GP s Consult Health Behaviour Change WONCA 03-07 september 2005 Kos - Greece

1. GP�s Consult &Health Behaviour ChangeWONCA 03-07 september 2005Kos - Greece

2. Health promotion and prevention of illnessStrategy of the Flemish government (1997) Health targets (5) Nutrition Smoking cessation Accidents Screening for Breastcancer Infectious diseases -vaccination Convenants with 26 (new) locoregional health networks (LOGO�s) Convenants with organisations Scientific Society of Flemish General Practitioners (WVVH) Health promotion organisations �

3. Flemish Health targetsand WVVH Recommendations/guidelines for good practice Smoking cessation/ Breastcancerscreening/ prevention of falls in the elderly/ Influenza In preparation: Cardiovascular risk / alcohol/colorectal cancer/obesity� Continued Medical Education Web information quality improvement materials voor peer review groups Projects BOKALOK GP�s Consult&HBC �..

4. Project GP�s Consult&HBC(2003- 2005) What do we want to do? Support of GP in the field of health promotion and prevention of illness questions put by the pati�nt risks established by the physician ->when a change in behaviour is wished for Systematic risk discovery by GP�s What does already exist? Minimal Intervention Strategy -MIS ( integrated in guideline smoking cessation) 5 A�s - strategy ( used by Alcohol - expert) ....?? Do we have to make new protocols for other health targets??

5. Project GP�s Consult& HBCdevelopment Definition-fase 2003 What is usefull for GP�s and effective ? How to fit in GP�s practice? Method Workgroup WVVH Search of Literature Information from experts on different topics Discussion group: experts on CME and HBC Analysis of main sticking points

6. Conclusions WHAT (is usefull for GP�s and effective)? TTM (Trans Theoretical Model � stages of change) as the theoretical framework Minimal Interventions based on motivational interview as the method how to motivate during different contacts Basicprinciples ( empathie, respect for autonomy, relation of trust�) and communication skills are even more important than the techniques used or the protocol HOW (to fit in GP�s practice)? Minimize the difference between prevention and curation Respect the autonomy of GP�s (in the way they are conducting their consultations) Start from �behaviour� in general, filling in different, specific topics later on Implementation needs multifaceted interventions and a proactive approach

8. Critical starting points TTM Change is a dynamic process, not an event�it takes time People go more than ones through the stages of change Without planned interventions people will stay in preliminary stages; there is no inherent motivation to change The majority �at risk� is not ready for change and is not served by action oriented strategies Strategies must be aimed at the stage and principally must have in view the amelioration of self control

9. ABC model for HBC in GP�s practice based on TTM and Minimal motivational interventions A Anamnese Ask (permission) Agendasetting B Be aware of the motivational phase of the patient for this behaviour (diagnose) and choose the most useful intervention (treatment) -> decision tree C Continuity Care for relapse prevention and continuity. ��it�s a Coaching process��

10. ABC concept : test Consensus Experts on different subjects) ? making 5 ABC charts ABC Behaviour change - general ABC Stop smoking ABC Alcohol ABC fysical activity ABC heatlthy food ABC Prevention of falls Goals: One behaviour change ��language��for GP�s Promotion tools

11. ABC instruments ABC - Charts 1. For GP�s in precontemplation /Contemplation / ->education/motivation Goal: from ��I won�t�� to ��I should�� to ��I will�� 2. Tool for GP�s in preparation /action -> how to start /what�s important� Goal: from ��I will�� to ��I am�� Website- information www.wvvh.be/Page.aspx?id=447 Training for GP�s/peer reviewgroups ?workshop(s)

12. The GPas a coach for a healthy behaviour workshop

14. There is not just one way to change behaviour

15. How do YOU do ��it�� now?What do you know about it?How do you feel about it now? What is going well, not well what is effective, what not? which are the reasons?

