EDUCATION AND COUNSELING: BEHAVIORAL CHANGE 1_Chapter 15... · behavior or reaction to his or her environmental cues through ... Models for Behavior Change Changing behavior is the

EDUCATION AND COUNSELING: BEHAVIORAL CHANGE

1

Chapter 15

Objectives 2

Behavior change- what is it?

Factors affecting the ability to change

Cultural competency

Tools for effective communication

Models for behavior change

Anatomy of a counselling session

Counseling Strategy: Motivational Interviewing Readiness scale

Setting goals

Education and Counseling: Behavioral Change

Case Study

Mr. R is a 45-year-old African-American man with a longstanding PMH of HTN. At a screening clinic, his BP was found to be 200/120 mm Hg.

Father died of stroke at age 60

Mother is alive but has hypertension

Mr. R Knows that he needs to limit his salt intake

Mr. R. Knows what foods are high in sodium because he was given a handout listing high Na foods at his last appointment

Behavior Change

Nutrition education will only get a patient so far, this is where

counseling comes in. Effective counseling will move a patient

in the right direction at his or her own pace.

Behavior modification: Techniques to alter an individual’s

behavior or reaction to his or her environmental cues through

positive and negative reinforcement.

Factors Affecting the Ability to Change

Educator/counselor’s ability to share information

Educator/counselor’s ability to stimulate and support small changes

Income

Lack of social/family support

Vision loss

Literacy

Transportation

Memory

Desire to change

Physical and emotional factors

Cultural Competency

Cultural Competency Sensitivity and awareness of a culture

Respecting and understanding: attitudes, values and beliefs

Multicultural awareness is the first step toward developing rapport and being an effect counselor

Communication

Each culture values ideas, assumptions and beliefs about life and has means of decoding verbal and nonverbal messages

The use of unofficial translators (e.g. family members) is not desirable in health care

When using an official translator speak directly to your patient when speaking

Communication

Nonverbal (posture, gestures, concepts of time, spatial relationships, facial expressions, eye contact)

A good counselor is empathetic, genuine and respectful Find out how your patient would like to be addressed

Listen well

Share control of the conversation

Respect culture

Listen to what the patient is telling you- not just what you want to hear

Communication

Active Listening 1. Non verbal: varied eye contact attentive body language (relaxed and leaned toward patient) respectful yet close space adequate silence (allow your patient time to think) encouraging comments 2. Verbal: Often your initial rxn will be to solve a problem or give advice; instead give time to

let your patient contemplate his or her own solutions. Use open-ended questions Avoid jargon and slang

Paraphrasing and summarizing are methods used to show that you understand your patient and they you’re listening

Models for Behavior Change

Changing behavior is the ultimate goal for nutrition counseling. Education is not enough.

Based in behavioral science research provides us with several health behavior theories.

Counseling deals with HOW to change, not WHAT to change: Cognitive Behavioral Therapy; lifestyle change is difficult for most people.


Health Belief Model is a psychological model that attempts to explain and predict health behaviors. This model focuses on barrier to and benefits of changing behaviors

The HBM is based on the understanding that a person will take a health-related action (i.e., consume Ca) if that person:

1. Feels that a negative health condition (i.e., osteoporosis) can be avoided

2. Has a positive expectation that by taking a recommended action, he/she will avoid a negative health condition (i.e., consuming Ca will be effective at preventing osteoporosis)

3. Believes that he/she can successfully take a recommended health action (i.e., he/she can incorporate Ca into his/her diet).


Social Cognitive Theory: Individual learning occurs within a social context (observational learning)

Behavior: Knowledge, skills,

self-regulation and control, goal setting

Environment: Imposed and

selected environments

Personal: Self-efficacy, goals and

intentions


Theory of Planned Behavior: Intentions predict behavior


Stages of Change (Transtheoretical model 1992)- Is this model effective 2009?

Counseling Strategy: Motivational Interviewing

Motivational interviewing is an intervention designed for situations in which a patient needs to make a behavior

change but is unsure about the change, or how to make the change.


Anatomy of an appointment First session Establish rapport How would you like to be addressed? Ask a question or two to make the patient comfortable- how was the

commute in, do you live near by. You do not need to talk much- listen. Begin the appointment by asking what brings the patient in to see you. “My doctor said I had to.” “I want to lose weight.” “I don’t know”

Second appointment and beyond Begin with open-ended questions


Anatomy of an appointment con’t

Second appointment and beyond

Begin with open-ended questions/statements

Tell me how things are going…

How has the week been?


Anatomy of an appointment con’t Middle of Appointment Being asking more pointed questions about social, medical and

eating behaviors (allergies, 24h recall, likes, dislikes) This whole time try to determine how willing a patient is to change.

