Effective clinician communication is important for a variety of patient outcomes.50,51 Clinician advice to change lifestyle habits is associated with increased efforts to change52,53 and is effective in encouraging smoking cessation,11,12,14,15 reducing problem drinking,11,16 and modifying some activity- and diet-associated cardiovascular risk factors.11,20 Clinician advice is also associated with increased satisfaction with medical care.30,54,55 Such advice has been suggested to "prime" patients, especially women, to attend to and act on subsequent educational information.56 In a recent cross-sectional study among members of a managed care organization,57 receipt of professional advice to change was associated with a higher readiness to change smoking, physical activity, and diet behaviors. Behavior Interventions To select the appropriate intervention consider what you think the most likely reason is for the student’s behavior problem. Most behaviors besides tobacco use—such as poor diet, physical inactivity, or risky sex—are complex to assess because clinicians need some details of usual practices, such as the frequency, intensity, and duration of various physical activities96 or "usual" intake of specific food items, both to identify individual candidates for intervention and to measure their progress.116,117 One approach to the demands of a more lengthy assessment is to obtain brief assessment by telephone in advance of the clinic visit.95,117 This has been shown to produce reasonably accurate results, at least for physical activity.118 Assessments rely on self-report and recall of customary behavior, and these can suffer from lapses in individual memory, errors in estimation, and the imprecise mapping of self-reported activities to meaningful, physiologically related measures.116 Overall, when reliable biological or biomechanical markers are available for comparison, self-reported health behaviors and risk factors tend to underestimate the proportion of general-population individuals considered "at risk. Important advances in the ways primary care interventions have been packaged have resulted from the past 2 decades of research. Behavioral counseling interventions occur all or in part during routine primary care and may involve both visit-based and outside intervention components. Some clinicians are reluctant to advise patients because people seeking clinical care are not consciously seeking medical advice about their behavior. To be congruent with the U.S. Public Health Service and Canadian Task Force concepts of the A's construct, we adopted the following terminology to describe minimal contact interventions that are provided by a variety of clinical staff in primary care settings: The content of each step in the Five A's construct necessarily varies from behavior to behavior, but clinical intervention targeting any behavior change can be described with reference to these five intervention components. ); the USPSTF (Steve Woolf, M.D., M.P.H. The USPSTF also considers other benefits (KQ 10) or potential harms (KQ 11) associated with the behavior change. Clinical interventions are predicated on a foundation of epidemiological research that adequately substantiates the link between particular behaviors and health outcomes,2 as depicted in Figure 1 (Analytic Framework 1, KQs 1, 2, 5). Behavioral Counseling Interventions: An Evidence-based Approach, USPSTF Recommendations App - Prevention TaskForce, Nominate a Recommendation Statement Topic, http://www.ahrq.gov/professionals/clinicians-providers/guidelines-recommendations/uspstf/index.html, USPSTF Program Office - 5600 Fishers Lane, Mail Stop 06E53A, Rockville, MD 20857, Rationale for Behavioral Counseling Interventions in Clinical Care, Objectives and Scope of Behavioral Counseling Interventions, The Potential Impact of Health Behavior-Change Programs in Clinical Care, Practical Approaches to Overcome Barriers to Behavioral and Counseling Interventions, Evidence-Based Methods for Evaluating Behavioral Counseling Interventions, The Five A's Organizational Construct for Clinical Counseling. 2. Using physical activity as an example, the majority of adults may be sedentary, but not all who visit the clinician need an exercise intervention, and there is no way to determine the need for activity counseling without a specific assessment. Assess: Because behavioral risks are largely invisible and are rarely the main reason for seeking clinical care, explicit systems for behavioral risk-factor assessment in clinical populations serve two purposes. For example, only 5 percent to 15 percent of those receiving an intervention make clinically significant changes, such as quitting smoking12 or reducing heavy drinking.11 Even at a population level, overall risk factors typically change only 1 percent to 20 percent.16,17,19,20,22,61 However, these "modest" impacts translate to significant benefits to the health of the population (and to multiple individuals) when systematically applied to a large proportion of those in need.48,62-65 This opportunity for substantial public health benefit comes about only when behavior change interventions are applied