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Health Behavior and Its Change

Health Behavior and Its Change. Geoffrey C. Williams MD, PhD July 29 th , 2009 University of Oklahoma, Tulsa. Institute of Medicine.

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Health Behavior and Its Change

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  1. Health Behavior and Its Change Geoffrey C. Williams MD, PhD July 29th, 2009 University of Oklahoma, Tulsa

  2. Institute of Medicine • “Interventions must recognize that people live in social, political, and economic systems that shape behavior and access to the resources they need to maintain good health.”

  3. Why is Motivation Relevant to Health Behavior? “Diseases are of two types: those we develop inadvertently, and those we bring on ourselves by failure to practice preventive measures. Preventable illness makes up approximately 70% of the burden of illness and associated costs.” ~ C. E. Koop (1995)

  4. Determinants of health and their contribution to premature death 5% 15% Adapted from Schroeder. NEJM, 2007

  5. Actual Causes of Death 2000 Mokdad et al., JAMA 2004; 291:1238-1245

  6. Goals • Understand the impact of lifestyle-related behaviors on health. • Understand facilitation and impact of long-term behavior change for physical activity, tobacco, healthy diet, and medication taking.

  7. Global Positioning • In order for practitioners to act effectively to improve patients’ health, they need to be aware of: • the relevant health effects • what interventions are effective • the relative benefit of one intervention versus another • How is your global positioning?

  8. Motivating Health Behavior“Global Positioning” • What is the lifetime risk for diabetes mellitus for people born in US in 2000? • 7-8% • 15-20% • 30-40% • 50-60% • 75-90%

  9. Motivating Healthy Behavior • 30-40% is correct. • One in three Americans will develop DM in their lifetime. • 33% males • 38.5% females • Diagnosis at age 40 will result in 11.6 life years lost for a male, and 14.3 life-years for a female.

  10. Motivating Healthy Behavior“Global Positioning” • Which of the following does not increase risk for first myocardial infarction? • Second hand smoke • Smoking • Chewing tobacco • Nicotine replacement • Systolic BP between 120 and 140

  11. Motivating Healthy Behavior “Global Positioning” • Which of the following does not increase risk for first myocardial infarction? • 1. Second hand smoke RR 1.3 -1.7 • 2. Smoking RR > 3 • 3. Chewing tobacco RR > 2.2 • 4. Nicotine replacement CORRECT • 5. Systolic BP between 120 and 140 RR 2

  12. Motivating Healthy Behavior“Global Positioning” • Healthy Lifestyle (diet, alcohol, tobacco, PA, managing weight) accounts for what percentage incidence of coronary heart disease events over 15 years? • <10% • 10-25% • 25-50% • 50-75% • 75-100%

  13. Motivating Healthy Behavior “Global Positioning” • Healthy Lifestyle (diet, alcohol, tobacco, PA, managing weight) accounts for what percentage incidence of coronary heart disease events over 15 years? • 1. <10% • 2. 10 -25% • 3. 25-50% • 4. 50-75% Correct answer 62% (49-74%) • 5. 75-100%

  14. Lifestyle + Medications Adherence to 5 healthy lifestyles reduced coronary events by ≈62% in 16 years Adherence to healthy lifestyles reduced coronary events by 57% in men taking medications for HTN or dyslipidemia Men who adopted 2 lifestyle factors had 27% lower risk than those who did not LIFESTYLE CHANGES Eliminate tobacco exposure Body mass index <25 30 min/day physical activity Moderate alcohol use (1-2 drinks/day) Top 40% of healthy diet score 14 HTN = hypertension. Chiuve SE, et al. Circulation. 2006;114:160-167; Teo KK, et al. Lancet. 2006;368:647-58

  15. Motivating Healthy Behavior“Global Positioning” • Environmental tobacco smoke causes about the same mortality as: • Colon cancer • Alcohol • It does not increase mortality • Lifestyle – exercise & diet • Illicit use of drugs

