The Health Care Provider's Role in Supporting Positive Health

Medical Research Archives, Vol. 5, Issue 9, September 2017 The Health Care Provider’s Role in Supporting Positive Health Behavior Change: Developing an Effective and Supportive Communication Approach

The Health Care Provider’s Role in Supporting Positive Health Behavior Change: Developing an Effective and Supportive Communication Approach

Authors: ABSTRACT Janet R. Bezner1, PT, DPT, Non-communicable diseases (NCDs) are the leading cause of PhD, FAPTA death and disability worldwide. Four chronic NCDs, including cardiovascular disease, cancer, chronic respiratory disease, and 2 Lisa K. Lloyd , PhD diabetes are responsible for more than 80% of NCD-related deaths. Unhealthy behaviors, such as physical inactivity, Sylvia H. Crixell3, PhD, RD smoking, poor nutrition, and excessive alcohol consumption are Tricia J. Burke4, PhD significant causes of chronic NCDs. However, even when faced with potentially debilitating effects associated with chronic NCDs, it is difficult for individuals to change their behaviors Affiliations: and adopt more healthful practices, such as being physically 1 Texas State University active, refraining from smoking, eating a healthful diet, and Department of Physical refraining from excess alcohol intake. Sometimes barriers seem Therapy insurmountable, and affected individuals need guidance. A San Marcos, TX 78666 potential resource that can help individuals overcome personal E-mail: [email protected] barriers and successfully improve their health behaviors is the health care provider. However, while health care providers are 2 Texas State University being tasked to address patients’ health behaviors, they often Department of Health and feel ill-equipped to assist their patients to engage in meaningful, Human Performance sustainable, health behavior change. Promising approaches to San Marcos, TX 78666 providing efficient and effective support for patients’ behavior E-mail: change revolve around provider-patient communication. Health coaching, for instance, is a process whereby health care [email protected] providers follow a standardized communication approach in 3 Texas State University working with patients that integrates health behavior change School of Family and theories such as the Transtheoretical Model and Self Consumer Sciences Determination Theory, utilizes conversational tools such as San Marcos, TX 78666 motivational interviewing, and incorporates evidence-based strategies to foster health behavior change. In so doing, the E-mail: [email protected] provider’s role shifts from that of an expert to that of a partner, 4 Texas State University which results in improved satisfaction in the provider-patient Department of relationship for both the provider and the patient, and improved Communication Studies health outcomes for the patient. Communication strategies that build provider-patient partnerships increase patient autonomy San Marcos, TX 78666 and self-efficacy, thereby enabling providers to better support E-mail: [email protected] their patients in adopting sustainable behavior change and addressing the burden caused by NCDs. Keywords: behavior change, health coaching, noncommunicable disease, communication

