The counseling and education done in conjunction with the Wellness Card in The Wellness Center and clinical health promotion in Student Health Services uses these guidelines plus client centered counseling.
Text below is from the Guide to Clinical Preventive Services: Second Edition (1996) available in the Student Health Services medical library and at the web page: http://text.nlm.nih.gov/ .
Today's major health care problems are increasingly the result of chronic and acute conditions related to individual behavior. A significant proportion of coronary disease and cancer can be attributed to use of tobacco or unhealthy diets, and the majority of sexually transmitted diseases and injuries are related to patient behavior. While mortality from some of these conditions is decreasing, morbidity from most chronic diseases continues to increase. For these conditions, prevention at all levels -- primary (preventing disease), secondary (early diagnosis), and tertiary (preventing or slowing deterioration) -- requires active participation by the patient with guidance and support from the clinician. The patient must take responsibility for carrying out the day-to-day preventive behaviors, accurately reporting progress to the clinician, and discussing health-related problems. Effective patient participation requires education, motivation, and counseling. While busy clinicians cannot fill all the educational needs, they can be pivotal in starting and guiding the process.
Effectiveness of Clinical Counseling
Published evidence regarding counseling's effectiveness in changing specific patient behaviors is reviewed in detail in Chapters 54 through 64. For a number of important health-related behaviors (e.g., smoking, problem drinking) there is good evidence from high-quality studies that clinicians can change patient behavior through simple counseling interventions in the primary care setting. For many other behaviors, the effectiveness of clinician counseling has been demonstrated only over the short term or in specialized settings involving relatively intensive counseling.9-4 In many cases, the effects of counseling on specific behaviors have never been examined in appropriately designed studies. Small changes in behavior may be difficult to prove in prospective studies, yet they could have important health benefits if applied to large populations at risk. Given the safety and generally low cost of advising patients about health-related behaviors, the U.S. Preventive Services Task Force (USPSTF) recommends routinely addressing some health behaviors even when the long-term effectiveness of such counseling has not yet been definitively proven. In their updated recommendations, however, the USPSTF explicitly distinguishes between recommendations based on good evidence of the effectiveness of counseling per se (e.g., smoking cessation) and recommendations made primarily on the basis of the strong link between behavior and disease (e.g., sexually transmitted disease prevention). The USPSTF recognizes that determining the effectiveness of counseling interventions, especially ones that are feasible in the primary care setting, is a research priority. Studies that have demonstrated benefits from brief counseling (e.g., for smoking cessation) help identify critical components of clinician counseling that may apply to other target conditions. This chapter will discuss the objectives of patient education and counseling and provide strategies that can be used in day-to-day practice, offering some examples of how these strategies can be applied.
Objectives of Patient Education and Counseling for Prevention
There are two major objectives of patient education and counseling related to primary prevention: changing health behaviors and improving health status. In addition to the studies cited above, a number of other studies of patient education have demonstrated successful health behavior change in areas such as weight control, exercise, and contraceptive use. No area of behavior change has been studied more thoroughly than compliance with medication and with other preventive or therapeutic regimens. Several general points have emerged from these and other studies of effective counseling to change behavior, which can be incorporated into strategies for effective patient counseling (see below).
A large range of health status changes can be achieved from well-implemented patient education efforts. Various programs have been reported to: lower blood pressure; reduce mortality from hypertension, melanoma, hematologic malignancies, and breast cancer; reduce pain and disability from arthritis; reduce the incidence of low birth weight babies; and maintain better blood glucose levels in diabetics. While many of these changes in health status are mediated by changes in health behaviors and better compliance with therapeutic regimens, it seems that some clinical benefits occur independent of these factors.
A growing body of evidence suggests that when people have confidence that they can affect their health, they are more likely to do so than those without such confidence. This confidence has been termed "perceived self-efficacy."4 Self-efficacy can be enhanced through skills mastery, modeling, reinterpreting the meaning of symptoms, and persuasion. Efficacy-enhancing strategies for use in clinical practice are included in the suggestions for patient education described below.
Patient Education/Counseling Strategies
An underlying principle of patient education and counseling is that knowledge is necessary but not sufficient to change health behaviors. If knowledge alone could accomplish changes in health behavior, there would be many fewer smokers and more exercisers. Patient education involves more than simply telling people what to do or giving them an instructional pamphlet.
Few studies compare the efficacy of different types of counseling. The following recommendations have been chosen because they each have been found to be useful in changing certain health behaviors. Most of the suggested strategies can be incorporated into the practice setting without changing existing practice patterns. Many can be implemented in brief periods of time during routine health visits.
