, and temptation which are important to change
-
Teaches how to identify which stage your patients are in before beginning counseling or recommending programs
STEP 1: IDENTIFY STAGE
The 5 stages of change and characteristic attributes of patients:
Precontemplation—Not intending to take action in the next 6 months. These patients are commonly referred to as resistant or unmotivated, but clearly, they are not ready to change. In reality, it is often our intervention programs that have not been ready for them.
Contemplation—Aware of pros and cons of changing and intends to change in next 6 months. This is the area where many get stuck.
Preparation—Intending to take action in the next month; patient may have done something already, i.e., read a book, talked to physician or counselor. Recruit these people for action-oriented programs.
Action—Patients have taken action that is significant enough to result in a reduction of risks for disease. For example, cutting fat down to 50% of total calories consumed is a step in the right direction, but would not be considered action until it was down to 30%.
Maintenance—Working to prevent relapse.
STEP 2: SELECT STAGE-APPROPRIATE INTERVENTION
Low retention rates and the failure of many programs to effect long-term behavior change result from a mismatch between the type of intervention and the patient's readiness to change. Many traditional programs are action-oriented while the majority of at-risk populations are not in the action stage. See the "Stage, Process, Intervention" chart below.
Remember: "There is no inherent motivation to progress through the stages of intentional change as there seems to be in stages of physical and psychological development." Prochaska, et al in Shumaker, et al (Eds.) (1998) Handbook of Health Behavior Change, p. 64.
STEP 3: UNDERSTAND THE CHANGE PROCESSES
How does movement between stages occur? The processes below are the tools people use to move from stage to stage. Although the structure of processes within stages is not as consistent across behaviors as the structure of the stages of change, this descriptive chart will be helpful. Note that in the early stages, processes may be cognitive, affective, or evaluative. With action, they become more behaviorally oriented. Also listed are examples and interventions associated with each process.
Stage Process
Intervention
Patient Education
As the majority of your patients are probably in the precontemplation stage, an effective patient education campaign is an integral component of your practice.
Educational materials in the form of brochures or videos can be helpful for those in precontemplation to start the patient thinking about the problem. These may be supported by a brief visit with a patient educator, nurse, or other support personnel who can answer initial questions.
There are several sources for patient education fact sheets/handouts that can be downloaded or ordered. Check out the following sites:
American Academy of Family Physicians
Centers for Disease Control and Prevention
Patient Education on the Web
As more and more patients have access to and/or computer skills, the World Wide Web has become an important distributor of health information.
Many health-related websites have support groups on-line, ask-an-expert chat rooms, and links to medical reference materials for more in-depth information. For a list of sites with patient-oriented information, click here.
Decisional Balance
Another component of the transtheoretical model is the decisional balance. Stated simply, before patients are ready to change, the pros for changing an unhealthy behavior must outweigh the cons. More specifically, in precontemplation there are more reasons not to change (cons) than reasons to change (pros), so to move from precontemplation to contemplation, the emphasis should be on increasing the pros. To move from contemplation to preparation and action, the emphasis is on decreasing the cons. Before taking action, the pros should increase twice as much as the cons decrease. Ask patients, "Can you think of some benefits to changing your ____ behavior?" For some patients, making lists of pros and cons may be helpful.
References
-
Shumaker, et al. (Eds.) (1998). "The Transtheoretical Model of Behavior Change" in The Handbook of Health Behavior Change, Second Edition. New York: Springer Publishing Company, Inc.
-
Sloane, P., et al (Eds.) (1998) "Helping Your Patients Stay Healthy" in Essentials of Family Medicine, Third Edition. Baltimore: Williams & Wilkins.
Contact Information
| Dr. Peggy J. Wagner Research Director Email: pwagner@mcg.edu (706) 721-7589 |