Cardiovascular Disease in WomenModule VIII: Behavioral Aspects for CVD Prevention in Women

This presentation is specifically designed to assist Primary Care

Providers in helping their patients TAKE HOME & TAKE

TO HEART THE HEART TRUTH

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 patient’s commitment to such change.

The following issues will 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

Also to be discussed:

What to Change

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

Adverse Behaviors

Sources: Mosca 2007

• 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

Level of Participation

What to Change

Sources: Prochaska 1992, Zimmerman 2000

• 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

Provider Obstacles

What to Change

• 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

Provider Obstacles

What to Change

• Having a specific strategy to address change saves time and alleviates the provider’s 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

Provider Obstacles

What to Change

Assess (or Ask)

AdviseAgreeAssistArrange

The “5-A”s

Counseling Framework for Change

Strategy for Change

Sources: Whitlock 2003

Assess (or Ask about) risk factors, beliefs, behavior, and knowledge about a lifestyle interventionAssess 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

Counseling Framework for Change

The “5-A”s

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’?”

Counseling Framework for Change

The “5-A”s

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

Counseling Framework for Change

The “5-A”s

Advise with a clear & personalized messageExpound on the dangers that are specific

to her in relationship to the targeted behavior

Advise her about the benefits of changeMake the source of your advice clear

(medical knowledge or from similar patients)

Counseling Framework for Change

The “5-A”s

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?”

Counseling Framework for Change

The “5-A”s

Agree on goals and plansGoals are something to achieve in 3-6

monthsCollaboratively select goals based on

patient’s interest and confidence in her ability to change the targeted behavior

Base goals on the patient’s prioritiesPlans are specific steps to help achieve

goals

Counseling Framework for Change

The “5-A”s

Assist with goals and plansDevelop a Personal Action Plan that

includes:What to do; How to do it; Where to do itWhat to use; When to do it; How oftenBarriers to doing it; Plans to overcome

barriersFollow-up plan

Counseling Framework for Change

The “5-A”s

AssistPersonal 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

Counseling Framework for Change

The “5-A”s

AssistPersonal 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

Counseling Framework for Change

The “5-A”s

Assist in problem solving with Personal Action Plan.Identify problemList all possible solutions (brainstorm)Pick oneTry it for 2 weeksIf it doesn’t work, try another

Counseling Framework for Change

The “5-A”s

Assist in problem solvingIf that doesn’t work, find a resource

for ideasIf that doesn’t work, accept that the

problem may not be solvable nowMove on (but come back later)

Counseling Framework for Change

The “5-A”s

Assist in changing behaviorProvide self-help and counseling

pathways to aid patient in achieving agreed upon goals

Aid the patient in acquiring skills, confidence, and social/environmental supports

Counseling Framework for Change

The “5-A”s

Assist in changing behaviorWomen tend to respond best to

intensive interventions between the provider and the patient

Women tend to respond, more so than men, to support groups

Counseling Framework for Change

The “5-A”s

Sources: Whitlock 2003

Assist with resourcesMatch resources (community, literature,

groups) with patient preferencesUtilize outreach and community

opportunities whenever feasible

Counseling Framework for Change

The “5-A”s

Arrange follow-upSchedule 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)

Counseling Framework for Change

The “5-A”s

Arrange follow-upMaking 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

Counseling Framework for Change

The “5-A”s

Prochaska & DiClemente model

Stages of Behavioral Change

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

Strategy for Change

Sources: Prochaska 1992

• 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-‘A’s at each stage of change process affords the provider a monitor in guiding and motivating the patient along her trip to ‘Transformation’

Stages of Behavioral Change

Prochaska Model

Sources: Prochaska 1992

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

Prochaska Model

Sources: Prochaska 1992

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

Prochaska Model

Sources: Prochaska 1992

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

Prochaska Model

Sources: Prochaska 1992

Action stage• She has started her journey towards

Transformation by applying herself to her definitive Personal Action Plan designed to facilitate behavioral modification

Prochaska Model

Sources: Prochaska 1992

Maintenance stage• She is maintaining new behavior

continuously over an extended period of time (>180 days) to accomplish the overall goal

Prochaska Model

Sources: Prochaska 1992

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

Prochaska Model

Sources: Prochaska 1992

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

Prochaska Model

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

Keeping Score of Clinical Impact• In documenting the stage of change, a

numbered scale from 1 to 6 might help:1 / pre-contemplation 2 / contemplation3 / preparation 4 / action 5 / maintenance 6 / transformation

• This enumeration creates a Change Scale

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?

Keeping Score of Clinical Impact

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 patient’s condition, inclusive of co-morbidities

Keeping Score of Clinical Impact

Clinical Impact

Keeping Score of Clinical Impact

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)