16.  �..wish to be more effective? ---> a tool for HBC applicable in your practice ? ABC model based on the ��stages of change, TransTheoreticalModel (TTM)�� and on minimal interventions of motivational interview

17. ABC model for HBC in GP�s practice based on TTM and Minimal motivational interventions A Anamnese Ask (permission) Agendasetting B Be aware of the motivational phase of the patient for this behaviour (diagnose) and choose the most useful intervention (treatment) -> decision tree C Continuity Care for relapse prevention and continuity. ��it�s a Coaching process��

18. Motivational Phase - GP�s Intervention Precontemplation I won�t Contemplation I should Preparation I will Action : I am Consolidation Termination Consciousness: ratio/emotion Help choosing for positive change Decisional balans Choosing strategies for change: how? ?Plan Support execution New skills An new habit

19. Decision Tree GP�s conclusions from the anamnesis ��is the specific (chosen) behaviour healthy (enough)?��  No ? ��Is there a plan to change within one month ?�� *No? Is there intention to�within the 6 months?�� No? Precontemplation Yes? Contemplation *Yes ? Preparation phase Yes ?�Did it change (improve) during the last 6 months��? *Yes ? Action *No? Consolidation/Termination

20. Continuity Care for Relapse Coach the client and his process�. Take notice / medical records If possible give a new appointment Keep the door open for the patient and the topic

21. Cases Do you recognize the phase? How would you react?

22. Video  Observation Discussion Role playing Discussion

23. Reality playing

24. Take home messages Change is a process; it needs time Succes-> to go from one stage tot the next Registration (medical records) is very usefull Care for relapse prevention and continuity Skills are needed and these must be trained

25. Cases

26. Case 1 A 20 year old man sees his doctor for such and such and for nausea and reflux. You prescribe medication, besides a stomach friendly diet and reflux measures. You know that he is overweight by 20 kilos and that he likes to eat. You have discussed all this already several times with him and your waiting-room is quite full. �

27. case 1What do you do? � You think that you have already invested enough time in this patient and you do not discuss the subject � You ask the patient if you can overview once again very briefly his nutrition habits You advise the patient to eat less and to limit the use of fat and you try once more to convince him of the positive effects of following these new habits You tell your patient that it does not make any sense to continue to show up at your consultation if he does not change his nutrition habits� Other possibilities? �

28. case 1: subjects of discussion Each consultation can be used as an introduction to tackle a problem. Some doctors will however be more comfortable if the reason of the consultation will be linked to questions relative to habits. Argument �shortage of time�? To question a patient about his nutrition habits and to ask him if he eventually considers to change them takes one minute of your time. The decision to discuss the subject with the patient in a more detailed way during the very same consultation or to opt for a follow-up one will be left to yourself. The discussion of the problem does not have to be limited to nutrition problems but can also include: An overview of the context of the patient No time to cook himself ? What are the reasons ? And of his own experience Need to have a social contact ? Psychological problems ? �

29. case 1: phase of motivation Which phase of change in behaviour with respect to �nutrition behaviour� (?) at �this moment� ? You can have an idea of the phase you are in if you ask your patient the permission to speak once again very briefly about his nutrition habits and he agrees to your proposal. At this moment: motivation is variable � phases are stable and at the same time variable ? learning process Motivation is specific: �nutrition behaviour� is a broad concept: Be concrete -> How : use of fat, vegetables, fruit, calories Monthly average use of �chips� Daily consumption of fruit How many meals a day What per meal ?

30. case 2 A 30-year old woman, clearly overweight, comes to the consultation and complains of coughing continuously.She says it is not the first time this year that this happens but previously the use of a syrup against the cough cured her. You question her about eventual provoking factors and her smoking habits. The woman tells you that she is smoking a pack of cigarettes on a daily basis since she is fifteen but that the coughing is unrelated. The cause is that she forgot to put a warm coat on an evening out.

31. case 2What do you do?? You tell her that there is scientific proof that smoking has a negative effect on the airways and that should she consider stopping to smoke you will always be ready to help her. You tell her she is wrong and that there is a direct link between her coughing and her smoking habit and you advise her to quit smoking.� You preach fire and brimstone and you hope you will succeed You think that this is not the ideal moment to antagonize the patient; the waiting room is full of patients. You ignore the story and close the consult. Other possibilities?

32. case 2: subjects of discussion Explicit action on your part against her opinion will generate opposition with the patient ( and eventually frustration with the doctor). To ignore is to miss an opportunity (smoking, weight, others?) It makes sense to advise to quit smoking but antagonizing the patient carries the risk of dropping out. To assert that there is a clear obviousness around the advantages of quitting smoking is forcing her to think about her smoking behaviour. Education about the global risk is to inform her �completely� Surrounding factors do play a part; for example an insufficient warm coat. Here one can agree with the patient and also point out that smoking will add to the general weakness. The doctor can obviously apply here the �yes....but� situation. The proposition to discuss the subject at an appropriate moment means that the doctor becomes a partner and not an ogre.

