Question

Provide an example of changing a behavior using the components of the PRECEDE-PROCEED model to improve the health of individuals.

Hints:

1. Use the 2 attached examples as a guideline.

2. Create a similar example in a different topic - such as smoking, obesity, drug abuse, or any other health issue - to improve the quality of life

(at least 400 words)

Answer 1

Behaviors and Social Practice
Our EHR system doesn’t necessarily prompt us to look at behaviors and social factors that may be obstacles to achieving optimal health. For my patients with hypertension, I’m going to care about aspects of their daily lives that prevent them from exercising healthier practices. I care about their environment—where they live, what they eat during the day, and how many hours they spend sitting each day. I care about whether there’s a grocery store in their neighborhoods where they can access fresh fruits and vegetables. The things I care about when I’m meeting with my patients look a lot different from the list of questions that pops up in the EHR. Yet these factors are equally, if not more, important than anything else when I’m looking at the causes of my patients’ medical conditions.

A Positive Conversation
Once I have a better understanding of the total picture of my patients, there is a second set of considerations I must test. Will my patients make the lifestyle and behavior changes needed to positively affect their health? Yes, I can tell them to eat better and exercise more, but if they work two jobs and don’t have access to a grocery store in their neighborhoods, they’re going to have a tough time with this. At this point, I might think back to the motivational interviewing training I received and think about how to frame the conversation with patients in the most constructive way. Motivational interviewing involves four stages of dialogue to help orient patients toward success with their change-related goals using support, advice, affirmation, and empathetic conversation. These stages include engaging with patients to help build rapport, focusing patients on the changes they want to make while offering advice and support, evoking the tools and desires they possess within them to effect change, and planning to implement the goals and next steps patients identified through the encounter.1 Supporting my patients’ awareness about their current behavior patterns, helping them become aware of the skills they already have, and respecting any initial resistance will be crucial to conducting a positive conversation.

Healthy Lifestyle Changes
Traditionally, the ability to achieve total good health has been dependent on an individual’s willingness to implement change in his or her everyday life. Behavioral design ultimately helps people find useful tools and tactics for making healthy lifestyle changes. It also helps determine how able and ready a person is to make a change, and what triggers are most likely to instigate that change. At times, if I’m unable to motivate my patients to change, I might need to enlist the expertise of others on my team and provide a referral. What kind of resources or outside referrals will be beneficial in helping my patients accomplish their goals? I may need to go beyond the test room and look to what the community can offer. There may be diet- and exercise-tracking apps, free nutritional and wellness counseling, cooking classes, sports clubs, and even community or church groups that could help my patients to make positive lifestyle changes once they leave my check room.
For individuals to sustain healthy lifestyle changes, we must make the healthy choice the easy choice. Something as simple as having well-lit and well-maintained stairwells in office buildings, having weekly walking meetings, or including healthy food choices at lunchtime meetings can make the difference for someone to implement healthy habits.

Behavior Change Conversations
However, to sustain healthy lifestyle changes, we must address them not only in communities but also in clinical settings. Clinicians and physicians are a crucial element to bridging the gap between individuals knowing what needs to change and actually implementing those lifestyle changes. Physicians are in a position to help educate patients about the importance of healthy behavior change and to guide them to resources that may aid them in living healthier lives. Training in motivational interviewing is one useful tool that can aid clinicians to have productive conversations about behavior change with their patients. One resource used in Northern California is the Motivational Interviewing however, there are many ways to approach behavior change conversations with patients. Discussions about behavior change help individuals understand healthy living in the context of preexisting goals they may have and to view overall health as a community issue, rather than as a medical condition.

Unhealthy Habits
The prevalent and growing obesity epidemic in the US initially stemmed, in part, from negative systematic change. New communities today are frequently designed around unhealthy habits: Suburban housing developments require people to drive to everyday destinations, and fast food restaurants make unhealthy food the most convenient option. This has created an unmet need for systematic changes in the opposite direction—changes that will help us to climb out of the unhealthy routine and to redesign for optimal default behaviors. Since 1994, there has been a dramatic increase in obesity in the US.2 According to the Centers for Disease Control and Prevention, 35.7% of US adults and approximately 17%—or 12.5 million—of children and adolescents aged 2 to 19 years are obese.3 Obesity can lead to more serious chronic diseases such as heart disease and diabetes. Obesity is a problem that begins by affecting communities and eventually spreads to a national level. Awareness campaigns such as HBO’s The Weight of the Nation (developed in partnership with Kaiser Permanente) are attempting to reach individuals in their communities and warn them of the severe and adverse effects of being overweight or obese.
The Centers for Disease Control and Prevention also reports, through the Diabetes Prevention Program national study, that intensive lifestyle change and intervention can prevent diabetes caused by obesity. The multicenter clinical research study aimed to discover whether modest (5% to 7%) weight loss through dietary changes and increased physical activity (150 minutes/week) could prevent or delay the onset of type 2 diabetes in study participants. The Diabetes Prevention Program ultimately found that participants who lost a modest amount of weight through dietary changes and increased physical activity sharply reduced their chances of developing diabetes.
Since Kaiser Permanente’s (KP’s) inception, the importance of prevention has always influenced our work and our values, and we have remained on the leading edge. Healthcare Effectiveness Data and Information Set (HEDIS) data show that KP’s Georgia and Southern California Regions are ranked first and second, respectively, in the nation for adult body mass index screening, with other KP Regions not far behind.