1. Frame the teaching to match the patient's perceptions. When counseling patients, the clinician should consider and incorporate, where possible, the beliefs and concerns of the patient. Research suggests that people have only a few important beliefs about any one subject. To persuade patients to change their behavior, it is first necessary to identify their beliefs relevant to the behavior and to provide information based on this foundation. The clinician can elicit important beliefs by asking such questions as "When you think of heart disease, what do you think of?" and "What gets in the way of your eating a low-fat diet?" (NOTE: these questions are like those Client Centered Counseling uses). Once the patient's concerns and understanding of the issues are apparent, teaching can then be focused appropriately.
In considering a patient's belief system, the provider is challenged to facilitate the bridging of cross-cultural gaps as well. Culturally sensitive education and counseling requires that clinicians assess their own cultural beliefs and be aware of local ethnic, regional, and religious beliefs and practices. Such knowledge aids the development of culturally specific health teaching. A fixed message will not be effective for all patients. By fitting teaching and recommendations to patients' perceptions of their own health and ability to change, clinicians can enhance self-efficacy, which has been shown to improve health behaviors and health status. If a patient with morbid obesity complains that he or she is not able to exercise, the clinician might reframe the patient's conception of what is meant by "exercise." One might initiate a very gentle and brief exercise program, such as minute of physical activity each hour.
2. Fully inform patients of the purposes and expected effects of interventions and when to expect these effects. Telling the patient when to expect to see beneficial effects from the intervention may avoid discouragement when immediate benefits are not forthcoming. When rheumatologists told patients about the purposes of their medications, 79% of them were compliant 4 months later, compared with only 33% compliance for those patients who were not given clear information about the purpose of the drugs. Informing patients that the beneficial effects of a low-cholesterol diet or regular physical activity may not become apparent for several months might increase the likelihood of long-term compliance. If side effects are common, the patient should be told what to expect, and under what circumstances the intervention should be stopped or the provider consulted.
3. Suggest small changes rather than large ones. Patients can be asked to do slightly more than they are doing now: "It is great that you are walking 10 minutes in the morning; could you add an additional 5 minutes?" When someone is very overweight, losing 100 pounds might seem like an impossible task, whereas losing 3-4 pounds in the next month seems reachable. By achieving a small goal, the patient has initiated positive change. The rationale for this suggestion comes from self-efficacy theory. Successful persuasion involves not only increasing a patient's faith in his or her capabilities, but also structuring interventions so that people are likely to experience success.
4. Be specific. Specific and informational instructions will generally lead to better compliance. For example, when suggesting a physical activity program, it is helpful to ask the patient how much he or she can comfortably do now. The patient can then be asked to perform this activity 3 times a week and then add to it by 10-25% per week, until the person is doing some type of aerobic exercise 20-30 minutes 3-4 times a week. Behavior change is enhanced if the regimen and its rationale are explained, demonstrated to the patient (if appropriate), and written down for patients to take home.
5. It is sometimes easier to add new behaviors than to eliminate established behaviors. Thus, if weight loss is a concern, suggesting that the patient begin moderate physical activity may be more effective than suggesting a change in current dietary patterns.
6. Link new behaviors to old behaviors. For example, a clinician might suggest to patients that they exercise before eating lunch, use an exercise bike while watching the evening news, or take prescribed medications twice daily when brushing the teeth.
7. Use the power of the profession. Patients see clinicians as health experts, and they regard what the clinician says as important. The clinician need not be afraid to tell a patient, "I want you to stop smoking," or "I want you to cut half the fat out of your diet." These direct messages are powerful, especially if they are simple and specific. It is important to recognize that some patients lack confidence in their ability to make lifestyle changes. The clinician can be sympathetic and supportive while providing firm, definite messages.
8. Get explicit commitments from the patient. Asking patients to describe how the intended regimen will be followed encourages them to begin to think about how to integrate this new behavior into their daily schedule. Clinicians should ask patients to describe what specifically they plan to achieve this week (i.e., what, when, and how often). For example, the patient can be asked to describe what physical activity he or she will undertake, when it will be done, and how often. The more specific the commitment from the patient, the more likely it is to be followed.