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1. INTRODUCTION The medical community, in particular, has Non-communicable diseases (NCDs), the potential to significantly impact positive i.e., non-infectious or non-transmissible health behavior change and maintenance. diseases, are the leading cause of death and Health care providers can and should disability worldwide.1 In 2012, NCDs address behavioral risk factors with their accounted for 38 million deaths (68% of patients. In fact, research has shown that, at 2 the very least, advice from a health care total deaths), up from 36 million (63% of total deaths) in 2008.3 Most NCDs are provider to change lifestyle habits can indeed incite positive health behavior chronic diseases characterized by a slow 15,16 progression and long duration.4 In fact, four change. Despite such positive results, chronic diseases – cardiovascular disease, health care providers often do not adequately cancer, chronic respiratory disease, and address behavioral risk factors with their diabetes – are responsible for more than 80% patients for many reasons, including lack of of NCD-related deaths.5 The United States is time, inadequate training on health behavior not immune to these global patterns, with 7 change, skepticism about patients’ willingness to change, and concern about out of 10 deaths each year caused by chronic 15,17,18 diseases.6 alienating patients. The risk factors for NCDs include In light of these challenges, tools to behavioral, environmental, economic, and help facilitate provider-patient conversa- other social health determinants.7 While the tions, thereby successfully promoting health prevalence of each of these risk factors behavior change, have been and continue to varies by geographical region, the steady rise be developed and tested. For instance, the Five A’s – Assess, Advise, Agree, Assist, in most NCDs worldwide is attributed, in large part, to increases in the prevalence of and Arrange - is a brief, feasible intervention behavioral risk factors.3 This is certainly true tool designed to assist health care providers in primary care settings with behavioral for the United States. While it is well-known 15,19,20 that tobacco use, poor nutrition, physical counseling. Another promising approach that has garnered attention in inactivity, and excessive alcohol intake are 15,21 significant contributors to the incidence of recent years is health coaching. Though NCDs,8 national trends illustrate little more involved than the Five A’s, this progress in adoption of healthy behaviors.9 approach can be learned by health care For instance, 50% of US adults currently do providers and easily integrated into routine not meet physical activity guidelines and the office visits. Health coaching allows health average US Healthy Eating Index score, a care providers to effectively and efficiently standard measure of diet quality, is address health behavior change without 59/100.9,10 sacrificing provider-patient trust. Clearly, changing and maintaining Given the enormity of the burden of healthy behaviors is challenging and NCDs, health care providers need to be part complicated.11,12 An integrated, socio- of the solution, in particular, by addressing ecological approach involving many levels – behavioral risk factors associated with NCDs individual, interpersonal, organizational, with their patients. To do so, they must be community, and policy – is required,13 as equipped with tools that will move them individuals’ health behaviors reflect mutual beyond increasing their patients’ awareness of the need to improve their health behaviors influence and coordination among these different elements of their environment.14 to actually teaching patients how to

Copyright 2017 KEI Journals. All Rights Reserved Page │2 Medical Research Archives, Vol. 5, Issue 9, September 2017 The Health Care Provider’s Role in Supporting Positive Health Behavior Change: Developing an Effective and Supportive Communication Approach successfully adopt and maintain positive 2.1. Transtheoretical Model health behaviors. The purposes of this paper The Transtheoretical Model, are to: (1) describe the theoretical foundation developed by James Prochaska in 1979, upon which effective and supportive integrates key constructs from several communication is based, and (2) provide theories into a single comprehensive theory practical communication strategies, to explain intentional behavior change. The including motivational interviewing and Transtheoretical Model posits that health health coaching, that health care providers behavior change involves progress through can easily integrate into routine patient six stages of change,24 and per this model, visits. ten processes of change, decisional balance, and self-efficacy are instrumental in bringing 2. HEALTH BEHAVIOR CHANGE about this progression. THEORIES The central organizing construct of the There are numerous theories that Transtheoretical Model is stage of change. 22,23 explain health behavior change. Basic Stage of change follows the notion that time knowledge of health behavior change and readiness are important components of theories can help health care providers better health behavior change, and that most understand that health behavior change is behavioral changes take place gradually over complicated, that simply raising awareness time rather than immediately as discrete among patients is not sufficient to instill events.25 Individuals move through the six behavior change, and that informed guidance stages of change, progressing and regressing is critical to bringing about successful health as they move forward in the process of behavior change. In this section, the adopting long-term positive health Transtheoretical Model and Self- behaviors. These stages include pre- determination Theory are presented. These contemplation, contemplation, preparation, theories inform contemporary health action, maintenance, and termination. The 22,23 behavior change strategies. stages and their descriptions are included in Table 1.

