Stages of Change

The purpose of patient education efforts often is to inform and to change behavior. Typically, the goal is to improve adherence to therapeutic regimens, encourage new lifestyles, or help the patient adopt other behaviors that prevent disease and disability. One of the most useful ways to understand the process of behavior change is the transtheoretical model, often called the "stages of change" model (Zimmerman et al., 2000). This model proposes stages called pre-contemplation, contemplation, preparation, action, and maintenance (Table 13-2). Precontemplation, contemplation, and preparation can be thought of as stages of motivation and readiness for change. In at-risk populations, typically 40% are precontemplators, 40% are contemplators, and 20% are in preparation (Prochaska and Velicer, 1997). Research has shown improvements in process and outcome measures when stage-matched interventions and recruitment methods are used (Prochaska et al., 2005). Although the model is described in a linear fashion, experience has demonstrated that patients naturally move back and forth among stages.

This model emphasizes the critical importance of the stage of change. Fortunately, it can usually be assessed with simple questions. Given typical constraints of time and resources in a primary care practice, most patient education efforts should focus on patients in the stage of preparation. Giving such patients the proper cue or knowledge to make a beneficial change is generally easy to provide. For simple

Table 13-1 USPSTF Recommendations for Patient Education and Table 13-2 Stages of Health Behavior Change

Counseling

Frame the teaching to match the patient's perceptions.

Fully inform patients of the purposes and expected effects of interventions and when to expect these effects.

Suggest small changes rather than large ones.

Be specific in recommending new behaviors.

Emphasize that it is easier to add new behaviors than eliminate established ones.

When feasible, link new behaviors to established ones.

Use the "power of the profession."

Obtain explicit commitments from the patient.

Use a combination of strategies.

Involve office staff.

Refer to community agencies, voluntary health organizations, reference material, and even other patients.

Monitor progress through follow-up contact.

From US Preventive Services Task Force: Guide to Clinical Preventive Services. Baltimore, Williams & Wilkins, 1996, p 953.

Precontemplation: Not intending to take action in the foreseeable future, usually measured as the next 6 months.

Contemplation: Intending to change in the next 6 months; aware of the pros and cons of changing, leading to procrastination.

Preparation: Intending to take action in the immediate future, usually measured as the next month; have a plan.

Action: Have made specific overt modifications to behavior within the last 6 months.

Maintenance: Working to prevent relapse, increasing confidence; typically lasts 6 months to 5 years.

From Prochaska JO, Velicer WF. The transtheoretical model of health behavior change. Am J Health Promot 1997;12:38-48.

behaviors (e.g., stretching before exercise), simple recommendations or an instructional pamphlet may be sufficient to accompany the physician's strong statement of support for the new behavior. For more complicated behaviors (e.g., dietary changes), one or more additional scheduled visits with the physician, a dietician, or other provider may be needed to set goals, convey knowledge or skills, and reinforce behavior change. A basic implementation of this thinking for health promotion has been called the "five As": ask, advise, assess, assist, and arrange. This approach has been promoted primarily for tobacco cessation (Kenford and Fiore, 2004).19

An important implication of the stages-of-change model is that encouraging action for patients in the precontempla-tion or contemplation stage is wasted energy. Instead, if the behavior is an important one, the goal should be to increase the patient's readiness for change. Research has shown that an increase in the "pros," or perceived benefits of change, is the most common finding when patients move from pre-contemplation to contemplation. Contemplators are usually weighing the perceived pros and cons of change in a manner that leaves them ambivalent about this decisional balance. Research indicates that movement from contemplation to action is most strongly associated with a decrease in the perceived cons of change. To reduce the cons for contemplators, the physician needs to identify these through open-ended questioning.

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