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FOOD TODAY 08/2010

Motivating change: Tips for health care professionals

73_4_smallMany chronic health problems are associated with modifiable lifestyle behaviours, such as poor dietary choices and physical inactivity. Existing behaviour patterns are, however, notoriously difficult to change, even when the individual recognises that their health is at risk. Health care professionals have a vital role in motivating their patients to adopt healthier lifestyles but effective strategies for change involve more than simply offering advice.
 

Motivational counselling

Traditionally, health care providers have adopted a ‘directive’ style of counselling their patients on health-related behaviours, giving information and instructions on changes that are deemed necessary.1 Whilst this paternalistic approach may be appropriate for some individuals, it can inadvertently increase resistance in other patients.2

A sustained change in behaviour is achieved more effectively when the motivation to do so is elicited internally by the patient rather than imposed by others.1 Behaviours are thus reinforced by internal rewards related to the individual’s needs, interests and emotions. Patient-centred techniques, such as motivational interviewing and collaborative goal setting, aim to promote internal motivation and have been associated with improved health outcomes.3-5 Such techniques encourage patient autonomy in deciding what changes are necessary and how they can be achieved.
 
Ready….

Behaviour change is a gradual process, accomplished in stages through which the patient must progress.6 Not all at-risk individuals will be ‘ready’ to change and behavioural interventions should be tailored accordingly. Raising awareness of the problem and providing relevant information in a non-confrontational manner may help increase an individual’s readiness to change.5

….willing….

Health-related behaviours are determined by a person’s understanding of the issues involved and by their perception of how relevant these issues are to their personal circumstances. For change to occur, they must believe that their behaviour makes them vulnerable to a particular health problem, that the problem is potentially serious, and that the benefits of taking action outweigh the potential costs.7 Social factors, such as social norms or ideals and the attitudes of friends and family, can also influence a person’s willingness to engage in behavioural change.

….and able

Fear of failure can be an important barrier to change. Health care professionals have an important role in enhancing the patient’s self-efficacy, or confidence in their own ability to realise a particular goal. This involves not only providing reassurance and constructive feedback, but also giving them the skills and resources they need to achieve success.

‘Goal setting and action planning’ is one tool that can help patients to improve diet and physical activity, particularly when they are planned in collaboration with a health professional.4,8 Action plans with a high probability of success are preferable, since even small successes can increase patient self esteem and motivation. The SMART acronym has been used as a guideline for setting suitable goals and refers to goals that are Specific, Measurable, Achievable, Relevant and Time-framed.9
 
Practical guidelines

  • Identify a target behaviour that would benefit the patient’s health.
  • Discuss the link between behaviour and health, and the patient’s perception of its relevance to their own situation.
  • Assess the patient’s readiness to change, according to the degree of resistance encountered, and tailor the consultation accordingly.
  • Avoid being judgmental or confrontational and do not persist in advocating change when resistance is high.
  • Explore and empathise with the patient’s own motivations, feelings and beliefs. Encourage them to weigh up the pros and cons of behaviour change in their own words.
  • If a decision to change appears imminent, guide the patient towards formulating their own action plan.
  • Encourage them to set SMART goals (up to three), incorporating behaviours that can be easily integrated into their current lifestyle and have a high probability of success. Support from family, friends or other patients may help achieve those goals.
  • Discuss potential barriers to change and how the patient plans to deal with them.
  • Provide access to information and other resources that will support the patient in the process. Individualised computer-generated materials can be beneficial.
  • Maintain contact, provide feedback and encourage self-monitoring of progress.
  • Recognise that relapse is common and does not constitute a failure of the process. Discuss options with the patient to deal with unmet goals.

Probably every therapist can benefit from the general non-judgmental, non-paternalistic tone of these motivational techniques. It should be recognised though that using them competently takes time and determination, and interested therapists are advised to seek professional guidance and training.
 
References
  1. Rollnick S et al. (2005). Consultations about changing behaviour. BMJ 331:961-963.
  2. Miller WR. (2005). Enhancing patient motivation for health behavior change. Journal of Cardiopulmonary Rehabilitation 25:207-209.
  3. Rubak S et al. (2005). Motivational interviewing: a systematic review and meta-analysis. British Journal of General Practice 55: 305-312.
  4. Handley M et al. (2006). Using Action Plans to Help Primary Care Patients Adopt Healthy Behaviors: A Descriptive Study.  Journal of the American Board of Family Medicine 19:224-231.
  5. Britt E et al. (2004). Motivational interviewing in health settings: a review. Patient Education and Counseling 53:147-155.
  6. Prochaska JO et al. (1992). In search of how people change: Applications to addictive behaviours. American Psychology 47: 1102-1114.
  7. Elder JP et al. (1999). Theories and Intervention Approaches to Health-Behavior Change in Primary Care.  American Journal of Preventive Medicine 17:275-284.
  8. MacGregor K et al. (2006). Behavior-Change Action Plans in Primary Care: A Feasibility Study of Clinicians. Journal of the American Board of Family Medicine 19:215-223.
  9. Siegert RJ and Taylor WJ. (2004). Theoretical aspects of goal-setting and motivation in rehabilitation. Disability and Rehabilitation 26:1-8.
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