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Table 1: Transtheoretical Model Stages of Change and Corresponding Strategies to Improve Health Behaviors24,26,27 Stage of Change Description of Stage Strategies Precontemplation Not intending to change in the  Use motivational interviewing near future  Provide educational resources  Increase awareness of consequences of unhealthy behavior  Express concern Contemplation Thinking about change but  Use motivational interviewing ambivalent; weighing the pros  Empathize with the ambivalence and cons (“I want to change,  Discuss benefits of changing but…”)  Praise for considering change seriously  Build self-efficacy Preparation Intending to take action very  Set S.M.A.R.T. goals soon or making small changes;  Praise and reinforce behavioral changes have identified a plan to help  Encourage identification of social improve the behavior support or a buddy with whom to change  Problem solve how to deal with barriers Action Engaged in making a change  Reinforce efforts within the last 6 months that is  Probe how the behavior is positively sufficient to reduce risk for impacting the patient’s life and roles disease  Identify additional environmental supports  Encourage and praise Maintenance Has been engaged in the  Discuss another behavior and apply behavior for 6 months or longer change strategies that were successful to and working towards sustained future success with the next behavior engagement  Discuss the risk of relapse and how to prevent it Termination The behavior has become  Not applicable permanent; there is no risk of relapse (applies to addictive-type behaviors but not behaviors such as physical activity and dietary intake) S.M.A.R.T. = specific, measureable, action-oriented, realistic, time-referenced. Per the Transtheoretical Model, there thoughts, feelings, or environment in order are 10 different processes that describe how to move forward from one stage to the next. people progress through the stages of change Five of these processes are experiential and associated with a particular health behavior. include: increasing knowledge, being aware These processes include both overt and of risks of continuing negative health covert strategies and techniques that an behaviors, caring about consequences to individual may use to modify his/her others, understanding benefits of change,

Copyright 2017 KEI Journals. All Rights Reserved Page │4 Medical Research Archives, Vol. 5, Issue 9, September 2017 The Health Care Provider’s Role in Supporting Positive Health Behavior Change: Developing an Effective and Supportive Communication Approach and increasing healthy opportunities. Five of stages, the pros outweigh the cons.25 these processes are behavioral and include: Considering an individual’s stage of change substituting alternatives for usual less is particularly salient with regard to tailoring healthy behaviors, enlisting social support, health messages to appeal to his/her personal rewarding oneself for performing the healthy circumstances, as well as to potentially behavior, committing oneself to the healthy stimulating progression through these stages behavior, and reminding oneself of the towards behavior change.31 26 healthy behavior. To successfully progress Research on the effectiveness of the through the stages of change and ultimately Transtheoretical Model in producing attain the desired behavior change, different behavior change is limited due to poor processes are used at different stages. In theoretical fidelity,32 as well as to general, experiential processes are used in inconsistent methodological quality and poor the earlier stages of change (precontem- application of the model.33 Some plation and contemplation) when patients are researchers have concluded that the thinking about change. The behavioral Transtheoretical Model may not be sufficient processes are used in the later stages by itself to support behavior change, (preparation, action, and maintenance) when suggesting that combining it with patients are engaging in the healthy 28 techniques, such as motivational behavior. For example, Marcus et al., interviewing, may yield better results.32 identified a relationship between stage of Broadly speaking, because behavior change change and process of change for engaging is complex, the literature suggests that no in exercise, wherein progression towards the single theory is adequate to guide behavior action and maintenance stages of change change. Therefore, providers should was accompanied by replacing the recognize that to effectively counsel their experiential processes of change with the patients about making lifestyle-related behavioral processes. behavior changes, their recommendations A unique aspect of the need to be theoretically-based and drawn Transtheoretical Model is that it focuses on from several theories.34 the individual’s decision-making process, Self-efficacy stems from Bandura’s rather than on social and biological factors 25,29 Social Cognitive Theory and refers to the that might influence health behavior. level of confidence an individual has about Decisional balance, a core construct of the performing a particular health behavior even Transtheoretical Model, posits that the when faced with barriers such as feeling decision to change behavior is made by tired, being in a bad mood, and not having weighing the pros and the cons of changing 35 30 enough time. Similar to the other the behavior. In order for a health behavior Transtheoretical Model constructs, self- to be adopted, one must see more positives efficacy changes as one moves through the (pros) than negatives (cons) to changing that stages of change. In the precontemplation health behavior. Thus, as one moves through and contemplation stages, self-efficacy is the stages of change, his/her decisional low. As one moves into the preparation balance also changes. In the stage, self-efficacy increases. In the action precontemplation and contemplation stages, and maintenance stages, self-efficacy the cons of changing behavior outweigh the continues to increase, peaking at about 18 pros. As one moves into the preparation months of maintenance. Self-efficacy is stage, the pros and the cons are roughly behavior-specific and has been shown to equivalent. In the action and maintenance

