Transcript HCA approach - HealthChange Home

HCA Core Training Part 1:
A Practical Guide to Health Behaviour Change
using the HCA approach
Presented by Angela Kinsella-Ritter
www.healthchangeaustralia.com
© 2012 Health Change Australia
Slide 1
Workshop essentials
• Housekeeping & OH&S
• Timings
• Workshop manuals (HCA Guide)
• Terminology & Glossary (Guide pages xii, xv and xvi)
• Practical exercises and confidentiality
• Interaction, questions, comments
• PowerPoint
• Attendance certificate requirements
• Introductions
© 2012 Health Change Australia
Slide 2
Patient case demonstration
Video - Geoff
• Back injury (medical discharge from Navy)
• Chronic pain
• PTSD, depression & other psychosocial
• Diabetes type 2
• Prostate cancer previously
• High cholesterol
• Weight management issues
• Resistance from previous experiences
© 2012 Health Change Australia
Geoff 6 minute video
Slide 3
HCA generic behaviour change pathway
Knowledge & understanding
Motivation & expectations
Decision
Line
Decision & commitment
Macro View
Planning
Micro View
Action
Self-regulation
Build Motivation
© 2012 Health Change Australia
Build Confidence
(G Inside Front Cover)
Slide 4
The purpose of the HCA approach is to increase
adherence for effective health self-management
14-21%
Patients who don’t fill their prescription
50%
Patients who act on GP referrals to other practitioners
and services
50%
Overall adherence to chronic conditions treatment including
lifestyle changes
25%
50%
Maintenance of new exercise behaviours after rehabilitation in
the general population, and following cardiac rehabilitation
(WHO 2003; GP clinic audit; Dishman 1988; Oldridge 1991)
© 2012 Health Change Australia
Slide 5
Different roles for clinicians
Traditional medical
and allied health
clinical
consultations
Client-centred
medical and allied
health clinical
consultations
Client-centred
clinical programs
and services
Wellness
counselling and
coaching
interventions
General
counselling and
coaching
interventions
Focus on
individualised
assessment,
treatment advice
and/or education for
specific conditions
(conducted by
clinicians)
Focus on
individualised
assessment,
treatment advice
and/or education for
specific conditions +
health behaviour
change support
(conducted by
clinicians)
Focus on general
recommendations and
education for disease
management,
rehabilitation and/or
lifestyle change for
better health
outcomes + health
behaviour change
support
(conducted by
clinicians)
Focus on general
recommendations and
education for general
health and wellbeing
+ health behaviour
change support
(not necessarily
conducted by
clinicians)
Focus on improving
general wellbeing and
mental health +
behaviour change
support
(not necessarily
specific to health or
conducted by
clinicians)
biomedical focus
psychosocial focus
HCA approach
health coaching
© 2012 Health Change Australia
(Gxi)
Slide 6
Health change contexts
Chronic Condition Management ~ Disability ~ Rehabilitation ~ Disease Prevention ~ Health/Wellness
HCA Model of Health Change ™
Health behaviour change principles and processes
applicable across the spectrum of health goals and clinical contexts
9 Practice Principles
• 3Cs: client centred, client
choice, client control
• Call it as you see it
• Four aspects of goal
setting
• One thing at a time, one
step at a time, adding up
over time
• The RICk principle
• First ask, then offer
• WAIT til 8
• Invite the client to write
• Trial & error
© 2012 Health Change Australia
7 Essential Techniques
10 Step Decision
Framework
• Client first technique
Set the scene & explain your role
• Menu of options
technique
1. Identify clinical issues & broad
• Using your RICk radar
• Asking RICk
• Decisional balance
technique
lifestyle & treatment categories
2. Prioritise & choose a category
3. Ask RICk 
4. Make a decision
5. Generate personal goal options
• Turning ANNTs into PETs
6. Choose & refine an option
• Tracking & monitoring
strategies
7. Create an action plan
(G inside Section 1 tab)
8. Identify & address barriers
9. Ask RICk
10. Consider review & referral
Slide 8
What topics will we cover?
1. Overview of the HCA approach
2. Practice principles
3. Essential techniques
4. Setting the scene
5. Above the line processes
6. Below the line processes
© 2012 Health Change Australia
Slide 9
Common patient predictors of
non-adherence & poor self-management
“Don’t tell me
what to do!”
© 2012 Health Change Australia
“Yes, Yes, tell me
what to do”
Slide 11
What stops people from taking action to
achieve better health and quality of life?
Behaviours
• Actions, everyday habits, planning or lack of
planning
Emotions
• Emotional reactions to things that happen to
us, mood states
Situations
• Medical, cognitive abilities, social, physical,
access, $, changes in circumstance, clinicians
Thinking
• Beliefs, attitudes, expectations & habitual
thinking patterns, motivation (RIC),
knowledge (k)
© 2012 Health Change Australia
(Gix) White Card
Slide 13
What gets in the way for you?
What are the recommended activity levels for adults?
Does your own activity level meet the guidelines?
If Yes: How do you manage to achieve this?
If No: What stops you from achieving this?
© 2012 Health Change Australia
Slide 14
What do clients want?