Exercise as Vital Sign
Last year, we determined the validity of asking our patients how many minutes per week they exercise and recording this number as a vital sign. This was a progressive step toward achieving optimal behavior design in a clinical setting, and toward achieving total good health. It was also our first foray into creating a clinical measure that determines how a patient’s lifestyle can directly translate into the prevention of the leading causes of death in our country. According to a KP study published in the journal Medicine and Science in Sports and Exercise, establishing a systematic method for recording patients’ physical activity in their EHRs ultimately helps clinicians better treat and counsel patients about their lifestyles.

Healthy Habits
Although recognizing exercise as a vital sign is a step in the right direction for healthy behavior change, there is still work to be done. Addressing exercise as a vital sign certainly opens the door to a larger conversation about healthy habits, but what keeps us from fully engaging with our patients is the fact that we don’t completely understand how to measure environmental determinants, or how to talk to patients about them. We must find a way to effectively relate to each patient individually to ascertain how they can fit healthy habits into their everyday routines. First, we must determine what changes each individual is willing to make. Then we must simplify these changes and guide patients through how to monitor their actions against an overall goal. We also must be aware that some patients may be initially resistant to change. Instead of challenging this resistance, we should respect it and encourage patients to drive toward their own goal-oriented solutions.
Karen J Coleman, PhD, research scientist at the KP Southern California Department of Research and Evaluation and lead author of the study examining exercise as a vital sign, stated, “Given that health care providers have contact with the majority of Americans, they have a unique opportunity to encourage physical activity among their patients through an assessment and brief counseling.”7 She added, “embedding questions about physical activity in the electronic medical record provides an opportunity to counsel millions of patients during routine medical care regarding the importance of physical activity for health.”

Prescribing Success
To focus on total health at a personal level with individuals, it is important to enlist the clinical community to help us prescribe success, rather than just prescribing medical interventions. A crucial question to ask ourselves is, “As a physician, am I equipped to prescribe success for my patient?” Although we, as physicians, have a role to play in the continued health of our patients, barriers to achieving this goal are inevitable.
We must incorporate behavior change as part of the total health framework that physicians advocate and model for their patients and that individuals implement in their lives and communities. As an integrated health care system, we should aim to change the course of how to approach and encourage healthier behaviors to prevent disease, as well as consider what fundamental elements encourage people to change their behavior, and sustain that change, understanding that personal behavior is a major contributor to overall health.
As the behavior change pyramid suggests, it is crucial to bridge the gap between the medical model of the physician’s office and the individual’s experience in the community (Figure 1). Because healthy behavior change begins at home, it’s important for primary care physicians to connect and engage patients on a personal level and to determine what matters the most to patients and what changes they are willing to make, so we can ultimately set them up for success in sustaining those changes. It’s equally important to reinforce ongoing successes once individuals do implement healthy habits in their everyday lives. Again, personal behavior is a major contributor to overall health.
One way to engage individuals in improving their health is to show them how healthy behavior changes can be major contributors to preventing or delaying the onset of disease or personal injury. Health care leaders are increasingly recognizing healthy behaviors as factors in the improvement of overall health. For example, studies indicate that there is a clear link between good emotional health and healthier behaviors.
In 1994, KP created the bone density screening program for osteoporosis prevention in Southern California. As part of this innovative initiative, we identified members with a higher risk of osteoporosis, and we performed bone density screenings on this population. We were also able to recommend calcium supplements, exercise, and other lifestyle changes that could help prevent fractures later on. By 2002, the fully integrated Healthy Bones program was in place at all Medical Centers in the organization’s Southern California Region. Since then, the Healthy Bones program has reduced the number of fragility fractures among Southern California members by 15%. The program has expanded to all KP Regions.
This is just one example of how early intervention combined with lifestyle and behavior change successfully altered the course of health history for a significant number of our members with the potential for bone disease. With this example in mind, it seems logical that, as a delivery system, we should consider our role in addressing intensive lifestyle change to prevent other diseases such as diabetes, cardiovascular disease, and lung disease.

