1. Cardiovascular Disease in Women Module VIII: Behavioral Aspects for CVD Prevention in Women

2. This presentation is specifically designed to assist Primary Care Providers in helping their patients TAKE HOME & TAKE TO HEART THE HEART TRUTH

3. What to Change: Most of the Heart Truth lifestyle interventions involve a need for behavioral change. This change involves both the provider and the patient. Strategy for Change: For Heart Truth lifestyle interventions to be effective they require a strategy that entails counseling for behavioral change and seeking the patient’s commitment to such change. The following issues will be discussed:

4. Clinical Impact: It is extremely important that the provider determines on an ongoing basis the overall progress of the patient relative to the effectiveness of the provider-patient relationship in terms of achieving behavioral modification and reaching Heart Truth clinical measures and benchmarks Also to be discussed:

5. What to Change Most of the Heart Truth lifestyle interventions deal with adverse behaviors  Cigarette smoking  Deficient physical activity  Deficient dietary plan  Deficient weight maintenance or reduction Adverse Behaviors Sources: Mosca 2007

6. Effective health care in general is an active phenomenon that requires the active participation of the patient and provider in order for positive outcomes to be achieved The degree of behavioral modification achieved is aggregate evidence of the effectiveness of this active participation Level of Participation What to Change Sources: Prochaska 1992, Zimmerman 2000

7. Some providers have doubts about their patients’ ability to change Some providers doubt that behavioral change will have any real impact on health outcomes of their patients Provider Obstacles What to Change

8. Some providers have difficulty finding the time they think they need to become a change agent for their patient Some providers fear that they do not know what to do even if they wanted to help due to lack of training in this area Provider Obstacles What to Change

9. Having a specific strategy to address change saves time and alleviates the provider’s fear of the unknown These provider-specific obstacles must be removed or the provider should refer the patient to another provider, in the best interests of the patient Provider Obstacles What to Change

10. Assess (or Ask) Advise Agree Assist Arrange The “5-A”s Counseling Framework for Change Strategy for Change Sources: Whitlock 2003

11. Assess (or Ask about) risk factors, beliefs, behavior, and knowledge about a lifestyle intervention  Assess whether she is willing to initiate steps towards modifying her behavior in the direction of the Heart Truth objectives  Assess knowledge, skills, confidence, conviction, supports, and barriers  Provide feedback to her about assessment Counseling Framework for Change The “5-A”s

12. Assess importance with good questions.  “How important do you think it is to change this [targeted] behavior?”  “On a scale of ‘1 to 10’ with ‘1’ being ‘not convinced at all’ to ’10’ being ‘totally convinced’, how important is it to you?”  “What makes you say ‘3’, why not ‘0’?”  “What would it take to move it to a ‘6’?” Counseling Framework for Change The “5-A”s

13. Assess what or who is important  “What or Who is important or of value to you?”  “What would they do without you or what would they do if you became disabled from a complication of heart disease?”  Use the answer to these questions as leverage in your dialogue about the importance of changing targeted behavior Counseling Framework for Change The “5-A”s

14. Advise with a clear & personalized message  Expound on the dangers that are specific to her in relationship to the targeted behavior  Advise her about the benefits of change  Make the source of your advice clear (medical knowledge or from similar patients) Counseling Framework for Change The “5-A”s

15. Advise with a clear, simple, and personalized message.  Provide advice at a patient-determined level of comprehension  Try not to overload her with information in one session  “Can you review for me what we just discussed so I know that I made it understandable?” Counseling Framework for Change The “5-A”s

16. Agree on goals and plans  Goals are something to achieve in 3-6 months  Collaboratively select goals based on patient’s interest and confidence in her ability to change the targeted behavior  Base goals on the patient’s priorities  Plans are specific steps to help achieve goals Counseling Framework for Change The “5-A”s

17. Assist with goals and plans  Develop a Personal Action Plan that includes: What to do; How to do it; Where to do it What to use; When to do it; How often Barriers to doing it; Plans to overcome barriers Follow-up plan Counseling Framework for Change The “5-A”s

18. Assist  Personal Action Plan Patient should give herself a confidence rating in achieving the Personal Action Plan The action plan should be re-worked if her level of confidence is lower than 7 on a scale of 1 to 10 Counseling Framework for Change The “5-A”s

19. Assist  Personal Action Plan Make certain that she has appropriate expectations Early on, help her pick some easily achievable goals (“the low hanging fruit”) to help build confidence to tackle greater goals Counseling Framework for Change The “5-A”s