• How do you know when a client is ready to take
action?
• How do you know your client is not ready?
• What do you want your clients to do when they leave
your consultation?
• What do clients want?
© 2012 Health Change Australia
Slide 15
Usual clinical practice processes:
Clinical Assessment
Clinical Decision-making
Algorithm
Do you regularly check
that your client is
ready, willing and able
to act on your
recommendations?
Diagnosis
E-b Treatment Plan or
Recommendations
What do you do if they
are not?
E-b = evidence-based
© 2012 Health Change Australia
Slide 16
Complementary clinical pathways:
Clinical condition/health behaviour change (HBC)
Clinical Assessment
HBC Assessment
Clinical Decision-making
Algorithm
HBC Decision-making
Algorithm
Diagnosis
RICk Clarity
E-b Treatment Plan or
Recommendations
E-b Behaviour Change
Recommendations
RICk = readiness, importance, confidence, knowledge
© 2012 Health Change Australia
(Gx)
Slide 17
Clinical & self-management aims - examples
• Engage in treatment
• Do rehabilitation exercises
• Manage clinical risk factors
• Manage BP, cholesterol, BGLs
• Attend referral appointments
• Manage chronic pain
• Manage medications
• Manage mood/stress
• Maintain independence
• Re-engage socially
• Monitor symptoms
• Use public transport
• Manage fatigue
• Use aids and equipment
• Communicate with doctors
• Improve nutrition
• Manage time
• Increase activity levels
• Increase mobility
• Damage control
• Manage acute/chronic injury
• Reduce alcohol/smoking
• Have tests and check-ups
• Return to work
• Prepare for death
• Other?
© 2012 Health Change Australia
(Gx)
Slide 18
What are the clinical and self-management
aims for your patients or clients?
What are the adherence issues?
© 2012 Health Change Australia
Slide 19
Section 1:
Overview of the HCA approach
A behaviour change
methodology for use by
clinicians and health
services within their usual
clinical consultations and
programs
© 2012 Health Change Australia
Slide 20
The HCA model of health change (HCA approach)
Integrates patient-centred communication and
behaviour change support into a clinical practice
decision framework
Client behaviour change pathway
1. Practice Principles
2. Essential Techniques
Knowledge & understanding
Motivation & expectations
Decision
Line
Decision & commitment
Planning
3. Decision Framework
Action
Self-regulation
Build Motivation
Build Confidence
© 2012 Health Change Australia
But, it is not a magic pill!
Slide 21
Key concepts
• Clinical information and treatment advice is
presented in a way that enhances patient knowledge,
understanding and engagement
• A decision framework is provided for clinicians to
quickly identify and address adherence issues
(barriers to patient engagement)
• The approach increases patient motivation and selfefficacy for following treatment advice and builds
patient self-management skills
© 2012 Health Change Australia
Slide 22
Purpose of using the HCA approach
1. Systematically embed a patient-centred
approach into clinical practice and services
2. Consistently support patient health literacy,
decision-making and engagement
3. Increase and support patient adherence to
evidence-based lifestyle and treatment advice
4. Provide a common language and clear, consistent
expectations for patients and clinicians across
disciplines
© 2012 Health Change Australia
Slide 23
Patient case demonstration
Video - Terry
•
•
•
•
•
CAD, heart attack
Hypertension
Diabetes T2
Obesity, Lap banding
Gall bladder removed
© 2012 Health Change Australia
Terry above the line video
Slide 26
Key questions above and below the decision line
Does the client know and understand the broad lifestyle and
treatment categories applicable to their condition/s?
Have they been assisted to collaboratively prioritise these?
Are they ready, willing, able and committed to taking action?
Decision Line
Macro View
Ready to
Take Action
Micro View
What options do they have for taking action in a particular
category?
What is their personal goal and plan?
Are they confident they can do this and what might get in the way?
Will I review the client and what other support do they need?
Build Motivation
© 2012 Health Change Australia
Build Confidence
(G5)
Slide 27
How can I assist this patient,
to achieve these specific health outcomes,
at this point in time, given their…..?
• Current clinical issues
• Current psychosocial issues
• Current level of readiness
• Current barriers to taking action
• Current knowledge levels
• Current life circumstances
• Levels of ability, and
• Consultation time constraints
© 2012 Health Change Australia
Slide 29
What’s the evidence?
• Evidence-based health behaviour change principles and
techniques
• Health behaviour change theory
• Brief motivational interviewing
• Solution-focused counselling & coaching literature
• Cognitive behavioural counselling techniques
• Health coaching literature
• Chronic disease prevention and management programs
• The HCA approach bridges the gap from theory to practice
© 2012 Health Change Australia
Slide 30
Applications
• Primary Care: General practice, allied health consultations and programs
• Community : Early Intervention in Chronic Disease, Hospital Admission Risk
Program, NSW Chronic Disease Management Program – Connecting Care in
the Community, Home and Community Care, Cardiac Rehabilitation, Heart
Failure, Diabetes Management, Mental health, Aged care, Disability Services,
other prevention and disease management support services
• Population Health: NSW/ACT/TAS Get Healthy program, NSW Live Life Well
Diabetes Prevention program, VIC WorkSafe WorkHealth Coach program
• Research: Deakin University NHMRC (HIPP Study/healthy pregnancy);
Melbourne University (knee osteoarthritis nurse coaching to support
physiotherapy interventions)
• Ottawa Regional Cancer Foundation (Canada): Patient support coaching for
cancer survivors
• Corporate health services
© 2012 Health Change Australia
Slide 31
Clinician role
(perceived
& actual)
Clinician
RICk
Knowledge
&
skills
Client’s
characteristics
Behaviour change support
challenges for clinicians
Management
& Systems
support
Client’s role
perceptions
Attitudes of
colleagues
Time?
