Applied Evidence
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PRACTICE RECOMMENDATIONS
› Determine the patient’s stage of change (Precontemplation, Contemplation, Preparation, Action, Maintenance, or Relapse) before selecting an intervention to help him or her change health-related behaviors. B
› Consider using motivational interviewing or narrative techniques to help patients who aren’t yet ready to change their health-related behaviors or who plan to do so within 6 months. C
› Be aware that patients seldom become motivated to change behaviors by being given information about health risks and benefits; to overcome ambivalence, they need to focus on their core values and goals. C
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series
CASE › Your patient, Bob G, age 47, has a body mass index of 33, hypertension (blood pressure 150/85 mm Hg), and elevated cholesterol (low-density lipoprotein level, 187 mg/dL) and glucose levels (fasting glucose 122 mg/dL, with an HbA1c of 6.1%). He gets out of breath when he plays with his 2 children. His father has diabetes and had a myocardial infarction (MI) at age 55; Mr. G tells you he is concerned he will develop similar health problems. Mr. G frequents fast food restaurants and eats high-calorie snacks after work, especially when he feels stressed. During a recent office visit, he expresses his desire to “be there” for his children and says he is motivated to lose weight to prevent diabetes and/or an MI.
How would you proceed?
Most health conditions in the United States are directly or indirectly the result of patients’ health-related behaviors.1 Fortunately, family physicians (FPs) and primary care teams are in an excellent position to help their patients make healthy behavior changes by using brief, evidence-based interventions that can be implemented during the typical office visit.
Specifically, the use of the following 7 techniques can build on patients’ own motivations, successes, and life circumstances to improve their satisfaction and self-efficacy:
- the 5 As (Ask, Advise, Assess, Assist, Arrange)
- the FRAMES protocol (Feedback, Responsibility, Advice, Menu, Empathy, and Self-efficacy)
- teachable moments (TM)
- solution-focused brief therapy (SFBT)
- cognitive behavioral therapy (CBT)
- narrative techniques (NT)
- motivational interviewing (MI).
But before we describe the practical application of these 7 techniques, we’ll begin by explaining a few underlying concepts for helping patients change their health-related behaviors.
Understanding what does—and doesn’t—help patients change
Research from the field of psychology and other social sciences has described several important concepts that affect how FPs can best help their patients change to healthier behaviors.2-9 First, several “common factors” have been found to reliably predict behavior change. The likelihood of change is strongly tied to the patient’s strengths, the environment, and the quality of the physician-patient relationship. The patient’s expectations and the techniques a physician uses also predict behavior change, but to a lesser extent.10
Second, patients seldom become motivated to change ingrained behaviors solely by being provided with information about the risks and benefits associated with those behaviors. People overcome ambivalence and develop motivation for change when they align their behaviors with their core values and goals. FPs can help patients link their motivation to change to specific plans and environments. This can then facilitate small changes that can yield large returns by increasing a patient’s self-efficacy and sense of control.2-9
Third, willpower is a finite but renewable resource that increases or decreases based on an individual’s internal and external environments. Reliance on willpower alone to make changes is unlikely to be successful without shaping the environment to support the new behavior.11
A patient’s readiness to change affects choice of technique
Knowing how ready a patient is to change is important for determining which approaches are likely to be effective at a given visit. Prochaska and DiClemente developed a model that defines 6 stages of change: Precontemplation (patient does not intend to change in the next 6 months), Contemplation (patient intends to change within the next 6 months), Preparation (patient intends to change within the next month), Action (patient has made specific changes within the past 6 months), Maintenance (patient works to prevent relapse), and Relapse (patient returns to an earlier stage) (TABLE).12
Patients who identify change as important and are ready to make changes benefit from collaborative work with an FP or other clinicians on the how, when, where, and who (eg, the patient, his or her significant other, family, and friends) of the new behaviors. These individuals are in the Preparation or Action stages of change, which comprise roughly 20% of patients.13 In these circumstances, techniques such as the 5 As, FRAMES, TM, SFBT, and CBT can be effective.