Green Book

Appendix A

Frameworks to change patient behaviour

A1. The 5As

The 5As is a key framework for organising the provision of preventive care in primary healthcare.1,2 This includes the actions taken by healthcare providers in supporting their patients to change their risk (Table A1).

A2. Motivational interviewing

Motivational interviewing (MI) is a non-confrontational, client-centred counselling strategy aimed at resolving ambivalence and increasing a person’s motivation to change.3,4 It is an acknowledged care skill required by a wide range of healthcare workers.5–10 The MI approach has strong evidence of benefit and impact on health outcomes across a number of areas, including lifestyle change, chronic disease and adherence.11–21
MI involves:
  • helping the patient to identify areas for change (ie engage in ‘change talk’)3,4,22
  • highlighting any discrepancies between present behaviour and broader goals
  • encouraging the patient to examine the benefits they would experience from improving their lifestyle  (eg nutrition, physical activity) and self-management skills
  • asking the patient to compare potential outcomes if they do make changes versus if they do not
  • asking the patient to identify any challenges, barriers or negative aspects involved in making improvements   (eg costs, access to good food)
  • helping the patient determine specific and achievable solutions to the challenges, barriers and negative aspects involved in change
  • establishing the patient’s motivation and confidence to make changes
  • asking the patient to summarise, in their own words, their goals and how they are going to achieve them.23

A core component of the MI approach is the MI ‘spirit’.3 This is based on four key elements: collaboration between the practitioner and the patient; evoking or drawing out the patient’s ideas about change; emphasising the patient’s autonomy; practising compassion.

There are various contributors and barriers to consider when determining the best approach to assess and assist behavioural change, including cultural issues, physical environment/residence, beliefs and expectations, literacy, interest and motivation, addictive behaviour, coping style, and emotions and mood.

For patients who are not confident about their ability to succeed, various methods can be used to help them commit to making a change. Asking patients to weigh up the pros and cons of making a change or staying the way they are is a common technique. This is called ‘decision balance’ and can help patients decide whether to make a change immediately.

For those patients who are ready to make a change, time can be spent explaining and planning how they can make that change. Patients who have already made a change may require follow-up to monitor progress and deal with any relapses or difficulties.

The process can provide the GP with insight into issues that patients might have regarding their current lifestyle, and the importance of, and their motivation and ability to, make any changes in their behaviour.

MI has superseded the trans-theoretical model of behaviour change (ie the stages of change model).24,25 The latter is intended to provide a comprehensive conceptual model of how and why changes occur, whereas MI is a specific clinical method to enhance personal motivation for change.25