20. Assist in problem solving with Personal Action Plan.  Identify problem  List all possible solutions (brainstorm)  Pick one  Try it for 2 weeks  If it doesn’t work, try another Counseling Framework for Change The “5-A”s

21. Assist in problem solving  If that doesn’t work, find a resource for ideas  If that doesn’t work, accept that the problem may not be solvable now  Move on (but come back later) Counseling Framework for Change The “5-A”s

22. Assist in changing behavior  Provide self-help and counseling pathways to aid patient in achieving agreed upon goals  Aid the patient in acquiring skills, confidence, and social/environmental supports Counseling Framework for Change The “5-A”s

23. Assist in changing behavior  Women tend to respond best to intensive interventions between the provider and the patient  Women tend to respond, more so than men, to support groups Counseling Framework for Change The “5-A”s Sources: Whitlock 2003

24. Assist with resources  Match resources (community, literature, groups) with patient preferences  Utilize outreach and community opportunities whenever feasible Counseling Framework for Change The “5-A”s

25. Arrange follow-up  Schedule follow-up visits or contacts for purpose of providing ongoing assistance and support  Try a variety of follow-up methods when feasible (in person, phone, email, groups) Counseling Framework for Change The “5-A”s

26. Arrange follow-up  Making sure follow-up happens builds patient trust in the agreed upon clinical pathway  Adjust the plan as needed during follow-up visits or contacts, including referral elsewhere for more intensive intervention Counseling Framework for Change The “5-A”s

27. Prochaska & DiClemente model Stages of Behavioral Change Pre-contemplation Contemplation Preparation Action Maintenance Transformation Strategy for Change Sources: Prochaska 1992

28. The provider should be able to determine which stage of change the patient is in with respect to the targeted behavioral concern. Applying the 5-‘A’s at each stage of change process affords the provider a monitor in guiding and motivating the patient along her trip to ‘Transformation’ Stages of Behavioral Change Prochaska Model Sources: Prochaska 1992

29. Pre-contemplation stage She is not ready to change She is not thinking about change She may be resigned to not changing She expresses feeling of ‘no control’ She exhibits denial or believes consequences are not serious Prochaska Model Sources: Prochaska 1992

30. Contemplation stage She is thinking about changing She is weighing the relative benefits and costs of the her current behavior and those of the proposed change Prochaska Model Sources: Prochaska 1992

31. Preparation stage She has begun experimenting with small changes She is getting ready to make a move towards behavioral modification She is establishing a goal or at least thinking about it Prochaska Model Sources: Prochaska 1992

32. Action stage She has started her journey towards Transformation by applying herself to her definitive Personal Action Plan designed to facilitate behavioral modification Prochaska Model Sources: Prochaska 1992

33. Maintenance stage She is maintaining new behavior continuously over an extended period of time (>180 days) to accomplish the overall goal Prochaska Model Sources: Prochaska 1992

34. Relapse ‘The Ups & Downs’ is a normal part of the process of change She may regress to the beginning stages of the Change Model She may feel demoralized or disappointed (which often occurs) by set back Sometimes original goals are set too high or low or aggressive Prochaska Model Sources: Prochaska 1992

35. Transformation She feels self-assured and feels that only time separates her from her ultimate goal (if not already reached) Transformed patients are often willing to and capable of being role models for other patients with similar clinical issues Prochaska Model

36. Clinical Impact Keeping Score of Clinical Impact For each identified behavioral change-dependent Heart Truth lifestyle intervention, document in the health record where the patient is with respect to the Prochaska stages

37. Keeping Score of Clinical Impact In documenting the stage of change, a numbered scale from 1 to 6 might help:  1 / pre-contemplation  2 / contemplation  3 / preparation  4 / action  5 / maintenance  6 / transformation This enumeration creates a Change Scale Clinical Impact

38. Where your patient is on the Change Scale scores how far you have advanced relative to the extent to which she is responding to your methodology and available resources Repeatedly ask yourself: Can I and What Can I do better or more of in helping and motivating my patient towards beneficial change, thus improving the score? Keeping Score of Clinical Impact Clinical Impact

39. The clinical impact of the Heart Truth objectives is dependent on:  Achievement of recommended Heart Truth clinical measures and benchmarks  Availability of and access to resources  Degree of difficulty and severity of the patient’s condition, inclusive of co-morbidities Keeping Score of Clinical Impact Clinical Impact

40. Keeping Score of Clinical Impact Clinical Impact Finally, the clinical impact of the Heart Truth objectives is dependent on:  The effectiveness of the provider-patient relationship and all that it entails (e.g., dedication of time, use of resources, intensity of participation of all parties, provider & patient resourcefulness, and contributions of all parties)