Copyright 2017 KEI Journals. All Rights Reserved Page │5 Medical Research Archives, Vol. 5, Issue 9, September 2017 The Health Care Provider’s Role in Supporting Positive Health Behavior Change: Developing an Effective and Supportive Communication Approach affect: the acquisition of new health human motivation.23 This theory examines behaviors, the inhibition of existing the role of motivation in initiating and unhealthy behaviors, the amount of effort a maintaining positive health behaviors. person is willing to commit to a particular Broadly, SDT categorizes the motivation health behavior, and the persistence a person that regulates one’s behavior as autonomous will demonstrate when faced with road or controlled.38 People with autonomous blocks.36 In short, a person with low self- motivation are either intrinsically motivated efficacy is unlikely to expend much effort or self-determined (i.e., integrated and towards adopting a health behavior, whereas identified regulation). These individuals a person with high self-efficacy is much incorporate the value of a behavior into their more likely to do so. sense of self, gain self-support and self- Taken together, health care providers advocacy through their own actions, and are are more likely to be successful in helping thereby more likely to adopt and maintain patients improve health behaviors if they the positive health behavior. More have a working knowledge of the constructs specifically, persons who are intrinsically of the Transtheoretical Model and consider motivated are likely to regularly engage in a the patient’s stage of change from the start. positive health behavior because they enjoy it and feel a sense of accomplishment. To do so, the health care provider would first need to assess both the patient’s stage of Persons who are self-determined are likely change and the patient’s self-efficacy to regularly engage in a positive health regarding the targeted health behavior. A behavior because the behavior has been simple survey could be administered to the assimilated into their sense of self (i.e., patient in the waiting room and quickly integrated regulation) or because they want evaluated by office staff before the patient to improve their physical health or sees the health care provider. Then, the appearance (i.e., identified regulation). health care provider could discuss strategies People with controlled motivation (i.e., tailored to the patient’s stage of change and introjected and external regulation), to a level of self-efficacy during the office visit. large extent, do not recognize the inherent value of a health behavior and instead their Table 1 includes such strategies. For instance, a health care provider could task a behavior is influenced by external factors. patient in the precontemplation stage with More specifically, persons with controlled motivation are likely to initiate, but not identifying the pros of behavior change, perhaps paving the way for changing necessarily maintain the behavior, because they want to avoid feeling guilty or shameful decisional balance. The provider could also discuss time management, which is a (i.e., introjected regulation) or because they practical skill that has been shown to want to be noticed and receive compliments increase individuals’ belief that they can during social engagements (i.e., external perform the behavior by helping them feel regulation). they can better control potential obstacles.37 Given its association with sustained More specific strategies will be discussed in health behavior change, fostering the next section. autonomous motivation is key. Therefore, understanding fundamental influences on 2.2. Self-Determination Theory autonomous motivation may be helpful. Self-Determination Theory (SDT), Autonomous motivation is strengthened developed by Edward Deci and Richard when three basic psychological needs – Ryan, provides a framework for the study of autonomy (being self-governed),