broadly to entire populations of patients. However, the use of additional resources within and outside the primary care setting to support the clinician by no means undermines the importance of the clinician-patient relationship in promoting behavior change. For instance, assessment of behavioral health risks may occur at the time of enrollment in a health plan or at the time of a clinical visit. The first evidence-based behavior intervention is to provide behavior-specific praise. Behavioral counseling interventions in clinical settings are an important means of addressing prevalent health-related behaviors, such as lack of physical activity, poor diet, substance (tobacco, alcohol, and illicit drug) use and dependence, and risky sexual behavior that underlie a substantial proportion of preventable morbidity and mortality in the United States. Assistance also can include direct support from the health care provider/team, guidance in obtaining social support from friends and family, the provision of self-help materials to support self-change efforts, and the provision or prescription of appropriate medication or medical devices (e.g., pharmacotherapy for tobacco dependence, contraceptives for prevention of unplanned pregnancy, and dietary supplements for certain weight loss regimens). Lack of detail and inconsistency of terms describing behavioral interventions in published reports seriously hamper rigorous reviews and limit the potential for research replication. If yes, are you seriously thinking about quitting in the next 6 months? Usually, this is accomplished by briefly repeating the first four A's (assess, advise, agree, assist) to update the behavior-change plan, taking into account the patient's intervening efforts, experience, and current perspective. By Evelyn P. Whitlock, M.D., M.P.H. Challenges for behavioral assessments include the tension between accuracy and feasibility.116 To be practical, many tools are abbreviated to require as little patient and clinician time as possible; thus, good evaluations consider both accuracy and applicability for any assessment approach. Referral to more intensive clinics in the community also may be included. The Guide to Community Preventive Servicesfeatures evidence-based recommendations from the Task Force on Community Preventive Services for population-based interventions. 290-97-0018) Rockville, MD. Expanding communication technologies allow both passive and interactive use25 of telephones, videos, CD-ROMs, the Internet, and other computer-assisted venues to enhance and personalize behavioral intervention content28,87 and to prolong contact with the patient, while reducing the services that must be directly provided by clinical staff.67 Such computer-based print, telephone, and video communications have boosted treatment outcomes over standard "one-size-fits-all" interventions in several behavioral areas (e.g., smoking cessation and diet modification), with greatest benefits sometimes seen in low-income populations.88-90 Although some of these technologies are relatively new and still under evaluation, advances in information and communication technologies hold great promise for enhancing intervention efficiency by automating assessment, education, and patient contacts, especially for ongoing followup and support. The authors gratefully acknowledge early manuscript review and suggestions by outside experts: Sue Curry, Ph.D.; Russ Glasgow, Ph.D.; Michael Goldstein, M.D. The lack of evidence-based behavioral interventions that are tailored to primary care poses a major barrier to their treatment.” Integrated care provides patients with on-site mental health care to prevent fragmented treatment and decrease the number of patients who slip through the cracks. There is a reason that educational professionals, including myself , bend over backwards to … The 1996 edition of the Guide to Clinical Preventive Services by the USPSTF concluded: "Effective interventions that address personal health practices ... [for] ... primary prevention ... hold greater promise for improving overall health than many secondary preventive measures, such as routine screening for early disease. Also, patient involvement in decisions promotes choices based on realistic expectations and patient values,128 which are important determinants of patient adherence or compliance.129 Patient-centered approaches in which the patient and clinician mutually agree on specific changes may require less visit time than provider-centered ones.130. There may be a limit as to how well we will ultimately be able to define any standardized approach, given the multiplicity of factors (patient, family, community, clinician, and health care setting) influencing behavioral change, and the range of states within each factor. Thus, their potential impact on the prevalence of smoking (Impact = Participation Rate x Efficacy) is substantially less than systematically delivered primary care interventions, which can feasibly reach the 70 percent of smokers who visit their clinicians each year and result in 5 percent to 10 percent overall quit rates.
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