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Primary care practitioners are expected to achieve a lot in their short interactions with patients or clients. The limited time available has a significant impact on satisfaction, outcomes and patient safety. In this context the question of developing innovations to support people to adopt different choices and reduce risk of chronic diseases, improve well being or reduce morbidity warrants careful consideration. The challenge is to innovate for impact on problems that are multidimensional and may be difficult to address with a ‘magic bullet’. There are many examples of topics that have been advocated as the purview of primary care practitioners they include-promoting weight loss and smoking cessation, reducing salt consumption, advocating safe sex, discouraging teenage pregnancy, encouraging exercise and a host of other issues where ‘prevention’ is touted as the best solution. Occasionally ‘health promotion’ in primary care is encouraged with financial rewards where time pressure is already a concern. In reality the evidence for health promotion in primary care is equivocal. Secondly and perhaps more to the point the drivers for behaviour change are more effectively addressed through taxation, legislation, public health campaigns, non government organisations, schools, parents and the media. Nonetheless when the rubber hits the road and a person develops early signs of chronic disease there is an opportunity to encourage that person to address the risks, albeit that nothing can guarantee longevity or good health.
At an individual level how do you activate behaviour change in people who just won’t seem to budge? For effective behaviour change three things have to occur at the same time:
1. the person must be motivated
2. the person must have the ability, or perceive they have the ability, to take action
3. an appropriate trigger (or prompt) must be applied.
Without all three behaviour will not change.
Motivators are those which are an inherent part of the human experience everywhere:
- sensation – pleasure/pain
- anticipation – hope/fear
- social cohesion – social acceptance/rejection
Of these, probably anticipation, is the only one which might conceivably be addressed relatively quickly. However:
Evidence of a direct correlation between risk perception and self-protective behavior is ambiguous at best. Rimal and Real
Recanting warnings about the dire consequences of persistent alcohol abuse are unlikely to result in abstinence in the vast majority of cases.
Ability may be even more problematic. There are two ways to amplify ability – enhance ability to perform the behavior, or make the behaviour simpler to do. In practice medical practitioners may struggle to achieve this in the context of a busy clinic. Enhancing a patients ability to control their weight for example means making it easier for that person to eat just enough. Michael Wu, breaks ‘simplicity’ down further, he identifies:
- effort resources (physical and mental effort)
- scarce resources (time, money, authority, permission, attention) and
- adaptability resources (capacity to break norms – personal/routine, social, cultural)
In reality this can rarely be achieved within a few minutes in a medical consultation. There are two ways to amplify ability – enhance ability to perform the behavior, or make the behaviour simpler to do. Fogg offers the following insight:
Simplicity is a function of your scarcest resource at that moment. Think about time as a resource, If you don’t have 10 minutes to spend, and the target behavior requires 10 minutes, then it’s not simple. Money is another resource. If you don’t have $1, and the behavior requires $1, then it’s not simple.
It may be the reason why it has been tempting to issue prescriptions in response to lifestyle related risk factors for chronic disease . However pharmacology is yet to solve all of mankind’s problems. That brings us to triggers. Fogg defines three kinds of triggers for three different contexts:
- sparks – a motivating trigger, applied where there is high ability but low motivation
- facilitators – enabling triggers, applied where there is high motivation but low ability
- signals – a prompt, applied where both motivation and ability are high
Therefore within a primary care context a trigger could be efficiently delivered to some people. For example it has been demonstrated in Australian primary care motivation is high:
Fifty six percent of patients intended to lose weight in the next six months. Females, younger patients, those with a level of education of trade certificate and above or those with high cholesterol had significantly higher odds of intending to lose weight. “Health” was the top reason for wanting to lose weight in normal weight (38%), overweight (57%) and obese (72%) patients. Yoong et al
On the other hand ability may be limited:
Australian consumers have a poor understanding of energy and kilojoules and tend to perceive higher energy products as healthier and providing sustained energy. Watson et al.
Therefore in this context an enabling trigger or prompt may be effective. An innovation can underline ‘why’ to someone who knows ‘what’ and ‘how’, even if it means stimulating them to find out how. Here’s one that worked for us for a similar problem. Finally, and to reiterate, innovation has to be easily adapted into the workflow in primary care as per normalisation process theory.
Picture by Nottingham Trent University