Copyright 2017 KEI Journals. All Rights Reserved Page │6 Medical Research Archives, Vol. 5, Issue 9, September 2017 The Health Care Provider’s Role in Supporting Positive Health Behavior Change: Developing an Effective and Supportive Communication Approach competence (ability to function in a interviewing fosters autonomous motivation particular way), and relatedness (feeling by helping patients resolve dissonance connected to others) – are met.38,39 In a between their personal values and their meta-analysis of 184 studies in health care health behaviors. For example, an important and health promotion settings, promotion of value, like being a good parent, is a more patient autonomy, in particular, was found to sustainable motivator for the performance of be very important to improving mental and healthy behaviors than is a health care physical health and to predicting the provider’s recommendation to exercise performance of healthy behaviors and more, or the desire to lose weight to look psychological well-being across a wide better in anticipation of a wedding or high variety of behaviors.40 In short, the literature school reunion.44 Referred to by the indicates that when health care providers acronym, RULE, the four guiding principles support patient needs for autonomy, of motivational interviewing include: competence, and relatedness, patients  Resist the righting reflex. The righting become more engaged in the treatment reflex is a natural desire of health care process and experience better long-term professionals to want to make things outcomes.40,41 right when there is a problem. For Health care providers are more likely example, it is common for health care to be successful in supporting positive health providers to communicate to their behaviors in their patients if they understand patients that their behavior is the pivotal role that autonomous motivation unhealthy and attempt to persuade plays in sustaining health behavior change. them to change. Consistent with For example, health care providers can reactance theory,45 such efforts often enhance their patients’ autonomous backfire and produce resistance from motivation by discussing how to link the patient, a natural response to personal values and goals to their health.42 perceiving interference from others. More specific strategies will be discussed in the next section.  Understand your patient’s motivations. Patients are persuaded by their own reasons for change, rather than by the 3. COMMUNICATION STRATE- provider’s rationale and goals. Instead GIES of telling a patient why he/she should 3.1. Motivational interviewing change, a better approach is to ask the patient about the benefits of adopting a Motivational interviewing is a health behavior and why he/she should conversational tool that health care providers change. People have more confidence can use to facilitate discussion about health in self-generated arguments,46 and behavior change among their patients. It therefore can persuade themselves to incorporates elements of both the change. Transtheoretical Model and SDT. For example, for patients who are not yet ready  Listen to your patient. A key to using to change (i.e., in the precontemplation motivational interviewing effectively stage), motivational interviewing elicits is to listen more than talking, intrinsic motivation for healthy behavior educating, or advising. Empathic adoption within the patient,43 thus listening is a primary skill involved in potentially stimulating progression through developing a patient-centered the stages of change. Further, motivational

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partnership to support behavior settings for four decades,48 its use in medical change.47 settings spans only the last two decades.49 A recent systematic review and meta-analysis  Empower your patient. Health determined that motivational interviewing outcomes are improved when patients can be used by a variety of health care actively engage in managing their own providers efficiently and effectively for a health. Through motivational variety of types of patients to promote interviewing, a provider can partner behavior change related to physical activity, with the patient to explore how the weight loss, blood pressure and cholesterol patient can improve his/her own management, and substance use.49 health. Patient empowerment is crucial Specifically, compared to control groups, to the development of patient self- patients who received motivational efficacy to make healthy changes.43 interviewing had, on average, a one and a By collaborating with the patient, the half times greater chance of improving.49 provider creates an atmosphere that is Thus, it is fairly evident that motivational cooperative rather than coercive, recognizes interviewing has the potential to be a that the patient possesses the resources and powerful tool that health care providers can motivation to change, and respects and use when broaching the topic of behavior affirms the patient’s right and capacity for change with their patients. self-direction. The primary skills of motivational interviewing include: 3.2. Health Coaching  Asking open-ended questions, which While motivational interviewing alone allows the patient to guide the is not sufficient to bring about health conversation, prevents yes/no answers, behavior change, health care providers can and respects patient autonomy. use this strategy to initiate a conversation about personal health behaviors.  Affirming and supporting, or actively Motivational interviewing should be a listening for patient values, strengths, component of a more comprehensive aspirations, and positive qualities, and communication approach to improving reflecting these back to the patient in health behaviors – health coaching.50 Much an affirming (nonjudgmental) manner. has been written about effective  Reflective listening, or mirroring what communication strategies with patients that the patient says, to keep the focus on patient-centeredness, humanism, 51–54 conversation focused on the patient, to meaning, and mindfulness. Learning and dive deeper into the patient’s story, applying health coaching (counseling) skills and to confirm mutual understanding can effectively shift a health care provider’s between the patient and the provider. focus from expert to partner in the mutual quest for improving the patients’ health  Summarizing periodically during the behaviors, thereby improving satisfaction in conversation to reinforce the patient’s the provider-patient relationship and patient motivations to change, to transition health outcomes.50,54 between topics, to point out progress, and to ensure the provider understands Given that most health care providers the patient.43 are educated and experienced in the Western medicine approach to patient care, which While motivational interviewing has involves collecting and interpreting been used and studied in non-medical information, forming a diagnosis, and