© 2012 Health Change Australia
(Sample Letter Appendix G, p. 89)
Slide 32
Consultation time
Less Time
Targeted assessment
Targeted education
Low complexity
High RICk
Fewer barriers
© 2012 Health Change Australia
More Time
Global assessment
Global education
High complexity
Low RICk
More barriers
Insulin pump video
Slide 33
Who should we spend behaviour change time on?
1. Clients who are clearly not interested in your
advice? 
2. Clients who are undecided (ambivalent) or
couldn’t be bothered? 
3. Clients who are motivated but lack confidence?
4. Clients who are clearly motivated and confident?
© 2012 Health Change Australia


Slide 34
Section 2:
HCA practice principles
RICk = Readiness, Importance, Confidence, knowledge
© 2012 Health Change Australia
(G inside Section 2 tab)
Slide 35
The 3Cs of health change
People have a need for autonomy
© 2012 Health Change Australia
(G19)
Slide 36
Traditional care & client-centred care
How are these different?
© 2012 Health Change Australia
(G20)
What is patient empowerment?
Slide 37
Is this patient-centred?
Pathology
Take
Meds
Quit
Smoking
Attend
Groups
Nurse
Selfmanage
GP
OT
Diet’n
Patient
Counsellor
Diab Ed
Diet’n
Nutrition
Physio
Ex Phys
Exercises
© 2012 Health Change Australia
Move
More
Attend
Appoint’s
Use
Aids
Monitor
Symptoms
Pod’st
Rehab
Program
Slide 38
Common patient/client responses
Fear
Hopelessness
Frustration
Guilt
Despair
Confusion
Anger
Shame
© 2012 Health Change Australia
Resistance
Resentment
Slide 39
Cognitive, behavioural & emotional
avoidance response
© 2012 Health Change Australia
Slide 40
Communication
What not to do:
• ‘Tell’ people what to do
• Argue the point
• Use scare tactics with someone low in confidence
• Using judgemental language
• Overwhelm people by expecting them to do too much
• Overwhelm them with too much information
© 2012 Health Change Australia
Slide 41
Client-centred communication process
Before conducting assessments, delivering education
or asking a lot of questions for any purpose:
1. Explain what you’re about to do
2. Ask for permission
•
Launching into questions without explanation can
reduce rapport
PP - a
© 2012 Health Change Australia
Slide 42
Call it as you see it (or hear it)
Avoid playing the
practitioner-patient game!
PP - b
© 2012 Health Change Australia
(G20)
Slide 43
Assessment
1
Clinical
targets
(physiological)
4
Motivational
drivers
Menu of
options
2
Broad
lifestyle &
treatment
categories
© 2012 Health Change Australia
(G21)
3
Specific
personal
health goals
Personal
action plan
PP - c
Slide 44
Patient assessment data: clinical indicators & risk factors
Diabetes
CAD
Asthma
Arthritis
Injury
Obesity
Nutrition
Meds/
Treatment
Attend
Appoint’s
Exercise
Monitor
Symptoms
Info/Edu
Ensure the patient knows:
1. what their health issues are
2. the broad categories of actions required to manage these health issues
© 2012 Health Change Australia
Slide 45
Different clients will have different motivators
What might motivate the following groups of clients?
• Children?
• Teens?
• Working age adults?
• Seniors?
• People with disabilities?
• People with mental health issues?
• Different cultures?
• Others?
© 2012 Health Change Australia
(G23)
Strategy
Slide 46
PP - d
© 2012 Health Change Australia
(G25)
Slide 47
The HCA RICk principle
Readiness
Importance
Confidence
knowledge
© 2012 Health Change Australia
}
(G26)
Action
Slide 48
RICk tips
1) If importance is low:
check knowledge,
build motivation,
raise priority
2) If confidence is low:
identify and
address barriers
PP - e and f
© 2012 Health Change Australia
(G26)
Slide 49
First ask the client,
Then offer:
• Assessment
• Clinical education
• Health recommendations
• Treatment and referral options
• Strategies to achieve goals
• Suggestions regarding possible barriers
PP - g
© 2012 Health Change Australia
(G29)
Slide 50
WAIT til 8
Why
Am
I
Talking?
Why
Am
I
Taking Notes
or Typing?
People often need time to think and answer
A response at the 8 second mark is common
PP - h
© 2012 Health Change Australia
(G29)
WAIT til 8 video
Slide 51
Invite the client to write
Why might this increase a client’s
success rate?