33. case 2phase of motivation Motivation is specific: smoking, nutrition, movement.... We learn from this story that the patient finds herself in the pre contemplative phase with respect to her �smoking behaviour�(she is a happy smoker) Increase of knowledge and consciousness of one�s own behaviour are the most important motivating techniques to lead the patient successfully to the next phase. An information leaflet over the after- effects of smoking on the health can also contribute Global cardio vascular risk profile In conjunction with the assurance of a follow-up ( cfr proposition to discuss the matter at a later moment and registration in the medical file as a memotechnical means!)

34. case 3 A 50 year- old man exercising a job under constant stress comes to the consultation for a renewal of his medication against blood pressure.He talks about his �sitting life�, his bulky stomach and says that he is planning to go jogging in the near future. Less than a year ago he underwent a cardiological examination coupled with an effort test for the purpose of the underwriting of an insurance policy

35. case 3What do you do? You tell him that this is the right moment to do something about it.To postpone is to renunciate. You give him a training program and advise him to start the next day . You ask him why he cannot start immediately with the training program. You confirm that this is a good idea and that you are ready and willing to advise him when he will be ready for it. You do not react: you know the man for many years and you think this is loosing your time because the man will always be too busy . Other possibilities ? �

36. case 3: subjects of discussion To increase the pression by forcing the patient to start now could increase the opposition. Not to examine the possibilities of increasing the motivation of the patient or to search for obstacles is missing an opportunity. Wether you simply support and encourage him or wether you examine more deeply his saying and explore with him the tresholds it all depends on the amount of time you are willing to invest during the consultation. �

37. case 3: phase of motivation � This man considers practising sport but does not have a clear plan. He is in the contemplative phase (going to jog). To help him in order to set up a concrete plan and to search for tresholds that are making it difficult for him to start, is the right attitude. Pros and cons can be outbalanced. To minimize only the disadvantages of the expected behaviour is often insufficient. SMART

38. case 4 Mid November a 40 year-old woman comes to the consultation.The Holidays are nearing and she would like to loose five kilos She weights 70k and is 1,65m tall.She asks your advice on how she should tackle the problem. She is going out three to four times a week and does not really have a chance to make her own healthy cooking with the result that her menu usually consists of pasta with a ready made sauce.

39. case 4What do you do? You tell her this is a question of willpower and she should say no to everytrhing that is sweet or fat; no snacks except fruit. You tell her that as she is motivated she will succeed. You give her a prescription for x medicine (and/or diet Y, dietist Z...) and tell her that with this treatment she will succeed. Together with her you make an overview of all the negative points of being overweight and you support her decision You ask her what is the meaning she gives to going out for dinner, the sauces..... and try together with her to find a way to change her habits. Other possibilities ?

40. case 4: subjects of discussion Willpower does not appear from nothingness. In the frame of change of behaviour it means on the one hand to be motivated and on the other hand to know how�. (WHY and HOW?) To question the reasons �why now� gives the doctor and the patient very quickly a clear view on two aspects: 1. How important is it for this patient at this particular moment (WHY) 2. How strongly can somebody believe in his capability to succeed ? The question of HOW one wishes to tackle the problem is a very important one. What are the difficulties one can expect and how shall they be handled. And what about a failure ? How does one cope ? What does one learn from that situation? The prescription of harmless and supportive medication is accepted but does only make sense if the patient is in the action phase.

41. case 4: phase of motivation Phase of preparation The patient gets ready for �action� And this in less than 1 month

42. case 5 A young man 23 year-old comes to the consultation because he wishes to stop the use of extasy pills. He is used to take them on and off when he went out but gradually he increased the consumption. On Mondays he is usually groggy and unable to go to work. The rest of the week he is down if he does not use them. He would like to stop but is afraid to loose his character. His mother is aware of the situation and sends him to you. She also called you prior to the meeting.

