The Heart Truth Educational Slide Module: Behavioral aspects

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Cardiovascular Disease in WomenModule VIII
Behavioral Aspects for CVD Prevention in Women
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This presentation is specifically designed to
assist Primary Care Providers in helping their
patients TAKE HOME TAKE TO HEART THE HEART
TRUTH
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The following issues will be discussed
What to Change Most of the Heart Truth
lifestyle interventions involve a need for
behavioral change. This change involves both the
provider and the patient. Strategy for Change
For Heart Truth lifestyle interventions to be
effective they require a strategy that entails
counseling for behavioral change and seeking the
patients commitment to such change.
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Also to be discussed
Clinical Impact It is extremely important that
the provider determines on an ongoing basis the
overall progress of the patient relative to the
effectiveness of the provider-patient
relationship in terms of achieving behavioral
modification and reaching Heart Truth clinical
measures and benchmarks
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What to Change
Adverse Behaviors

• Most of the Heart Truth lifestyle interventions
  deal with adverse behaviors
• Cigarette smoking
• Deficient physical activity
• Deficient dietary plan
• Deficient weight maintenance or reduction

Sources Mosca 2007
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What to Change
Level of Participation

• Effective health care in general is an active
  phenomenon that requires the active participation
  of the patient and provider in order for positive
  outcomes to be achieved
• The degree of behavioral modification achieved is
  aggregate evidence of the effectiveness of this
  active participation

Sources Prochaska 1992, Zimmerman 2000
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What to Change
Provider Obstacles

• Some providers have doubts about their patients
  ability to change
• Some providers doubt that behavioral change will
  have any real impact on health outcomes of their
  patients

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What to Change
Provider Obstacles

• Some providers have difficulty finding the time
  they think they need to become a change agent for
  their patient
• Some providers fear that they do not know what to
  do even if they wanted to help due to lack of
  training in this area

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What to Change
Provider Obstacles

• Having a specific strategy to address change
  saves time and alleviates the providers fear of
  the unknown
• These provider-specific obstacles must be removed
  or the provider should refer the patient to
  another provider, in the best interests of the
  patient

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Strategy for Change
Counseling Framework for Change

• Assess (or Ask)
• Advise
• Agree
• Assist
• Arrange

The 5-As
Sources Whitlock 2003
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The 5-As
Counseling Framework for Change

• Assess (or Ask about) risk factors, beliefs,
  behavior, and knowledge about a lifestyle
  intervention
• Assess whether she is willing to initiate steps
  towards modifying her behavior in the direction
  of the Heart Truth objectives
• Assess knowledge, skills, confidence, conviction,
  supports, and barriers
• Provide feedback to her about assessment

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The 5-As
Counseling Framework for Change

• Assess importance with good questions.
• How important do you think it is to change this
  targeted behavior?
• On a scale of 1 to 10 with 1 being not
  convinced at all to 10 being totally
  convinced, how important is it to you?
• What makes you say 3, why not 0?
• What would it take to move it to a 6?

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The 5-As
Counseling Framework for Change

• Assess what or who is important
• What or Who is important or of value to you?
• What would they do without you or what would
  they do if you became disabled from a
  complication of heart disease?
• Use the answer to these questions as leverage in
  your dialogue about the importance of changing
  targeted behavior

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The 5-As
Counseling Framework for Change

• Advise with a clear personalized message
• Expound on the dangers that are specific to her
  in relationship to the targeted behavior
• Advise her about the benefits of change
• Make the source of your advice clear (medical
  knowledge or from similar patients)

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The 5-As
Counseling Framework for Change

• Advise with a clear, simple, and personalized
  message.
• Provide advice at a patient-determined level of
  comprehension
• Try not to overload her with information in one
  session
• Can you review for me what we just discussed so
  I know that I made it understandable?

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The 5-As
Counseling Framework for Change

• Agree on goals and plans
• Goals are something to achieve in 3-6 months
• Collaboratively select goals based on patients
  interest and confidence in her ability to change
  the targeted behavior
• Base goals on the patients priorities
• Plans are specific steps to help achieve goals

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The 5-As
Counseling Framework for Change

• Assist with goals and plans
• Develop a Personal Action Plan that includes
• What to do How to do it Where to do it
• What to use When to do it How often
• Barriers to doing it Plans to overcome barriers
• Follow-up plan

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The 5-As
Counseling Framework for Change

• Assist
• Personal Action Plan
• Patient should give herself a confidence rating
  in achieving the Personal Action Plan
• The action plan should be re-worked if her level
  of confidence is lower than 7 on a scale of 1 to
  10

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The 5-As
Counseling Framework for Change

• Assist
• Personal Action Plan
• Make certain that she has appropriate
  expectations
• Early on, help her pick some easily achievable
  goals (the low hanging fruit) to help build
  confidence to tackle greater goals

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The 5-As
Counseling Framework for Change

• Assist in problem solving with Personal Action
  Plan.
• Identify problem
• List all possible solutions (brainstorm)
• Pick one
• Try it for 2 weeks
• If it doesnt work, try another