PP - i
© 2012 Health Change Australia
(G30)
Invite to write video
Slide 52
Working with low literacy
• Use visual tools
• Ask clients how they usually remember
• Visual and auditory memory aides
• Tactile tracking strategies
(marbles/buttons/strokes of a pen)
• Rehearse action plans verbally
© 2012 Health Change Australia
Slide 53
Working through interpreters
• Invite interpreters to brief you on culture
• Brief interpreters on your practice style
• Learn how to say hello, goodbye, yes and no in each
language.
• Use as little speech as possible
• Promote client choice - use visual tools
• Break dialogue into small chunks – to avoid interpreters
summarising and oversimplifying
• Ask clients to paraphrase information to check accuracy
• Use appropriate eye contact
• Allow extra time
© 2012 Health Change Australia
Slide 54
Working with cognitive impairment
•
•
•
•
Identify who the decision-maker is
Work with the client and/or carers
Work with patient idiosyncrasies, likes and dislikes
Incorporate reminders/visual cues and aids to
comprehension
• Adapt pace and style of language to client
• Check comprehension
© 2012 Health Change Australia
Slide 55
Adapt the HCA approach
to suit your clients!
Cognitive
Impairment ?
Acute/Chronic
Health
Issues ?
Cultural
Issues ?
Resistance ?
Clients
Psychosocial
Issues ?
Language/
Lit. Issues ?
Passive
Compliance ?
Depression
Anxiety ?
Age-Related
Issues ?
© 2012 Health Change Australia
Slide 56
Trial & error
When you don’t succeed…
...try a different strategy!
PP - j
© 2012 Health Change Australia
(G30)
Trial and error video
Slide 57
Teach a man to fish…
© 2012 Health Change Australia
Derek
Slide 58
Section 3:
HCA essential techniques
© 2012 Health Change Australia
(G inside Section 3 tab)
Slide 59
Are you ready to do something
about your own health?
1. Knowledge & Understanding
2. Motivation & Expectations
3. Decision & Commitment
Decision
Line
4. Planning
© 2012 Health Change Australia
Slide 60
Knowledge & understanding: What can you do to be healthier?
Consider your own clinical indicators & risk factors:
Other?
Health
Checks?
ZZZZZ…
© 2012 Health Change Australia
Slide 61
Motivation & expectations: readiness
How ready are you to work on this issue
today, given all the other things that you are
already doing?
Some optional ways to answer:
1. Draw a line and place a cross on it;
2. Pick a number out of 10; or
3. Rate as low, medium, or high
© 2012 Health Change Australia
X
Slide 62
Motivation & expectations: importance
How important is it to you personally to work
on this issue (given all the other priorities
currently in your life)?
Some optional ways to answer:
1. Draw a line and place a cross on it;
2. Pick a number out of 10; or
3. Rate as low, medium, or high
© 2012 Health Change Australia
X
Slide 63
Motivation & expectations: confidence
How confident are you that you will make
some manageable and sustainable behaviour
changes in relation to this issue?
Some optional ways to answer:
1. Draw a line and place a cross on it;
2. Pick a number out of 10; or
3. Rate as low, medium, or high
© 2012 Health Change Australia
X
Slide 64
Decision & commitment
In relation to your chosen health issue consider...
1. If you continue to do what you are currently doing (or
not doing), what will the long-term consequences be for
you? What about the people or things that are important
to you?
2. If you do make some manageable and gradual changes,
what immediate or long-term benefits would you expect
to gain? What would the impact of this be?
3. Do these expected negative or positive outcomes make it
important enough for you to work on this issue now?
© 2012 Health Change Australia
Slide 65
Decision & commitment
• Are you ready to do something about this?
• Is it relatively important to you?
• Are you confident that you will take some action?
• Do you have all the information you need to make a
decision and take action?
Did your RICk levels change?
© 2012 Health Change Australia
Slide 66
Planning: create a wish list of possible options
for pursuing your health aims
• Write down at least 6 or more different ways that
you could take action in the lifestyle or treatment
category that you selected
• Think of this as a wish list: for the time being ignore
any barriers that might come to mind for any of the
options you consider
• Try to include some options that you have not tried
before
© 2012 Health Change Australia
Slide 67
The client first technique
Client First
Elicit information from the client prior to
offering your own education and suggestions:
• What do they already know?
• What are they already doing?
• What would work for them?
• What could they do to address a particular
barrier?
© 2012 Health Change Australia
(G33)
Slide 68
The HCA client first technique
High readiness technique to do planning & increase confidence
Person 1 – The clinician
•
Use reflection, summarising and questioning
•
Provide NO suggestions or advice for this exercise
•
Guide partner toward creating a goal and an action plan
•
Use prompt questions
•
Respect confidentiality
Person 2 – The client
•
Choose a REAL change that you are very ready to work on from the options list
you created
•
Avoid story telling! (10 mins each – we will tell you when to swap)
•
Write down your personal goal and action plan (handout)
•
Give your partner a big cheery “yes but” if they give suggestions!
© 2012 Health Change Australia
Slide 69
Optional prompt questions for client first technique
• Which health aspect would it benefit you to work on?
• How ready are you to work on this health area with me today?
• What are you currently doing regarding this issue?
• What benefits do you expect to achieve?