43. case 5What do you do? You try to persuade the patient with all your convincing powers to stop immediately. You review with him the advantages and disadvantages of his use of extasy pills, you stress the advantages of stopping, you prescribe him some medicine and give him a new appointment for next week. You ask him how important he feels about stopping now and how he evaluates his chances of succeeding. Together with him you look for factors that could increase the importance and the self-esteem. You tell him that this is a serious problem and that you will refer him to a specialised unit. Other possibilities ? �

44. Interpretation case 5 Although the patient took the initiative to consult and wishes to be helped to stop the use of extasy he is not really ready to stop.Tentatives to persuade him make no sense. Prescription of medicine is also pointless. One could eventually question the relation with his mother and ask him what he thinks of the fact that she sends him to the doctor, or that she phoned prior to the meeting ?How do these facts influence his will to stop ? The essential factor that will concurr to the success of stopping to take the pills is the importance attached to the fact of stopping itself and the self-confidence. The latter is clearly non-existent. The increase in self-esteem can only lead to a successfull intervention.On the other hand one should also check if there is related dependence on alcohol and other drugs in which case specialised help is needed.

45. case 5: phase of motivation With regard to the use of the extasy pills we can say that this man is clearly in the contemplative phase. The presence of an ambivalent attitude is clear: I want but I can�t. There might be some additional problems (smoking, alcohol, other drugs) for which this person is rather precontemplative. This is worth questioning. Assure continuity and support an eventual relapse.

46. Case 6 A 16 year-old girl comes for the first time for a prescription for� the pill�. You complete your anamnese and ask about her smoking behaviour. She answers that she smokes 10 cigarettes a day since a year. When you remark that the use of the pill in conjunction with smoking contains a risk factor for her health she answers that all her girlfriends smoke and that they are in very good health. Her own mother smokes and takes the pill and she is in excellent physical condition.

47. Case 6What do you do? You explain to her that it is a very good thing that everybody feels great but nonetheless smoking and taking the pill do create a risk factor. You complete your explanation by telling her that when the day will come that she would like to stop smoking you will always be there to give her some help and advise You tell her that it is your duty as a doctor to protect her health and that you will be compelled to refuse to give her a prescription next time if she did not stop smoking in the meantime You repeat again your argumentation and you add some additional motivated elements ( the earlier one stops the easier, what if she gets pregnant,...) You do not react further, to try to convince the youth to stop smoking is not in my class and a lost case for a general practitioner Other possibilities ?

48. Interpretation case 6 Phase: This girl is clearly in the pre contemplative phase. The consequences of smoking on her health are far away thoughts However not to do anything in this case is not a good solution. Patients do expect from their doctors objective information accompanied with the promise of support when requested. This information can trigger a process of �thinking� with the patient and generate a change in attitude in their behaviour pattern. To keep the door open for a follow-up consultation makes more sense than refusing to give a prescription next time. The latter only shows the way to the patient to go to another doctor. Trying to convince the patient despite her opposition will only lead to increase that opposition and will create frustration and unhappiness with the patient and even with the doctor.

49. Case 7 A married couple (35year-old) come to the consultation.The husband has been addressed by his foreman at work because he often smells of alcohol. His wife is afraid he is going to loose his job and that they end up in financial problems. The husband admits that he usually drinks a glass of beer during lunchtime and that in the evenings (in front of the tv, after practising sport,...) he sometimes enjoys a couple of them but he is not aware of the problems

50. Case 7What do you do? You add up the dangers and even get upset because he endangers his future and the future of his family You judge that the patient is coming because of his wife and therefore he is not motivated.You take a BD, and make a blood test and you confirm that he must continue to decrease his consumption of alcohol You ask him if it could happen that he drinks more than 6 glasses a day and you try to figure out the seriousness of the use of alcohol. You ask him why he drinks at work knowing that this attitude could generate dangers? Other possibilities ?

51. Interpretation case 7 Phase: The husband is probably in the precontemplative phase (he comes to the consultation because of his wife). The wife probably does not (yet) see her role in the story (she is also in a precontemplative phase). It is important to figure out the degree of the use of alcohol. Is there dependency? Is it a problematic behaviour due to the use of alcohol or was there previous use of other risk factors? If there is dependency one should refer to specialised help. To get upset and angry carries the risk that the patient will not come back and will not seek help when necessary. Not to accept the request of the wife is not a solution. To discuss the consequences of the behaviour of the partner is positive, what does drinking imply for each of them,... support both partners. To question the reasons of the behaviour can be the introduction to two important questions in the change of behaviour: 1.����� How important is the change of behaviour for someone 2.����� How confident is someone about his possibilities to succeed One should built continuity in: (in a later stage) the wife can be supported in order to be less dependent on the � problemdrinker�. One could ask the problemdrinker what could be done to help him solve his problem: accountability ?