This will ebb and flow through all your appointments Our case study: 24h recall

B: 7a: 6 slices of bacon, 2 pieces of Wonder bread with jam S: 9am: 2 cans Sprite L: 12pm: Bologna on white bread. 1 cup of cottage cheese with 0.5 c. canned

peaches, potato chips (unknown amount) 2 cups of 2% milk D: 7pm: Spaghetti (5 cups) with jarred tomato sauce (2 cups) 4 turkey balls (golf

ball size) 2 Sprites, piece of birthday cake- about the size of 2 sponges


Tools to help you garner more information and facilitate behavior change Expressing empathy Patient says, “I know salty foods are making my pressures high but I like them.” Response: “I understand how choosing foods with less salt may not taste as good at first” Reflective Listening Listening well to all that the patient is saying. ***Use with caution, you don’t want your patient going off into an unhelpful tangent. You will likely hear that a patient wants to make changes but they want to pretend it’s not important. If it truly is not important to them you will not be able to get them to change. Developing Discrepancy Identifying awareness of advantages and consequences of changing is important. Where is there discrepancy in the above statement? Response: “Changing habits is hard for most people; I understand why you’re concerned.”


Tools to help you garner more information and facilitate behavior change

Rolling with Resistance Invite new perspective without imposing them. Let the client choose his or her own path even if it’s not the one you as the nutrition expert would have chosen. Response: “Many of my other clients feel the same way- do not make this about YOU. Do not say, “yeah me too”- this appointment has nothing to do with you. Supporting Self-efficacy The client needs to believe in his or her ability to change. Asking, “what else could you have done in that situation?”, then affirming the patient’s response often works.


Tools to help you garner more information and facilitate behavior change

Reflecting and Reframing (Summarizing) “What I hear you saying is that you love your life the way it is and you don’t want to change what you eat.” “Let me see if I understand what is making you feel frustrated. Your concerned because your parent died young so you think it will happen to you too no matter what.” Affirming Whatever what the patient says it’s important that you validate what they’re saying or feeling even if you disagree. I can see how you would be very nervous about following in the footsteps of your dad can be something you don’t like to think about. Changing habits is hard for most people; I understand why you’re concerned.


Eliciting Change: The 4 common strategies for self-motivated change:

1. Reflective listening

2. Asking open ended questions

3. Affirming

4. Summarizing

The goal is to get the client to realize a problem exists, establish a degree of concern about that problem, and assure the patient that the problem can be alleviated with positive behavior. One tool for doing this is the readiness scale.

Motivational Interviewing

Readiness scale

On a scale of 1-12 ask your patient a series of questions not only about the habit, but their confidence in changing that habit.


Mr. R is a 45-year-old African-American man with a longstanding previous history of hypertension. At a screening clinic, his BP was found to be 200/120 mm Hg. Father died of stroke at age 60 Mother is alive but has

hypertension Mr. R Knows that he needs to limit his salt intake Mr. R. Knows what foods are high in sodium because he was given a handout listing high Na foods at his last appointment

Our case study: 24h recall B: 7a: 6 slices of bacon, 2 pieces

of Wonder bread with jam S: 9am: 2 cans sprite L: 12pm: Bologna on white

bread. 1 cup of Cottage cheese with canned peaches potato chips (unknown amount) 2 cups of 2% milk

D: 7pm: Spaghetti (5 cups) with jarred tomato sauce (2 cups) 4 turkey balls (golf ball size) 2 Sprites, piece of birthday cake- about the size of 2 sponges


One a scale of 1-12 (12 being very concerned and 1 being not concerned at all) how concerned are you with your blood pressure being high? **Always answer positively If your patient says 2, indicating he is not concerned at all, you can ask say, “I see you picked a 2, why didn’t you choose a 1?” I see you like 6 slices of bacon as breakfast, bacon is a salty food. Could you make that number of slices smaller? On a scale of 1-12 how likely are you to make that change every day at breakfast? If your patient says 10, indicating he is very confident, you can ask say, “I see you picked a 10, why didn’t you choose a 9?” This will always frame their answer in a positive light and enhance the conversation and increase the patients confidence in their ability to change.


Anatomy of an appointment con’t

Ending the appointment

Have the patient set up 1-3 goals of their own- NOT goals you think are right for them.

I like to make one goal really easy to increase confidence, and have one that is a little harder, if the patient can “handle” it I let them set three goals. I like to have the patient write his or her own goals

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EDUCATION AND COUNSELING: BEHAVIORAL CHANGE 1_Chapter 15... · behavior or reaction to his or her environmental cues through ... Models for Behavior Change Changing behavior is the