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The 5-As
Counseling Framework for Change

• Assist in problem solving
• If that doesnt work, find a resource for ideas
• If that doesnt work, accept that the problem may
  not be solvable now
• Move on (but come back later)

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The 5-As
Counseling Framework for Change

• Assist in changing behavior
• Provide self-help and counseling pathways to aid
  patient in achieving agreed upon goals
• Aid the patient in acquiring skills, confidence,
  and social/environmental supports

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The 5-As
Counseling Framework for Change

• Assist in changing behavior
• Women tend to respond best to intensive
  interventions between the provider and the
  patient
• Women tend to respond, more so than men, to
  support groups

Sources Whitlock 2003
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The 5-As
Counseling Framework for Change

• Assist with resources
• Match resources (community, literature, groups)
  with patient preferences
• Utilize outreach and community opportunities
  whenever feasible

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The 5-As
Counseling Framework for Change

• Arrange follow-up
• Schedule follow-up visits or contacts for purpose
  of providing ongoing assistance and support
• Try a variety of follow-up methods when feasible
  (in person, phone, email, groups)

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The 5-As
Counseling Framework for Change

• Arrange follow-up
• Making sure follow-up happens builds patient
  trust in the agreed upon clinical pathway
• Adjust the plan as needed during follow-up visits
  or contacts, including referral elsewhere for
  more intensive intervention

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Strategy for Change
Stages of Behavioral Change

• Pre-contemplation
• Contemplation
• Preparation
• Action
• Maintenance
• Transformation

• Prochaska DiClemente model

Sources Prochaska 1992
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Prochaska Model
Stages of Behavioral Change

• The provider should be able to determine which
  stage of change the patient is in with respect to
  the targeted behavioral concern.
• Applying the 5-As at each stage of change
  process affords the provider a monitor in guiding
  and motivating the patient along her trip to
  Transformation

Sources Prochaska 1992
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Prochaska Model
Pre-contemplation stage

• She is not ready to change
• She is not thinking about change
• She may be resigned to not changing
• She expresses feeling of no control
• She exhibits denial or believes consequences are
  not serious

Sources Prochaska 1992
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Prochaska Model
Contemplation stage

• She is thinking about changing
• She is weighing the relative benefits and costs
  of the her current behavior and those of the
  proposed change

Sources Prochaska 1992
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Prochaska Model
Preparation stage

• She has begun experimenting with small changes
• She is getting ready to make a move towards
  behavioral modification
• She is establishing a goal or at least thinking
  about it

Sources Prochaska 1992
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Prochaska Model
Action stage

• She has started her journey towards
  Transformation by applying herself to her
  definitive Personal Action Plan designed to
  facilitate behavioral modification

Sources Prochaska 1992
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Prochaska Model
Maintenance stage

• She is maintaining new behavior continuously over
  an extended period of time (gt180 days) to
  accomplish the overall goal

Sources Prochaska 1992
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Prochaska Model
Relapse

• The Ups Downs is a normal part of the process
  of change
• She may regress to the beginning stages of the
  Change Model
• She may feel demoralized or disappointed (which
  often occurs) by set back
• Sometimes original goals are set too high or low
  or aggressive

Sources Prochaska 1992
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Prochaska Model
Transformation

• She feels self-assured and feels that only time
  separates her from her ultimate goal (if not
  already reached)
• Transformed patients are often willing to and
  capable of being role models for other patients
  with similar clinical issues

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Clinical Impact
Keeping Score of Clinical Impact

• For each identified behavioral change-dependent
  Heart Truth lifestyle intervention, document in
  the health record where the patient is with
  respect to the Prochaska stages

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Clinical Impact
Keeping Score of Clinical Impact

• In documenting the stage of change, a numbered
  scale from 1 to 6 might help
• 1 / pre-contemplation
• 2 / contemplation
• 3 / preparation
• 4 / action
• 5 / maintenance
• 6 / transformation
• This enumeration creates a Change Scale

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Clinical Impact
Keeping Score of Clinical Impact

• Where your patient is on the Change Scale scores
  how far you have advanced relative to the extent
  to which she is responding to your methodology
  and available resources
• Repeatedly ask yourself Can I and What Can I
  do better or more of in helping and
  motivating my patient towards beneficial change,
  thus improving the score?

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Clinical Impact
Keeping Score of Clinical Impact

• The clinical impact of the Heart Truth objectives
  is dependent on
• Achievement of recommended Heart Truth clinical
  measures and benchmarks
• Availability of and access to resources
• Degree of difficulty and severity of the
  patients condition, inclusive of co-morbidities

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Clinical Impact
Keeping Score of Clinical Impact

• Finally, the clinical impact of the Heart Truth
  objectives is dependent on
• The effectiveness of the provider-patient
  relationship and all that it entails (e.g.,
  dedication of time, use of resources, intensity
  of participation of all parties, provider
  patient resourcefulness, and contributions of all
  parties)