Copyright 2017 KEI Journals. All Rights Reserved Page │8 Medical Research Archives, Vol. 5, Issue 9, September 2017 The Health Care Provider’s Role in Supporting Positive Health Behavior Change: Developing an Effective and Supportive Communication Approach prescribing medications or interventions, a health-related reasons to change behavior are shift towards health coaching requires important, providers should partner with education and practice.50 Competencies patients to identify patient-centric goals and necessary to effectively coach a patient motivations for change that are aligned with include: patients’ needs and desires in an effort to sustain behavior change over time.  Applying a patient-centered approach wherein the patient feels self-directed Consistent with the notion of rather than provider-directed, partnering with the patient, providers can instill a “trial and learn” approach in lieu of

 Assisting patients in identifying their the more common “trial and error” approach goals and motives for change, 50(p.74) to behavior change. A “trial and learn”  Using a self-discovery process in approach entails experimenting with various which patients explore achievable strategies and approaches to learn which intervention strategies and engage in ones work best for each individual, while active learning about their health, avoiding the blame and shame that a “trial and error” approach can yield. Building  Helping patients establish self- healthy habits can and should be a positive accountability and monitoring experience, and refraining from references to practices, and making mistakes, errors, and failure is more  Building relevant health knowledge to likely to build self-efficacy and success.50 assist the patient in changing Encouraging self-discovery allows patients unhealthy behaviors.55 to identify their readiness to change, as well as the relative effectiveness of different Health care providers not trained in approaches to behavior change, which can health coaching often try to motivate lead to greater investment and long-term patients by connecting health behaviors with success. For example, while patients in the disease prevention. For example, a health precontemplation stage of change are not care provider might educate a patient about ready to actively improve their behavior, the role of good nutrition and physical they may derive value from identifying activity to lower blood pressure and/or benefits of the health behavior, problem- reduce the risk for cardiovascular and solving identified barriers, and seeking metabolic disease. Providers may rely on social support. Rather than the provider resources, such as Exercise is Medicine,56 simply giving this information to the patient, which provide patients with pre-established he/she can “prescribe” homework, exercise programs. This approach meets the encouraging the patient to brainstorm about needs of the provider in improving patients’ the benefits of behavior change, options for health, but does not incorporate patients’ overcoming barriers, potential sources of unique needs. Ample evidence suggests that social support, and strategies for marshaling most patients are not motivated to be support. In this way, patients themselves physically active for the long-term factors identify suitable strategies for engaging in that coincide with providers’ goals, such as meaningful behavior change instead of preventing disease and improving health. merely following directions from their Instead, patients are motivated by positive provider. This approach allows for tailored affective experiences, such as having fun, communication between providers and improving overall well-being, and attaining patients that is focused on unique patient a high quality of life.44 In other words, while

