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Strategies for Health Behavior Change
To improve the health of children, pediatricians often ask patients and caregivers to make behavioral changes. These may be lifestyle changes to manage a chronic condition (e.g., obesity, asthma), adherence with the recommended timing and frequency of medications, or recommendations to seek assistance from other health providers (e.g., dieticians, mental health providers, physical, occupational, or speech therapists). However, change is difficult and can cause distress, and families often express reluctance or ambivalence to change due to perceived barriers. When families do not believe change is needed or possible, pediatricians may become discouraged or uncomfortable in providing care. This can make it difficult for clinicians to form an alliance with families, which is central to finding a solution to most problems identified in the medical setting.
Many healthcare problems may require complex, multifaceted interventions, but the first step is always to engage the family in identifying the healthcare problem driving the need for behavior change. Once a problem is identified and agreed on, clinicians and families need to set an achievable goal and identify specific behaviors that can help families reach their goal. It is important to be specific and precise about the actual behavior and not simply identify the category of the behavior. When counseling a patient on weight loss for obesity, for example, one might discuss 3 possible approaches: making dietary changes, increasing exercise, and decreasing screen time. The choice of which behavior to focus on should come from the patient but needs to be specific. It is not enough for the patient to state he will exercise more. Instead, the clinician should help the patient identify a more specific goal, such as playing basketball with his friends 3 times a week at the park near home. This takes in to account the action, context, setting, and time of the new behavioral goal. Specific examples of problems that would necessitate a behavior change to improve outcomes are used throughout the chapter.
Unified Theory of Behavior Change
There are several theories of health-related behavior change. Each highlights a different concept, but frameworks that unite these theories suggest that the factor most predictive of whether one will perform a behavior is the intention to do so. The unified theory of behavior change examines behavior along 2 dimensions: influences on intent and moderators of the intention-behavior relationship ( Fig. 17.1 ). Five main factors that influence one's decision to perform a behavior are expectancies, social norms/normative influences, self-concept/self-image, emotions, and self-efficacy. Table 17.1 provides specific examples on how to explore influences of intent when guiding families in decision-making, such as deciding to start a stimulant medication for a child diagnosed with attention-deficit/hyperactivity disorder (ADHD). It is not necessary to ask about each influence, but these principles are particularly useful when guiding patients who may be resistant to change.
Table 17.1
Influences of Intent and Possible Use During a Patient Encounter (Specifically, Starting Stimulant for ADHD)
| INFLUENCE OF INTENT | STRATEGIES TO ENGAGE FAMILIES USING INFLUENCES OF INTENT | POSSIBLE FACTORS INFLUENCING THE DECISION |
|---|---|---|
| Beliefs and expectancies Perceived advantages and disadvantages of performing a behavior. |
Ask questions about their beliefs and experiences. “What do you know already know about stimulants?” “Have you heard about other children's experiences taking stimulants?” “What do you expect will happen if your child takes a stimulant?” Ask permission to give information addressing their prior beliefs or experiences. “Is it all right if I give you some information addressing your concerns?” |
“I know that stimulants helped my nephew do better in school.” “I heard stimulants stunt children's growth.” |
| Social norms Pressures to (or not) perform a behavior because of what is standard among social groups. |
Share information about the normative nature of the behavior and ways to cope if performing a behavior that is not the social norm. “I have a lot of patients who have improved in school after starting a stimulant.” |
“Do other parents give their children stimulants if they are diagnosed with ADHD?” “What would my mother think if she found out my child was taking a stimulant?” |
| Self-concept/self-image Overall sense of self and whether behavior is congruent with that and with the image they want to project to others. |