Mood and Sleep
Increased physical activity can directly and positively affect mood in individuals who experience depression. Physical activity has been examined as an adjunctive treatment strategy for major depressive disorder.9 This type of evidence can help patients see the positive effects of physical activity on not only their weight and blood pressure, but also on more serious emotional issues, such as depression and anxiety.
Similarly, lack of sleep has been directly linked to obesity. According to a new University of California, Berkeley study, something as simple as getting a good night’s sleep could be a habit that directly affects an individual’s weight.10 The study found that not only did sleep-deprived individuals crave unhealthy choices, but their brain behaved differently as well. Ultimately, the brain impairment that occurs when sleep deprivation occurs leads to unhealthy food choices and can eventually cause obesity. However, on the other side of the coin, this means that getting enough sleep is a factor that can help promote weight loss in overweight patients, as long as we can share relevant information with them and engage them to implement this healthy change.

Advertising Unhealthy Habits
Some environmental factors such as television advertising are beyond individual control, making it even more difficult to break unhealthy habits. Furthermore, advertisements also become a contributing factor to poor eating choices, creating a vicious cycle of bad behavior that is difficult to break. Advertisements are a telling example of environmental factors that individuals face in their daily lives that they cannot change or control. Television marketing increased by 8.3% for children ages 2 to 5 years and by 4.7% for children ages 6 to 11 years from 2009 to 2011, reversing declines in previous years, according to Lisa Powell, PhD, of the University of Illinois at Chicago School of Public Health, and colleagues.12 In addition, by examining television analytics data, the researchers found that teens’ exposure to food ads increased by 9.3%.
“Teens’ exposure to food-related TV advertising has continued to increase steadily since 2003, reaching almost 16 ads per day in 2011,” the authors wrote in the American Journal of Preventative Medicine.12 Challenges such as the advertising of unhealthy habits are an inherent problem for individual communities—which makes it more crucial for physicians to connect with individuals, better understand where they come from and the challenges they face, and effectively motivate them to change their lifestyles.

Invest in People in Community
In the end, for the medical community, including KP, to be successful in helping individuals implement healthy behavior change, it is crucial to approach prevention in a different way. To ultimately produce good health, we must make investments in the personal lives of our patients —understanding the communities they live in and what intersection is needed between the clinical system and changes that are easily supported by communities. As a health care system, we know that there is no more important relationship than the one between physician and patient. We have reached a point where we have an opportunity to help the primary care system prescribe success among individuals, empowering them to restore and maintain healthy lifestyles, and we have tools available to help us guide the necessary conversations to effect change. Recognizing exercise as a vital sign is one step forward in this process, and we will continue to engage physicians and patients to ultimately change the way healthy behavior change is approached and perceived.

Smoking- The dangers of smoking and the beneficial effects of smoking cessation on health are well established. However, less is known about how quitting smoking affects quality of life. Smokers report various reasons for wanting to smoke, such as coping with stress and cravings, social facilitation and improving mood. Further, smokers report concerns about the effects of quitting smoking such as gaining weight, decreased ability to cope with stressors and negative affect, social ostracism, loss of pleasure and intense cravings. Such findings raise questions about how quitting vs. continued smoking actually affects general mood, perceived health status, life satisfaction and quality of life long-term—once the effects of withdrawal have dissipated. Increases in subjective well-being may be as important or relevant to smokers as quitting to reduce disease risk. More compelling evidence on this issue could be used to quell smokers’ fears and might actually be used to encourage more quit attempts.