• From the list of options that you wrote down, which of these
options might work for you now?
• What personal goal could you set for yourself?
• What actions would you need to take to achieve this goal, step by
step? What else?... What else?
• Would it help to write these steps down to remember them?
• What might get in the way and what could you do about it?
• How confident are you that you will achieve this personal goal?
© 2012 Health Change Australia
(G33)
Slide 70
How did you go?
Was it difficult to refrain from
jumping in with your own solution?
•
•
What was it like being the client?
What was it like being the clinician?
ET - a
© 2012 Health Change Australia
Slide 71
How do you offer suggestions & avoid
“yes, but…” ?
Offer a menu of options!
Behind every “yes, but” is a barrier
© 2012 Health Change Australia
(G35)
Slide 72
Offering a menu of options:
1. Use a lead-in explanation
2. Ask permission
3. Provide multiple strategies where possible
4. Invite the client to think of something else that
may suit them better
5. Ask the client if they think any of the ideas might
be suitable
ET - b
© 2012 Health Change Australia
(G35)
Slide 73
Using your RICk radar
Client First
Observe body language, tone of voice and other
verbal and non-verbal cues to pick up low RICk or
ambivalence
ET - c
© 2012 Health Change Australia
(G38 & Glossary)
Slide 74
Client case demonstration
Video - Peter
The potential pitfalls of scaling questions
© 2012 Health Change Australia
Peter video
Slide 75
Asking RICk
Small group exercise:
How many different ways can you
think of to ask RICk?
ET - d
© 2012 Health Change Australia
(G37-39)
Slide 76
Common above the line thinking barriers
I have a problem
The problem is serious
enough to consider action
It could adversely affect
things or people that are
important to me
There is an effective course
of action open to me
Weigh up
expected
costs and
benefits
Decide to
take action
or not
I am able to pursue this
course of action
I can’t put off making a
decision
© 2012 Health Change Australia
Adapted from the Health Belief Model (Becker & Rosenstock, 1984)
Slide 77
Beware the Motivation Trap!
Motivation to
reduce pain
lose weight
retain independence
etc.
© 2012 Health Change Australia
(G27)
≠
Motivation to engage in
actions or tasks
required to reduce pain,
lose weight, retain
independence etc.
Slide 78
Understanding importance
Why do people say an issue is important when really
they are still above the decision line?
1. Expected responses: playing the patient role or
pleasing you
2. Intellectualised responses: something I feel I
‘should’ do
3. Wanting outcomes: but not prepared to take the
actions required to get the outcomes
© 2012 Health Change Australia
Page 79
Signs of shaky commitment (ambivalence)
• Body language or tone of voice contradict RICk
responses
• Statements like ‘I know I should…, but, ….’
• Laughing nervously when talking about a topic
• Strong emotion when discussing condition/s ,
lifestyle/treatment categories or goals and actions
• Weak reasons to take action & strong reasons not to
• Changing the subject during discussion
• Others?
© 2012 Health Change Australia
(G26)
Slide 80
Exploring the tradeoffs to increase importance
Smoking
Quitting
Pros
Cons
© 2012 Health Change Australia
Slide 81
Decisional balance framework
Good
Outcomes
Not so
Good
Outcomes
Take no action
Take action
1.
3.
Barriers to
taking action
Benefits of
taking action
2.
4.
Negative consequences
of not taking action
Barriers to
taking action
Focus on quadrants 2 & 3 to  importance
Focus on quadrants 1 & 4 to  confidence
© 2012 Health Change Australia
(G45)
Slide 82
Client case demonstration
Video - Justine
Decisional balance assistance for smoking
Things to consider:
• Why did the clinician ask DB questions?
• Which DB questions were asked?
• What were the pros/cons of smoking and
quitting for this client?
© 2012 Health Change Australia
Justine video
Slide 83
Justine: quitting viewed as negative
The decision: Will I quit smoking or not?
Continue smoking
• It is social – something I do with
friends and partner
Good
• I enjoy it
Outcomes
• I don’t get bored
• It gives me a time out relaxation
Quit smoking
•
•
•
•
Healthy skin
Look better
Feel better
Smell better
• Wheezing, coughing
• Be seen as selfish – letting my
• My skin not so good and will get
friends down
Not so
worse as I age
• Lose my partner in crime –
Good
impact on my relationship
Outcomes
• Judged as a failure ‘here we go
again’
© 2012 Health Change Australia
Slide 84
Justine: quitting viewed as positive
The decision: Will I quit smoking or not?
Continue smoking
Quit smoking
• It is social – something to do with
friends and partner
• I enjoy it
Good
Outcomes • I don’t get bored
• It gives me a time out - relaxation
• My skin will have a ‘glow’
• I will look better, smell better, feel
better
• Confidence
• Won’t be judged as a ‘smoker’
• I will not be labelled with having a
‘dirty habit’
• Greater social acceptance
• Wheezing, coughing
• My skin not so good – will get
worse, smokers lips etc.
