GP

1
GPs Consult Health Behaviour ChangeWONCA
03-07 september 2005Kos - Greece

Scientific Society of Flemish General
Practitioners
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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 (LOGOs)
• Convenants with organisations
• Scientific Society of Flemish General
  Practitioners (WVVH)
• Health promotion organisations

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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
• GPs ConsultHBC
• ..

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Project GPs ConsultHBC(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 patiënt
• risks established by the physician
• -gtwhen a change in behaviour is wished for
• Systematic risk discovery by GPs
• What does already exist?
• Minimal Intervention Strategy -MIS ( integrated
  in guideline smoking cessation)
• 5 As - strategy ( used by Alcohol - expert)
• ....??
• Do we have to make new protocols for
• other health targets??

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Project GPs Consult HBCdevelopment

• Definition-fase 2003
• What is usefull for GPs and effective ?
• How to fit in GPs 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 GPs 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 GPs practice)?
• Minimize the difference between prevention and
  curation
• Respect the autonomy of GPs (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

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TTM model
Figure Spiral of change From Prochaska,
DiClemente Norcross, 1992, p1104
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Critical starting points TTM

• Change is a dynamic process, not an eventit
  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

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ABC model for HBC in GPs 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)
• -gt decision tree
• C Continuity
• Care for relapse prevention and continuity.
•  its a Coaching process 

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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 GPs
• Promotion tools

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ABC instruments

• ABC - Charts
• 1. For GPs in precontemplation /Contemplation /
• -gteducation/motivation
• Goal from  I wont  to  I should  to  I
  will 
• 2. Tool for GPs in preparation /action
• -gt how to start /whats important
• Goal from  I will  to  I am 
• Website- information
• www.wvvh.be/Page.aspx?id447
• Training for GPs/peer reviewgroups
• ?workshop(s)

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The GPas a coach for a healthy behaviour
workshop

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Are you ready, willing and able to coach the
patiënt? (...MR)
importance motivation selfconfiden
ce

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There is not just one way to change behaviour

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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?

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• ..wish to be more effective?
• ---gt 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

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ABC model for HBC in GPs 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)
• -gt decision tree
• C Continuity
• Care for relapse prevention and continuity.
•  its a Coaching process 

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Motivational Phase - GPs Intervention

• Precontemplation
• I wont
• 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

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Decision Tree GPs 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 towithin 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

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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

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Cases

• Do you recognize the phase?
• How would you react?

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Video

• Observation
• Discussion
• Role playing
• Discussion

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Reality playing
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Take home messages

• Change is a process it needs time
• Succes-gt 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

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Cases
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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.
•  

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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?
•  

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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 ?
•  

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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 -gt How use of fat, vegetables,
  fruit, calories
• Monthly average use of chips
• Daily consumption of fruit
• How many meals a day
• What per meal ?

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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.

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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?

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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.

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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 ones
  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!)

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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

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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 ?
•  

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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.
•  

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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

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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.

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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 ?

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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.

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case 4 phase of motivation

• Phase of preparation
• The patient gets ready for action
• And this in less than 1 month

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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.

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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 ?
•  

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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.

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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 cant.
  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.

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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.

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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 ?

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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.

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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

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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 ?

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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 ?

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Is the patient ready, willing and able to
change?
importance motivation selfconfiden
ce
Miller Rollnick