  16. Motivating Healthy Behavior “Global Positioning” • Environmental tobacco smoke causes about the same mortality as: • 1. Colon Cancer (50K per year) • 2. Alcohol (100K) • 3. It does not increase mortality • 4. Lifestyle-Exercise & Diet (300K) • 5. Illicit Use of Drugs (20K)

  17. Motivating Healthy Behavior “Global Positioning” • In order for you to know how to best spend your time, you need to know: • What is the effect of intervening vs. not • Relative effect of different interventions • How to motivate people

  18. Adherence • Adherence is defined as the percentage of patient behavior/ the “recommended” amount of behavior • A complex interaction of the patient with practitioner and broader social climate • A motivated behavior that requires effort to maintain

  19. What I feel and think T Gordon, 1970 is different than What I say is different than What you hear is different than How you interpret what you have heard How you behave may be different than what you intend, and it is likely to be different than what I intended

  20. Adherence matters 31% of prescriptions are never filled Only 50% of long-term medications are taken as prescribed Non adherence costs $177 billion/yr Results in lost days at work, increased days in the hospital, and premature mortality NCPA, 2006 20

  21. Clinical Preventive Services Priorities • In spite of best intentions, adult patients have average of 12 risk factors requiring 24 preventive services • Resources are limited, and knowledge that an intervention is effective isn’t sufficient to set priorities • Therefore interventions need to be compared in their effectiveness to improve health

  22. Priorities Among Effective Services

  23. The Five A’s • ASSESS: Ask about/assess behavioral risk • ADVISE: Be clear, specific, & personalize • AGREE: Collaboratively set goals • ASSIST: Aid the patient in achieving goals • information, skill training, social supports and pharmacotherapy • ARRANGE: Schedule follow-up contact Whitlock, Amer J Prev Medicine, 2002:22 (4);267-284.

  24. Clinician Advice • Increases patient efforts to change behavior • Increases long-term abstinence from tobacco use by 30% (NNT=25-44) • Reduces problem drinking • Results in modification of some activity and diet related behaviors • Increases patient satisfaction

  25. Estimate of Effects of Advice Only versus Advice + Assist • If the percentage of physicians providing 1-3 min of tobacco counseling increased from 60-90%, it would result in 63,000 additional quitters each year. • If physicians provided 5A’s (10 minutes) it would result in 630,000 additional quitters each year.

  26. Motivation & Health Behavior • Several theories exist to support the USPSTF 5A’s Guidelines • Systematic counseling improves tobacco and alcohol outcomes • Practitioners need a concept of how we act to change patient behavior

  27. Motivation & Health Behavior • What is motivation? • What are your health related behaviors? • Tobacco, alcohol, regular exercise, diet • Why do you do what you do? • What affects your health behaviors? • How does your motivation affect your counseling?

  28. Motivation & Health Behavior • Motivation is human energy (psychological energy) directed at a particular goal • Energy and goals need to be accounted for to understand motivation and how to facilitate maintenance of the desired behavior or change. • Motivation for growth and health is intrinsic

  29. Motivation & Health Behavior • What interpersonal qualities would you want in your health care practitioner to begin to deal with changing a health related behavior (exercise, tobacco, alcohol, diet, drugs)?

  30. Motivational InterviewingMiller and Rollnick • F - Feedback • R - Responsibility • A - Advice • M - Menu • E - Empathy • S - Self-Efficacy

  31. What is Self-Determination Theory?

  32. Self-Determination Theory • An organismic dialectic • Motivation is human energy directed to a goal • Free choice • Assumptions: Humans are innately motivated toward growth, and health.