Not so
• I struggle paddling out
Good
Outcomes • It is stopping me from doing sports
that I enjoy – my fitness is bad
• It is inhibiting me
• I am losing friendships with nonsmoking friends
• Be seen as selfish (but actually my
friends will accept this change and
support me)
• Expectation that I am a smoker (but I
can change this)
• Lose my partner in crime (but he will
support me if I am serious about it)
• Judged as a failure ‘here we go again’
(it takes a number of attempts to quit)
© 2012 Health Change Australia
Slide 85
Digging down in the benefits:
Should I give up smoking?
I will look better and not wheeze
I’ll feel better
I’ll be able to be more active (body boarding)
I want to be able to keep enjoying life as I get older
(and this won’t happen if I don’t give up before I get older) *
Therefore, I want to give up now
© 2012 Health Change Australia
(G49)
* Intrinsic motivator
Slide 86
Digging down in the consequences:
Should I go to bed earlier or not?
I will be tired in the morning
I’ll have a worse start to the day (less organised/feel worse)
I’ll have a worse day at work (less productive, more grumpy)
I’ll get home in a bad mood
I’ll be grumpy at home and
likely to fight with my wife *
© 2012 Health Change Australia
* Intrinsic motivator
Slide 87
Conceptual framework for decisional balance
Decision: __________________________________________
Good
Outcomes
Not so
Good
Outcomes
Alternative A
Alternative B
1.
Acknowledge reasons
for current behaviours
(barriers)
3.
Identify possible
benefits to be gained
from taking action
2.
Identify possible
negative consequences
of inaction
4.
Acknowledge undesirable
aspects of taking action
(barriers)
Is anything you have mentioned important enough for you to want to work on this?
© 2012 Health Change Australia
(G45)
Slide 88
Decisional balance - pairs exercise
• Talk each other through decisional balance framework one at a time
• 10 minutes each
• Pick an action or topic that you are ambivalent about working on:
Importance = 4, 5 or 6 to start with
• There is no need to write anything down – use a conversational
approach:
1. Clarify beginning level of importance
2. Use the quadrants approach or use the key questions on the next slide
3. Finish by asking if the things you have discussed have helped your partner to
make a decision to take action or not on their issue, or
4. Ask whether the benefits or consequences to themselves or others are
important enough for them to want to work on this issue further
5. Clarify RICk to see if any of it changed
© 2012 Health Change Australia
(G Appendix B p.63 & Appendix C p.65)
Slide 89
Decisional balance key questions
1. What are the benefits of what you are currently doing?
2. What’s the downside of what you are currently doing?
What are the possible long-term consequences for you and
the things/people that are important to you? *
3. Why might you consider doing things differently? What
benefits could you expect from this? *
4. What’s the downside of doing things differently?
5. Is anything that you have mentioned important enough to
make you want to work on this issue?
* Questions that may increase Importance
© 2012 Health Change Australia
(G Appendix B p.63 & Appendix C p.64)
Slide 90
How did you go?
Who decided to make a change and who didn’t?
Who would you use this technique for?
© 2012 Health Change Australia
Slide 91
Possible outcomes from decisional balance
1. Client decides not to work on chosen
category
2. Client decides to take action within the
category
3. Client needs more information to make
the decision
4. Client remains ambivalent
ET - e
© 2012 Health Change Australia
DB Examples
Slide 92
Common below the line barriers
Thinking & emotions
• Undermining beliefs: Treatments shouldn’t have side effects,
If it hurts, I can’t do it, It’s not fair!, I feel okay so I must be
fine
• Uncertainty: I am not sure whose advice I should take
• Unpleasantness of new things: It will hurt, It is too much
effort
• Procrastination: I’ll do it later
• Energy levels: It’s all too hard, I am too tired
• Fear/concerns about injury: Exercise may aggravate my
condition, I can’t exercise I have arthritis
© 2012 Health Change Australia
Slide 94
Addressing everyday thinking barriers
Thoughts
Health
Behaviour
Feelings
(from: Aaron T. Beck’s cognitive therapy )
© 2012 Health Change Australia
Slide 95
Turning ANNTs into PETs
Automatic
Neutral or
Negative
Thoughts
Positive or
Enabling
Thoughts
(Adapted from Grant & Greene 2001)
© 2012 Health Change Australia
(G53)
Slide 96
More about ANNTs
Fire ANNTs
I can’t do this. This is hopeless, why bother!
Sugar ANNTs
I’m fit as a fiddle. I don’t feel sick, so I must be OK!
Angry ANNTs (Resist ANNTs)
No one tells me what to do!
Garden Variety ANNTs
More sleep would be good…
I’ll just have this cup of coffee…
© 2012 Health Change Australia
(G53)
Slide 97
Turning ANNTs into PETs: Early Riser example
Decision point
& decision
being made
Automatic neutral or
negative thoughts
(ANNTs)
Negative
consequences of
ANNTs & not taking
intended actions
Situation:
I’ll do it tomorrow
I don’t get up
The alarm goes off
at 6 am
Just one more press of
the snooze button…
I feel more tired
Decision:
Will I or won’t I get
out of bed &
exercise before
work today?
It’s cold out there
It’s nice and warm in
here
I’m tired and need
more sleep
Positive or enabling
thoughts
(PETs)
I will feel more energised
if I get up now and do it
I’ll enjoy it once I get going
I feel like I’ve let
myself down
My mood will be better
I get grumpy with
myself (and others?)