After getting the commitment, the clinician can also ask the patient how sure he or she is that he or she will carry out the commitment, for example using a scale of 0 (not at all sure) to 10 (totally sure). A patient with a high degree of certainty that he or she will carry out the commitment is more likely to follow through. If a patient expresses uncertainty, the clinician can explore the problems that might be encountered in carrying out the regimen. This is best done in a non-judgmental manner, e.g., "Many people have problems starting or continuing an exercise program; do you think you may have any problems? How will you begin?" The clinician and patient can then seek solutions for potential problems.
NOTE: Explicit commitments are what I get after the client has written goal tasks on the "Health Promotion Contract." JG
9. Use a combination of strategies. Educational efforts that integrate individual counseling, group classes, audiovisual aids, written materials, and community resources are more likely to be effective than those employing a single technique. Programs can be tailored to individual needs; for example, some patients will not attend group classes, and others may have inflexible work schedules. Written materials strengthen the message (NOTE: While the client writes a "Health Promotion Contract" I leave him/her alone and get "self-help sheets" and pamphlets related to the things we talked about) and may be personalized by jotting pertinent comments in the margins (I do this on the "self-help sheets" and back of the Wellness Card - JG); this will help to remind patients later of the clinician's suggestions. The clinician should ensure that printed materials are accurate, consistent with their views, and at a reading level appropriate to their patient population. Printed materials cannot, however, substitute for verbal communication with patients. Multiple studies have demonstrated that clinicians' individual attention and feedback are more useful than the news media or other communication channels in changing patient knowledge and behavior.
10. Involve office staff. Patient education and counseling is a responsibility that is shared among physicians, nurses, clinical nurse specialists, health educators, dietitians, and other allied health professionals as appropriate. A team approach facilitates patient education. The receptionist can encourage patients to read materials that the clinician has reviewed, approved, and placed in the reception area. Staff members and the office environment can communicate consistent positive health messages. Forming a patient education committee can help to generate program ideas and promote staff commitment.
11. Refer. In a busy practice, it may not be possible to do complete patient education and counseling. In some situations, patients are best served by appropriate referrals. There are four major referral sources: community agencies, national voluntary health organizations such as the American Heart Association and the American Cancer Society, instructional references such as books and video tapes, and, finally, other patients. (I refer or suggest going to Counseling and Psychological Services to about half the students who need to lose weight). JG
One of the best ways to change health behavior is to connect the patient with a role model, someone with the same problem who has made changes and is doing well. An up-to-date, written list of specific referral sources (including name, address, and telephone number) can be prepared for each of the most common counseling topics and given to patients who need referral. Clinicians should check the credibility and appropriateness of an agency, organization, or other references before the referral.
12. Monitor progress through follow-up contact. Scheduling a follow-up appointment or telephone call within the next few weeks -- to evaluate progress, reinforce successes, and identify and respond to problems -- improves the effectiveness of clinician counseling.
In one study, a monthly call to older persons with osteoarthritis reduced their reported pain and utilization of services. A study in which calls were made to internal medicine patients between visits reduced visits by 19% and hospital days by 28%.
Provider-initiated contact may be more effective than patient-initiated phone calls. Proactive calls (calls made by the provider to the patient) have been shown to reinforce behavior change effectively. It is also important for the clinician to follow-up on referrals to monitor progress and support continued compliance.
NOTE: Follow-up letters are sent to all clinical health promotion clients at 1-, 3-, 6-, 12-, 18-, and 24-months after the first visit. Research indicates that about 80% of clients with follow-up for 2-years are successful. And only 20% without follow-up are successful. Also, students doing the Wellness Card "Email Health Reminder" get 3 emails per quarter.
Implementing Patient Counseling in the Practice Setting
As described in Chapter i, clinicians face important barriers to implementing counseling interventions, such as insufficient reimbursement, provider uncertainty about how to counsel effectively, varying interest on the part of patient or staff, and lack of organizational/system support to facilitate the delivery of patient education. Many of these barriers are addressed by "Put Prevention into Practice" (PPIP), the Public Health Service's prevention implementation program. PPIP provides tools that can assist the provider in delivering appropriate counseling to change patients' personal health practices every time patients are seen. Other publications also provide useful information on the effective delivery of prevention-related education and counseling.
NOTE: The Wellness Card program is modeled after PPIP.
The clinician and public health community are faced with substantial morbidity and mortality from chronic, infectious, and traumatic conditions that are related to personal behaviors. With a large and growing body of literature demonstrating its effectiveness in promoting healthier behavior, patient education and counseling has become an increasingly important part of the delivery of clinical preventive services.
The draft update of this chapter was prepared for the U.S. Preventive Services Task Force by Kate Lorig, RN, DrPH.
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