Interact with family in a partnering, supportive, respectful manner. Identify strengths. Reframe any negative images they foresee may happen with the behavior. “I am sure your in-laws will be so happy when your child is doing better in school.” |
“Am I a good parent if I give my child medications that affect his brain?” “What will other parents at school think if I allow my child to start a stimulant? What will my in-laws think?” |
| Emotions Emotional reactions to performing behaviors, in intensity and direction (positive or negative). |
Allow patients to express their feelings. Suggest ways to manage negative or avoidant feelings. “Many parents are scared to start stimulants at first. However, once their child is succeeding in school, they realize the benefits outweighed the risks. Let's talk more about your fears.” |
“I am so nervous about my child starting to take a stimulant.” “I am so upset with how my child is doing in school and really do not know what to do next.” “I am so relieved that there is a medication that may help improve my child's grades and chance of going to college.” |
| Self-efficacy Perceived confidence they can perform the behavior. |
Provide information, model the behavior, encourage success, and teach skills. Explore what obstacles they foresee and how confident they are they can overcome obstacles. Help strategize ways to overcome obstacles. “Do you feel confident you will be able to get your child to take the medication?” “Let's brainstorm how we can prevent any of the side effects.” “Many of my patients have a large breakfast before taking the medication. Can I help you figure out how to fit that into your schedule?” |
“Will I be able to remember to give my child his medication every day?” “Will I be able to make sure my child has a large breakfast in the morning before taking her medication?” |
ADHD, Attention-deficit/hyperactivity disorder.
Once a decision to make a change is made, 4 factors determine whether an intention leads to carrying out the behavior: knowledge and skills, environmental facilitators and constraints, salience of the behavior, and habits. The pediatrician can help ensure intent leads to behavior change by addressing these factors during the visit. In the ADHD example, the clinician can help the family build their knowledge by providing handouts on stimulants, nutritional pamphlets on how to minimize the appetite-suppressant effects of the medication on weight, and information on how the family can explain to others the need for medication. Asking about morning routines will help identify potential barriers in remembering to take the medication. Lastly, clinicians can help families think about cues for remembering to give the medication in the morning, since their morning routines, or habits, will have to be adjusted to adhere to this medication.
By using these principles of behavior change, pediatricians can guide their patients toward change during an encounter by ensuring they leave with (1) a strong positive intention to perform the behavior; (2) the perception that they have the skills to accomplish it; (3) a belief that the behavior is socially acceptable and consistent with their self-image; (4) a positive feeling about the behavior; (5) specific strategies in overcoming potential barriers in performing the behavior; and (6) a set of identified cues and enablers to help build new habits.
Transtheoretical Model of Health Behavior Change
It is difficult to counsel families to change a behavior when they may not agree there is a problem or when they are not ready to build an intention to change. The transtheoretical model of health behavior change places an individual's motivation and readiness to change on a continuum. The premise of this model is that behavior change is a process, and as someone attempts to change, they move through 5 stages (although not always in a linear fashion): precontemplation (no current intention of making a change), contemplation (considering change), preparation (creating an intention, planning, and committing to change), action (has changed behavior for a short time), and maintenance (sustaining long-term change). Assessing a patient's stage of change and then targeting counseling toward that stage can help build a therapeutic alliance , in contrast to counseling a patient to do something she is not ready for, which can disrupt therapeutic alliance and lead to resistance. Table 17.2 further describes stages of change and gives examples for counseling that targets the adolescent's stage of change in reducing marijuana smoking.
Table 17.2
Stages of Change and Strategies for Counseling *
Adapted from Implementing mental health priorities in practice: substance use, American Academy of Pediatrics. https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/Mental-Health/Pages/substance-use.aspx .