  33. Psychological Needs: Supporting Optimal Motivation • Autonomy • The need to feel choiceful and volitional in one’s behavior • Competence • The need to feel optimally challenged and capable of achieving outcomes • Relatedness • The need to feel connected to and understood by important others Deci & Ryan, 1991, 2000 Ryan & Deci, 2000

  34. Medical Professionalism –A Physician Charter • Primacy of patient welfare: a dedication to serving patients’ interests • Patient autonomy: to empower patients to make informed decisions • Social justice: to eliminate discrimination ABIM Foundation. Ann Intern Med. 2002;136:243-246

  35. Motivation • Autonomous motivation • Behaviors are chosen, and volitional • Behaviors are performed for their inherent value • Controlled motivation • Behaviors are pressured or coerced • Behaviors are performed for some separable outcome Ryan & Deci, 2000; Deci & Ryan, 1991, 1995 Sheldon, Ryan, Rawsthorne, & Ilardi, 1997 Nix, Ryan, Manly, & Deci, 1991 Ryan, Deci, & Grolnick, 1995

  36. The Role of Needs in Autonomous Motivation • Autonomy support • Keys to autonomy support • Elicit & acknowledge feelings & perspectives • Provide meaningful rationale • Support patient initiations to change • Expect failure in behavior change, reframe • Emphasize choice, effective options • Minimize control • Why autonomy support is important Deci, La Guardia, Moller, Scheiner, Ryan, 2006

  37. Internalization An inherent, proactive process by which autonomous and competence motivations are increased naturally over time

  38. Autonomy Support vs. Control Health Care Climate SDT Health Model of Health Behavior Change Mental Health Depression Somatization Anxiety Quality of life Autonomy Competence Relatedness Personality Differences in Autonomy Physical Health Not Smoking* Exercise* Weight Loss Diabetes Control Medication Use* Healthier Diet* Dental Health* Intrinsic vs. Extrinsic Values * RCT of Intervention to increase autonomy

  39. Autonomy Support Autonomous Motivation Composite Adherence .37 .78 Autonomy and Medication Adherence (N = 126) 39 Adapted from Williams GC, et al. Health Psychology. 1998;17:269-276

  40. Computer Assisted Intervention to Improve Autonomy Support • 866 patients with type 2 diabetes in primary care offices in Colorado were randomized to receive computer assisted, patient centered intervention to improve NCQA recommended diabetes outcomes over 12 months (Glasgow, 2005). • Secondary analysis of this study involved determining if the intervention increased patient perceived autonomy support.

  41. Baseline Autonomy Support 6-month Autonomy Support Improved Lipid Profile Reduced Diabetes Stress Decreased Depression Symptoms Baseline Perceived Competence 12-month Perceived Competence Change in Health Indicators Over 12 Months Williams GC, et al. Health Psychol. 26(6):728-34 41

  42. Summary Adherence and Motivation • Autonomy support, autonomy and competence all predicted glycemic control and healthier cholesterol in diabetes • Autonomy support, autonomy, and competence are all correlated with better quality of life for patients with diabetes and thus, enhancing autonomy and PC even if the patient isn’t adherent may enhance QOL. • Computer assisted case management may improve autonomy support

  43. Smoker’s Health Study Design • Randomized controlled trial of smoker’s invited to discuss their health whether they wanted to stop or not • Questionnaire assessments: • * autonomous motivation • * perceived competence • * autonomy support • Outcomes: • * Took Medication • * Tobacco Abstinence at 6, 18, and 30 months • * Reduction in % calories from fat, LDL-C

  44. The Intervention • The clinical endpoint of the intervention was to guide the patient to making a clear choice about whether he wanted to change or not. • If the patient wanted to stop smoking or change diet then the clinician provided competence training on how to reach that goal.

  45. Participants 1,006 smokers Slightly more than half did not to want to make a quit attempt Median income $10,000 below county Average education far below county

  46. SDT + Tobacco and Cholesterol Guideline • Intensive Treatment included: • 4 contacts over 6 months • Need support and information giving • Explore barriers and values • Shared decision making used to set plan • Problem solving/skills building • Pharmacotherapy (smoking only) • Control: Community care, encourage MD visit

  47. Values Exploration • Please tell me 2 or 3 important life goals • How does smoking help you reach that goal? • How does smoking prevent you from reaching that goal? • I think I understand more about how smoking fits into your life.

  48. Motivation and Medication Use in Intervention and Control Groups

  49. Health Outcomes at 6-months and 18-months

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