Copyright 2017 KEI Journals. All Rights Reserved Page │9 Medical Research Archives, Vol. 5, Issue 9, September 2017 The Health Care Provider’s Role in Supporting Positive Health Behavior Change: Developing an Effective and Supportive Communication Approach experiences,31 which could ultimately lead to A recently published compendium of behavior change. the health and wellness coaching literature Adopting a standardized approach to indicates that health coaching can be a valuable tool to improve behavior change as health coaching can help reduce the 21 provider’s apprehension about it relates to addressing chronic disease. communicating with patients during office Articles included in this review met criteria recommended in this paper, including that: visits. With the abatement of apprehension, the provider will become more facile at (1) the health coach was a trained health care using health coaching on a routine basis. professional and used behavior change Table 2 displays a process, incorporating the theory and coaching processes; (2) the Transtheoretical Model, Self Determination patient determined the behavior change or Theory, and elements of motivational health goals either in part or in whole; (3) interviewing, that can be adopted and there was an element of patient modified as needed to guide behavior accountability included in the coaching change conversations with patients. This interaction; and (4) a patient-clinician relationship was established (at least 3 visits approach is designed to avoid resistance and 21 defensive responses from patients. While occurred). Based on the reviewed literature, the authors suggested that health patient defensiveness or resistance could mean that the patient is not ready to address coaching is a worthwhile intervention for the behavior, it could also be a signal from patients with cancer, diabetes and heart the patient that the provider’s disease, and it is especially effective in addressing obesity, high cholesterol, and communication style reflects an expert 21 approach rather than a coaching approach. hypertension. Furthermore, the US For example, asking questions that begin Preventive Services Task Force rates with “why” can result in a defensive behavioral counseling a grade of B in the response from a patient; therefore, rather treatment of adults who are overweight or than asking, “why do you find regular obese with risk factors for cardiovascular physical activity difficult?”, a provider could disease, indicating that there is high certainty that the net benefit of counseling is moderate say “tell me about your experience in trying or that there is moderate certainty that the to make physical activity regular.” To the 57 extent that the provider can elicit responses net benefit is moderate to substantial. Based on these reviews, health coaching is from the patient rather than directing the patient, the patient will become engaged, an intervention approach that health care providers should consider utilizing to stem interested, and successful in making health behaviors habitual.50 the growth of chronic disease.

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Table 2: Communication Process to Discuss Behavior Change Step Example Ask permission to discuss a behavior “I noticed you indicated that you are not regularly physically active on your medical history form. Would it be okay for us to discuss this behavior?” Ask about history with the behavior “Was there a time in your life when you were regularly physically active? Tell me about that time. What was different in your life then?” Ask about the benefits of the behavior “If you were regularly physically active now, how would your life be different? What are the benefits of regular physical activity for you now?” Ask about the barriers to the behavior “What is getting in the way of being regularly physically active? How can you problem-solve to reduce these barriers?” Identify environmental and social “What resources do you have that would help you supports to be regularly physically active? Are there individuals in your daily life who would support your efforts to be regularly physically active?” Assess readiness to change “How ready are you today to become more physically active?” (1 to 10 scale) Assess confidence to change “How confident are you today that you could become more physically active? (1 to 10 scale) Ask if patient is ready to take a first step “If you were to take a step toward being more regularly physically active, what would that first step be?” Create a S.M.A.R.T.* goal Example goal: I will ask my spouse to walk with me after dinner for 30 minutes on two evenings next week. Inquire about confidence in achieving “How confident are you that you will accomplish goal this goal?” (1 to 10 scale) Express appreciation for the patient’s “I’m glad we had this conversation and that you willingness to make positive changes have created the start of a plan to become more physically active. I am confident that you will be successful.” Arrange for follow-up/accountability “At your next visit I look forward to discussing your progress in making physical activity a regular habit.” S.M.A.R.T. = specific, measureable, action-oriented, realistic, time-referenced