QOL measures can be divided into instruments that focus on health-related outcomes and functionality (i.e., health-related QOL), and ones that also include dimensions in addition to health: e.g., social, recreational, affective/mental health, and life circumstances (i.e., global QOL). Some cross-sectional studies have focused on differences in health-related quality of life (HR-QOL) amongst smokers, never smokers and former smokers. Such studies have shown that active smoking is associated with lower levels of self-reported functioning in all health-related domains as compared to never-smokers. In fact, smoking has also been associated with decreased HR-QOL over-and-above other chronic or severe medical conditions. Cross-sectional studies have also shown that HR-QOL ratings of ex-smokers more closely approximate never smokers than they do smokers, suggesting that quitting may improve HR-QOL. However, only a few longitudinal studies have focused on the relation between cessation and changes in HR-QOL For example, Sarna et al.used data from women smokers who participated in the Nurses’ Health Study and tracked changes in HR-QOL over eight years. In that research, continuing smokers reported lower physical and mental health status compared to never smokers and smokers who quit at some point during the 8 years of the study. While this study is consistent with the cross-sectional data, the generalizability and robustness of the findings are limited as it is restricted to women and does not have very close temporal resolution since assessments were at 4-year intervals and were not timed to quitting. Further, the few extant longitudinal studies are not treatment studies; rather, smokers quit throughout the study. Thus, later differences between quitters and continuing smokers may strongly reflect differences that spurred quit attempts (e.g., illness concerns, dissatisfaction with smoking). In the current study, all participants were motivated to quit smoking and engaged in a quit attempt at the study’s inception. This produces some consistency in the timing of the quit attempt and initial motivational status of the participants.
In conclusion, this research suggests that in addition to improvements in objective, physiologic health indices such as HDL cholesterol and endothelial function, over the three years after a quit attempt, successful quitters, in contrast to continuing smokers, reported better global quality of life, improved health-related quality of life, improved affect, and fewer stressors. These findings could be used to motivate quit attempts by individuals who are low in motivation to quit or who are daunted by concerns about what life will be like without cigarettes. Smokers might believe that quitting will decrease life satisfaction or quality of life—because they believe it disrupts routines, interferes with relationships, produces a loss of reinforcement (loss of smoking related pleasure), or because cessation deprives them of a coping strategy. The current findings suggest that over the long-term, individuals will be happier and more satisfied with their lives if they quit smoking than if they do not.

Obesity- With a seemingly ever-increasing global prevalence rate of obesity, it has never been more important to evaluate the impact of this condition on an individual and on society as a whole. The physical health risks associated with obesity have been widely studied but just as important are the emotional and psychological risks that exist. There have been a number of studies that have looked at obesity and health-related quality of life (HRQL), which is particularly important to measure, as it can quantify not only the physical but also the psychological and social well-being of a person. These broader qualities of HRQL are closely aligned to the World Health Organization’s definition of health and can effectively capture a range of states of disease to well-being.

When compared to the general adult population or with age- and sex-matched controls, those with obesity (body mass index [BMI] ≥30) have significantly lower HRQL. Physical and mental well-being may be affected more by those with obesity who also suffer bodily pain or from other comorbidities. A population-based survey of 155,989 American adults found that obesity increased the risk of poor physical and mental health outcomes, but once pain and obesity-related comorbidities were removed from the model, the adjusted risks decreased significantly. Another study found that the presence of comorbidities strongly affects emotional well-being in those with obesity, while yet another study found that obese persons with pain report the greatest impairments in overall health.

Treating obesity with clinical interventions in the past has shown that it is possible to improve HRQL through weight loss. For example, a randomized trial of a clinical weight loss program found that participants scored lower than age-specific population norms on HRQL at baseline, but those who completed the intervention improved in physical functioning, general health, vitality, and mental health. Furthermore, in those participants who regained some of the weight at 2-year follow-up, HRQL improvements were maintained. Studies of other obesity treatments, such as surgical intervention studies, have found similar improvements. Results from a meta-analysis of 54 studies containing nearly 100,000 participants suggested that the additional body weight alone that these individuals carried was not enough to explain lower HRQL scores than those not seeking surgical treatment. Lower scores were likely explained by the negative effect the presence of comorbidities has on quality of life.

HRQL can be improved through various weight loss interventions. For those seeking nonsurgical treatment for obesity, many options exist (eg, various diets, behavioral therapies, exercise interventions, pharmacotherapy, commercial weight loss programs), but attending these programs may be met with cost and accessibility barriers or may fail to provide the necessary support to adhere to the program. One way to improve access and adherence – and therefore, provide an opportunity to lose more weight and improve HRQL – is to use a free or low-cost community-based obesity reduction program with a strong emphasis on social support.

The Healthy Weights Initiative (HWI) is a free, multidisciplinary, community-based obesity reduction program that uses evidence-based strategies and strongly emphasizes social support as a key to adherence and better outcomes. Prior to starting the HWI, 153 community consultations took place in the city. Prior to its implementation, every family doctor, cardiologist, and internist in the city, as well as the medical health officer of the health region, provided letters of support. The Mayor, the City Manager, the Chief of Police, both provincial Members of the Legislative Assembly, the local federal Member of Parliament, and the federal Minister of Health also provided letters of support. Additional letters of support were also provided by the Regional Intersectoral Committee (all local government agencies such as the school boards), the Healthy Active Living Committee, the In Motion Committee, not-for-profit organizations such as the Young Men’s Christian Association (YMCA), key businesses such as the Credit Union and the Co-op, the Chamber of Commerce, the Heart and Stroke Foundation, the Canadian Cancer Society, and the Public Health Agency of Canada. In total, 71 letters of support were obtained.