| STAGE/DEFINITION | GOAL AND STRATEGY | SPECIFIC EXAMPLES |
|---|---|---|
| Precontemplation Not considering change. May be unaware that a problem exists. |
Establish a therapeutic relationship. Increase awareness of need to change. |
“I understand you are only here because your parents are worried and that you don't feel that smoking marijuana is a big deal.” “Can I ask if smoking marijuana has created any problems for you now? I know your parents were worried about your grades.” “It's up to you to decide if and when you are ready to cut back on smoking marijuana.” “Is it okay if I give you some information about marijuana use?” “I know it can be hard to change a habit when you feel under pressure. It is totally up to you to decide if cutting back is right for you. Is it okay if I ask you about this during our next visit?” |
| Contemplation Beginning to consider making a change, but still feeling ambivalent about making a change. |
Identify ambivalence. Help develop discrepancy between goals and current behaviors. Ask about pros and cons of changing problem behavior. Support patient toward making a change. |
“I'm hearing that you do agree that sometimes your marijuana use does get in the way, especially with school. However, it helps relax you and it would be hard to make a change right now.” “What would be one benefit of cutting back? What would be a drawback to cutting back? Do you think your smoking will cause problems in the future?” “After talking about this, if you feel you want to cut back, the next step would be to think about how to best do that. We wouldn't need to jump right into a plan. Why don't you think about what we discussed, and we can meet next week if you are ready to make a plan?” |
| Preparation Preparing for action. Reduced ambivalence and exploration of options for change. |
Help patient set a goal and prepare a concrete plan. Offer a menu of choices. Identify supports and barriers. |
“It's great that you are thinking about ways to cut back on your smoking. I understand your initial goal is to stop smoking during the week.” “I can give you some other options of how to relax and reduce stress during the week.” “We need to figure out how to react to your friends after school who you normally smoke with.” “Do you have other friends who you can see after school instead, who would support this decision?” |
| Action Taking action; actively implementing plan. |
Provide positive feedback. Identify unexpected barriers and create coping strategies. |
“Congratulations on cutting back. Have you noticed any differences in your schoolwork? I'm so happy to hear your grades improved.” “Has it been difficult to not see your friends after school? How have you reacted when they get annoyed you don't want to smoke with them?” “Let's continue to track your progress.” |
| Maintenance Continues to change behavior and maintains healthier lifestyle. |
Reinforce commitment and affirm ability to change. Create coping plans when relapse does occur. Manage triggers. |
“You really are committed to going to a good college and improving your grades. I'm so happy the hard work has paid off.” “I understand that it was hard to say no to smoking with your friends last week when it was someone's birthday. How did you feel after? Are there triggers that we can think about preventing in the future?” |
* This table uses an example of an adolescent who is initially resistant to cutting back on smoking marijuana. His parents caught him smoking in his room and arranged for him to see the pediatrician.
Common Factors Approach
Conversations around behavior change are most effective when they take place in a context of a trusting, mutually respectful relationship. The traditional medical model assumes that patients and their families come with questions and needs, and that the pediatrician's job is to offer specific advice and advocate for its acceptance. This approach fails when families are reluctant, ambivalent, demoralized, or unfamiliar with the healthcare system or the treatment choices offered. A context more supportive of behavior change can be developed when pediatricians use communication strategies that facilitate collaboration and building therapeutic alliance.
The common factors approach is an evidence-based communication strategy that is effective in facilitating behavior change. The skills central to a common factors approach are consistent across multiple forms of psychotherapy and can be viewed as generic aspects of treatment that can be used across a wide range of symptoms to build a therapeutic alliance between the physician and patient. This alliance predicts outcomes of counseling more than the specific modality of treatment. The common factors approach has been implemented and studied in pediatric primary care for children with mental health problems. Children who were treated by pediatricians trained in the common factors approach had improved functioning compared to those who saw pediatricians without this training.
A common factors approach distinguishes between the impact of the patient–provider alliance and the pediatrician's use of skills that influence patient behavior change across a broad range of conditions. Interpersonal skills that help build alliances with patients include showing empathy, warmth, and positive regard. Skills that influence behavior change include a clinician's ability to provide optimism, facilitate treatment engagement, and maintain the focus on achievable goals. This can be done by clearly explaining the condition and treatment approaches while keeping the discussion focused on immediate and practical concerns.
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