3.3. Specific Strategies for pressure often experienced by patients. Enhancing Self-Efficacy and Autonomy Indeed, self-efficacy and autonomy, the two In addition to following the process major goals of health coaching, can be outlined in Table 2, the health care provider cultivated by a variety of strategies. can mindfully employ communication Strategies to increase self-efficacy can strategies that foster empowerment, patient be categorized in four ways, including: (1) self-regulation, and autonomy, thereby performance accomplishments, (2) vicarious avoiding the guilt, shame, and social experience, (3) verbal persuasion, and (4)

Copyright 2017 KEI Journals. All Rights Reserved Page │11 Medical Research Archives, Vol. 5, Issue 9, September 2017 The Health Care Provider’s Role in Supporting Positive Health Behavior Change: Developing an Effective and Supportive Communication Approach emotional arousal.58 Performance persuading patients that they have the accomplishments refers to breaking a capacity to be successful. Together, these behavior into small, achievable, yet approaches can ameliorate patients’ self- challenging steps. For example, in line with doubt, while also promoting their behavior the sample S.M.A.R.T. goal in Table 2, a change. patient might ask his/her spouse to walk Finally, emotional arousal calls after dinner for 30 minutes on two nights per attention to how patients feel as they week. While fitting in one hour of exercise experiment with behavior change. Although per week is a small and achievable step, at behavior change is often physically and the same time it can be challenging to alter emotionally beneficial (e.g., improved sleep, one’s routine and to include one’s partner in mood, and energy), patients might not healthy behavior change. It is important to readily make connections between their identify achievable goals like these because behavior change and these positive achieving small goals invites further outcomes, perhaps focusing on the physical progress; in contrast, failing to achieve and emotional challenges associated with ambitious goals can deplete self-efficacy. behavior change instead. As such, health Ensuring that patients are challenged and care providers should highlight these supported to accomplish a behavioral step is connections and benefits in an effort to crucial in trying to enhance self-efficacy and enhance patient motivation and self- promote behavior change. efficacy.50 It is imperative that patients make Vicarious experience, also known as connections between the health behavior observational learning, involves observing change and positive outcomes, as intrinsic someone else succeed in changing a specific, motivation is necessary to sustain behavior or target, behavior, thus confirming that the change. When health behaviors are aligned target behavior is attainable. For example, with a patient’s values, they become more observing that a friend has been able to stop natural to perform and serve to enhance life smoking or attend an exercise class on a roles. For example, when a patient weekly basis may help convince an recognizes that regular physical activity individual that change is doable. The success enhances his or her ability to care for his or of the friend can serve as a point of reference her children or grandchildren, the value of for successfully changing the target engaging in regular physical activity is behavior. compounded. This realization is consistent Verbal persuasion includes both social with the suggestion from Segar et al. that and self-persuasion. Patients invest more patients will be more motivated to perform effort in behavior change to the extent they healthy behaviors when practitioners believe they can succeed and that they have promote them through “cultivating choice, the requisite support to succeed.58 featuring emotions/affect instead of logic, Consequently, a health care provider’s and prescribing [them] for vitality, enjoyment, and well-being.”44(p.101) Providers expression of confidence in a patient’s ability to be successful combined with an are challenged to find non-health-related emphasis on positive experiences versus reasons to adopt healthy behaviors; however, struggles or failures can result in a patient when they do identify these reasons, persuading him- or herself that he/she can communicating them to their patients can successfully change the target behavior. promote greater success in health behavior Mental practice and imagery can also aid in change.

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4. CONCLUSION providers can change the conversation they All health care providers are being have with their patients from a health-focus tasked to address the burden of NCDs by to a patient-focus and produce improved promoting the adoption of healthy behaviors, results and outcomes. By partnering with like regular physical activity, consuming a patients to identify intrinsic motivators and nutritious diet, not smoking, and refraining applying strategies to intentionally improve self-efficacy, health care providers can from excess alcohol intake with their patients.15 Despite the time restraints reasonably address health behavior change, experienced by health care providers and the invariably reducing the burden of disease skepticism that patients will take action, and improving the health of members of society.

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