The Initiative was designed to follow the ten evidence-based principles included in the International Obesity Task Force guidelines for long-term obesity reduction.31 The objectives of this study were to determine the impact of the HWI on HRQL and to determine the adjusted risk factors for lack of improvement from baseline to follow-up on the overall score of the Medical Outcomes Study 36-Item Short-Form Health Survey.

During the past decades there was an increasing predominance of chronic disorders, with a large number of people living with chronic diseases that can adversely affect their quality of life. The aim of the present paper is to study quality of life and especially Health related quality of life (HRQoL) in chronic diseases. HRQOL is a multidimensional construct that consists of at least three broad domains physical, psychological, and social functioning that are affected by one’s disease and/or treatment. HRQoL is usually measured in chronic conditions and is frequently impaired to a great extent. In addition, factors that are associated with good and poor HRQoL, as well as HRQoL assessment will be discussed. The estimation of the relative impact of chronic diseases on HRQoL is necessary in order to better plan and distribute health care resources aiming at a better HRQoL. According to WHO, QoL is defined as individuals’ perceptions of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards and concerns. QoL is the feeling of overall life satisfaction, as determined by the mentally alert individual whose life is being evaluated. This appraisal is subjective, and encompasses all domains of life, including elements of a biopsychosocialspiritual model. The use of the term subjective has different connotations to different people and can be perceived as not reliable because it is not objective. Subjective can be synonymous with self-perceived meaning that a person primarily gives information about himself. Other definitions of QoL suggest that it is a global personal assessment of a single dimension which may be causally responsive to a variety of other distinct dimensions: it is a unidimensional concept with multiple causes. Therefore, it encompasses the entire range of human experience, states, perceptions and spheres of thought concerning the life of an individual or a community. Both objective and subjective QoL can include cultural, physical, psychological, interpersonal, spiritual, financial, political, temporal and philosophical dimensions. QoL implies a judgment of value placed on the experience of communities, groups such as families or individuals. Finally, it is suggested that QoL can theoretically encompass a wide ranging array of domains and components. These involve functional ability including role functioning (functional ability in different roles like in physical activities and achievement beliefs), the degree and quality of social interaction, psychological well-being, somatic sensations, happiness, life situations, life satisfaction and need for satisfaction. It also reflects life experiences’, significant life events and the current phase of the life and the factors defining QoL in this respect further include sex, socioeconomic status, age and generation. QoL is thus a complex collection of interacting objective and subjective dimensions: encompasses the individual’s perspective, is assessed through the eye of the experiencer, and is likely to be mediated by cognitive factors.
Health related quality of life :- Patrick and Erickson (1993) define health-related quality of life (HRQoL) as the value assigned to duration of life as modified by the impairments, functional states, perceptions and social opportunities that are influenced by disease, injury, treatment or policy. A main topic in HRQoL includes patients’ appraisal of their current level of functioning, as well as satisfaction with it, compared to what they believe to be ideal. An important aspect in HRQoL study is how the manifestation of an illness or treatment is experienced by an individual. Patients’ heath status assessment includes personal experiences which are affected by health care interventions as well as changes over time with a chronic disease and no particular treatment. For example, evaluation of HRQoL over time after disease such as stroke, for individuals who have completed treatment and rehabilitation and are living with the effects of this disease. It is generally accepted that HRQOL is a multidimensional construct that consists of at least three broad domains physical, psychological, and social functioning that are affected by one’s disease and/or treatment. Physical functioning is usually defined as the ability to perform a range of activities of daily living, as well as physical symptoms resulting from the disease itself or from treatment. Psychological functioning ranges from severe psychological distress to a positive sense of well-being and may also encompass cognitive functioning. Social functioning refers to quantitative and qualitative aspects of social relationships and interactions and societal integration. A model of HRQoL might lead to a better explanation of the previous statements. Wilson & Cleary (1995) describe a conceptual model of HRQoL that provides a theoretical approach to conceptualizing HRQoL as a multidimensional construct and integrates biological and psychological aspects of health outcomes. This model consists of five different levels namely, physiological factors, symptom status, functional health, general health perceptions and overall QoL. It has been widely applied to different populations, including patients with cancer, arthritis, Parkinson’s disease and HIV. It is indicated that symptom status, functional health, general health perceptions, and overall QoL are dimensions of HRQoL.