I will achieve my fitness
goals
I never achieve my
fitness goals
I’ll feel good about myself
I deserve to sleep in
Just do it!
I beat up on myself &
feel like a failure
Confidence in getting
up - 2/10
© 2012 Health Change Australia
(G59)
Confidence in getting up 9/10
Slide 98
Turning ANNTs into PETs Short method:
Thinking strategies to support action plans
• Do you ever procrastinate or talk yourself out of doing things
you had planned to do?
• What excuses do you usually give yourself for not taking
action?
• What do you need to say to motivate yourself instead, to
make sure you do what you are planning to do?
• How will you practise these thoughts so that you can say them
to yourself when you need them?
© 2012 Health Change Australia
(G54)
Slide 103
Client case demonstration
Video – Terry
Identifying and addressing
thinking barriers
ET - f
© 2012 Health Change Australia
Terry below the line video
Slide 104
Tracking actions versus outcomes
Why do we monitor physiological outcomes?
What’s the problem with only monitoring
physiological outcomes?
What are the benefits of tracking actions also?
© 2012 Health Change Australia
(G60)
Slide 105
Tracking and monitoring strategies
• Pen & paper
• Electronic
• Other visual or graphical
• Accumulating objects
• Recording measurements
• Reward systems
• Subjective scales
• Others?
© 2012 Health Change Australia
(G61)
Slide 106
What you track is what you get
Family blocks of chocolate
Week
Starting
(date)
28/4
Mon
5/5
Wed
3
squares
Chocolate
Exercise
Tue
15
mins
Thur
Fri
2
squares
20 mins
10 mins
Sat
Sun
2
squares
Total days
goals met
Ex
hours
total
3!
3!
45
mins!
Chocolate
Exercise
12/5
Chocolate
Exercise
ET - g
© 2012 Health Change Australia
Slide 107
Which technique would you use…?
© 2012 Health Change Australia
Slide 108
Section 4:
Setting the scene for health change
© 2012 Health Change Australia
(G inside Section 4 tab)
Slide 109
What are you offering clients?
• A complimentary health risk assessment and
information
• More energy
• A better ability to do the things that are
important to you in life
• Functionality
• Physical and emotional resilience (coping)
© 2012 Health Change Australia
Slide 110
What can you ask clients?
• This program helps people to have better
general health so that they can avoid
developing chronic diseases such as diabetes
and heart disease in the long term.
• In the short term it can help you to feel better,
have more energy and a better ability to do
the things that are important to you in life on
a daily basis.
• Is this something that interests you?
© 2012 Health Change Australia
Slide 111
What I am not going to do
• Tell you all the things that you already know
• Tell you to go on a diet
• Tell you to engage in a difficult exercise
program
• Tell you to make sudden big changes to your
lifestyle
• Add pressure to your life (in fact I can help you
to do the opposite)
© 2012 Health Change Australia
Slide 112
What I can do for you
• Provide a health assessment that will tell you what risks you might
have for developing chronic diseases like diabetes or heart disease.
• Provide any extra information that you might need to help you to
be healthier.
• Help you to change things a bit at a time so that the changes stick.
• Ensure that any changes that you make are suited to your particular
lifestyle.
• Help you to do things in a manageable and sustainable way that is
as stress-free as possible.
• We start with where you are at now, and slowly chip away at
changing any unhelpful habits to be more healthy and give you
more energy.
© 2012 Health Change Australia
Slide 113
Section 5:
Above the line processes
© 2012 Health Change Australia
Slide 118
HCA 10 step decision framework
Above the line processes
Set the Scene & Explain Your Role
 Identify Clinical Issues & Broad Lifestyle & Treatment Categories
 Prioritise & Choose a Category to Work on
 Ask RICk   Make a Decision
Decision
Line
Ready to
Take Action
Readiness
Build Motivation
RICk = readiness, importance, confidence, knowledge
© 2012 Health Change Australia
(G inside Section 5 tab)
Slide 119
Key questions above the decision line
Does the client know and understand the broad lifestyle &
treatment categories applicable to their condition/s?
Have they been assisted to collaboratively prioritise these?
Are they ready, willing, able and committed to taking action?
