Supporting Change

last authored: Oct 2009, Dave LaPierre

"Thoughts always reflect themselves in behavior. As humans, we are often contradictory - we say one thing and do another. If we want to change our behavior, we need to notice our actions as see if we can uncover the belief that led to the response." Margaret Wheatley, Turning to One Another

 

Our choices have a big role to play in how our lives turn out, but it can be tough sometimes to both figure out the 'right' thing to do, and then do it. Health care providers have a big role to play in helping people decide on the best course of action and then follow through with it. Effective members of the health care team have skills in behavioural support, working collaboratively so as to deliver consistent messages.

 

 

Ambivalence

Ambivalence is feeling two ways about something or someone - "I love smoking, but I hate that I do it". It is very common and is a normal part of change. It can often be called 'lack of motivation", though it is, in fact, rare that someone is completely non-motivated to make healthy changes. For lasting change, it is important to identify and explore ambivalence.

 

It can be helpful to visualize a list of costs and benefits to a choice.

 

 

 

Factors Affecting Change

People need understanding of why a choice is good before they will be willing to participate in change (Krummel et al, 2002; Manne et al, 2002) Turning understanding into change depends on many factors, including: aversion to health risks, value of future health versus competing choices such as wealth or lifestyle, information sources, and advertising and marketing.

 

Understanding is only part of the story, however: people with addictions struggle to change their behaviours despite knowing how their choices harm themselves and others.

 

Perceived risk is a subjective assessment of personal risk, based on an individual's interpretation of epidemiological and other data, and even when it is understood, people sometimes prefer to enjoy current benefits without thinking of future health costs. "You're only young once" is a common statement. Social support networks (social capital) can have a big influence on change, and ambivalence cannot be understood outside the social context. People are also influenced by other external conditions - antimalarial bed nets may not be used due to availability and affordability.

 

Threats to Change

The closer someone moves to one choice, the more attractive the alternative frequently becomes (get info on this!) A choice also becomes more attractive if personal freedom is threatened or removed, similar to counterwill.

 

 

Self-Management

"The question is not whether patients can manage their chronic illness, but rather how well they manage." Bodheimer, 2002.

Supporting patient self-management module

Zwar et al. 2006.

• meta-analysis

 

 

 

Goal Setting

 

SMART Goals

help patients come up with the goal. Then ask 'how confient are you that you'll be able to accomplish this?" to measure Realistic.

If below 7, then a closer assessment of barriers and possible solutions is necessary.

 

SMART Goals:

Specific, Measurable, Achievable, Relevant, and Timely

Shape your behaviour: start small and build

stimulus control: identify events, situations, and people that elicit the unhealthy behaviour

reinforcement management

 

There are three broad mechanisms of change activity:

• pacing: small, gradually increasing steps
• pushing to tolerance: up and down
• waiting: activity gradually decreases

 

Stages of Change

The stages of change were identified by Prochaska and DiClemente as a universal pathway along which people travel as they change their behaviours. They include:

• precontemplation - not considering change
• contemplation - considering pros and cons of making change
• preparation
• action
• maintenance
• relapse

Discussing past experiences can be useful in opening dialogue.

 

 

 

The Five A's Model

 

The 5 A's model was developed by the National Cancer Institute to help people quit smoking, and has been refined to be applied to any behaviour change. The 5 A's stand for:

• Ask (to get pts to listen to you, listen to them)
  • do you view inactivity as a problem?
  • does being inactive concern you in any way?
  • are you interested in becoming more active?
  • are you ready to do something to accomplish right now?
• Assess
  • readiness to change
  • importance in relation to other values
  • why do you want to become more active?
  • how hard are you willing to work to fit increased activity into your life?
  • are you ready to work now to gain benefits later?
• Advise
  • make clear, specific, personalized recommendations
  • encourage SMART goals
  • remind patient to accept small gains
  • advise the patient to identify barriers/temptations/confidence
• Assist
  • use behaviour-change techniques, either self-help or counseling, to help the patient reach goals
  • encourage and support success through skills, confidence, and social/environmental supports
  • problem solve to address barriers and temptations
  • make yourself available contingent upon change - "if you meet goals, I'll see you more often"
  • suuplement with other treatments, ie medications, if necessary

 

• Arrange
  • schedule followups
  • refer to community supports
  • encourage patients to seek out active others

 

 

Molaison EF. 2002. Stages of change in clinical nutrition practice. Nutritional Clinical Care 5:251-7.

Prochaska JO and DiClemente CC. 1982

Zimmerman GL, Olsen CG, Bosworth MF. 2000.

 

 

Practical Strategies

get staff to pre-contact before visit

waiting room assessment forms: get patients to say how they're doing and what they'd like to work on

 

 

Three questions to open up self management, enabling the patient to discuss what is most helpful for them in their visit at that time.

• what worries you most about your health?
• how do you feel about it?
• what do you think you may be able to do about it?

Document SMART goals to review with patients when they return to clinic.

 

 

Self-Efficacy

Successful acievement of a goal is more important than the goal itself.

 

 

Motivating People to Not Get Sick

"I want you to work really hard for two weeks, and I won't throw you down the stairs" is very different than

"I want you to work really hard for two weeks, and I'll give you 500 dollars"

 

Behaviour is all about negotiation; it's their perspective

 

 

Barriers

Ambivalent patient

Reasons for Low Adherence

Intervention only works when you have control" - M. Vallis

Baserate for medication adherence is 50% McDonald, JAMA, (2002) 288:2868-9.

Mitka, JAMA, 2007, DASH

Woolf, JAMA, 2008 - 35% of all death

Reeves Rafferty Arch Int Med 2005; 165:854-7

• 3% of US population

Change is hard. Healthy behaviour has become abnormal.

• pleasure principle
• delayed gratification
• the more work you willingly do, the higher the quality of life; the more work you unwillingly do, the lower the quality of life
• we are more interested in short term gain, regardless of long term consequences
  • how would I feel two hours after eating this cake
  • next time time you hve a craving, eat it. just wait 20 minutes. In 40% of people, they'll decidie they don't want it
• the biggest predictor of what people eat is availablity: environment, social factors

avg caloric intake has gone up only a small amount; its the decrease in energy expenditure that is instead behind the obesity epidemic.

 

Don't take it personally and get offended. If patients don't change, don't feel like you've failed.

 

Problems arise in 3 main areas. Ask:

• is this a problem of motivation?
• is this a problem of behaviour modification?
• is this a problem of emotion management?

 

 

Systems Change

Change grows best when there is a safe space for it to grow. We need to develop and protect this space for others.

It has been said that when changing systems, both a top-down and grassroots cooperation are required.

 

With big change, timing is of incredible importance. Change can be slow or fast, depending on circumstances.

 

Look for clarity within the process of chaos (chaordic theory)

 

Do your homework and make action fly.

 

 

References

• Krummel DA, Humphries D, Tessaro I. Focus groups on cardiovascular health in rural women: implications for practice. Journal of Nutrition Education and Behavior 2002; 34(1):38-46.
• Manne S, Markowitz A, Winawer S, Meropol NJ, Haller D, Rakowski W et al. Correlates of colorectal cancer screening compliance and stage of adoption among siblings of individuals with early onset colorectal cancer. Health Psychology 2002; 21(1):3-15.

Five Steps to Intervention (the 5 A's). US Public Health Service, Agency for Healthcare Research and Quality.

Bodenheimer et at. 2002.

http://www.healthpartnerships.org

 

slides available at www.stonechurchclinic.ca

lmccart@mcmaster.ca