Decision
Line
Ready to
Take Action
Build Motivation
© 2012 Health Change Australia
(G inside back cover)
Slide 120
Step 1: identify clinical issues & broad lifestyle &
treatment categories
1. Identify clinical issues
• Assessment, referral letters, care plans, client information
2. Check client knowledge and understanding of condition/s:
• Health conditions, clinical indicators, risk factors
• Implications of these and reasons for clinical targets
• Check what they already know before offering information
3. Provide treatment advice, education & guidance:
• Broad lifestyle and treatment categories for action
• Rationale for taking action (macro level education)
• Check what they are already doing before offering advice
© 2012 Health Change Australia
(G93)
Slide 121
Step 2: prioritise and choose a category to work on
1. Prioritise broad lifestyle and treatment categories
2. Balance duty of care with client choice
3. Prevent the client from becoming overwhelmed
© 2012 Health Change Australia
(G99)
Slide 122
Step 3: ask RICk 
Readiness, Importance, Confidence, knowledge
Use your RICk radar,
but when in doubt, ask the client
© 2012 Health Change Australia
(G105, 38, 42)
Slide 123
Step 4: make a decision
Client choices:
1. “yes”
2. “no”
3. “maybe”
Clinician choices:
1. Client “yes” - proceed below the
decision line
2. Client “no” – revisit Step 2 or
invite them to opt out
3. Client ambivalence – ask
decisional balance questions
© 2012 Health Change Australia
(G109)
Slide 124
Client case demonstration
Video – Greg
Steps 2-4
© 2012 Health Change Australia
Greg steps 2-4 video
Slide 125
Step 1: using assessment data to inform behaviour change
Patient problems, needs
& relevant conditions
Clinical goals
Required
treatment &
services
Provider for
treatment & services
Type 2 Diabetes
HbAlc < 7%
3 monthly checks
Diabetes Education
Exercise Program
Foot care
GP/Practice Nurse
D. Educator/Dietitian
Ex. Physiologist
Podiatrist
Hypercholesterolaemia
TC: < 4mmol/L
LDL < 2.5mmol/L
HDL> 1.0mmol/L
TG < 2.0 mmol/L
Lipitor 10mg
Low saturated fat
diet
GP/Practice Nurse
Dietitian
Obesity
BMI < 25
Maintain a healthy
diet
GP/Practice Nurse
Dietitian
Back pain
Reduce pain &
improve mobility
Physiotherapy
Bone density scan
Physiotherapist
Nuclear imaging
© 2012 Health Change Australia
Slide 126
Steps 1-4: Case coordination example
Documenting priorities to create a personal self-management plan
Lifestyle/Treatment
Categories
Priority
1. Medications
(see GP)
2
2. Rehabilitation
exercises
(already provided)
2
3. Wound care
1
4. Dietary changes
(see dietitian)
3
5. Tests (bone density
scan & bloods)
4
6. Home assessment
(see OT)
2
© 2012 Health Change Australia
Readiness
X
Importance
X
Moderate Moderate
High
High
(G115, Appendix I p.121)
Confidence
Knowledge
Moderate
Moderate
X
Low
Moderate
Good
Date
##/##

Slide 127
Steps 1-4: profession-specific example – managing arthritis
Documenting priorities to create a personal self-management plan
Lifestyle/Treatment
Categories
1. Medications
Priority
Readiness
-
Taking
action
2. Specific
exercises
1
3. General activity
2
4. Pain management
strategies
1
5. Weight management
2
© 2012 Health Change Australia
Importance
X
X
High
High
Moderate Moderate
High
High
(G115, Appendix I p.121)
Confidence
Knowledge
Date


##/##
X
Low
Moderate
X
Low
Moderate
Good
##/##
after educ
Pacing
activity
##/##
Slide 128
Summarising above the line processes
Lifestyle/Treatment
Categories
Priority
1. Eat healthily
2
2. Be more
active
3
3. Reduce my
alcohol
consumption
1
4. Manage my
stress
1
5. Reduce
smoking
4
6. Get more
sleep
1
© 2012 Health Change Australia
Importance
Confidence
Readiness
Knowledge
Date
6
Pretty
low
So-so

##
HMS Screenshots
Slide 129
1.Identify clinical issues / lifestyle / treatment
categories
2.Prioritise & choose one category to work on
3.Ask RICk for the chosen category
4.Use the decisional balance technique if
readiness or importance are low to moderate
© 2012 Health Change Australia
(G115 & Appendix I p.121)
Slide 134
Section 6:
Below the line processes
© 2012 Health Change Australia
Slide 136
HCA 10 step decision framework
Below the line processes
Decision
Line
Ready to
Take Action
 Generate Personal Goal Options
 Choose & Refine an Option  Create an Action Plan
 Identify & Address Barriers  Ask RICk
 Consider Review & Referral
Readiness
Build Confidence
RICk = readiness, importance, confidence, knowledge
© 2012 Health Change Australia
(G inside Section 6 tab)
Slide 137
Key questions below the decision line
Decision
Line
Ready to
Take Action
What options do they have for taking action in a particular
category?
What is their personal goal and plan?
Are they confident they can do this and what might get in the way ?
Will I review the client and what other support do they need?
Build Confidence
© 2012 Health Change Australia
(G inside back cover)
Slide 138
Step 5: generate personal goal options
Ways to generate options
1. Treatment strategies
from assessment
2. Collaborative problem
solving using:
a) Client first technique
b) Menu of options
technique
© 2012 Health Change Australia
(G125)
Lifestyle/treatment
category
Options
Personal goal
& action plan
Slide 139
Create goal hierarchies for education, menus of options & consistency of
advice in programs
Reduce diabetes
risk
Increase CV
exercise
Increase muscle
mass
Reduce total
fat/& saturated
fat
Increase fibre
Reduce body
weight by 5%
Water-based
exercise
Gym exercises
Change to low
fat dairy
5 serves
vegetables
Reduce portion
sizes
Walk, jog or
ride
Home exercises
Change cooking
oils
2 serves fruit
Reduce serves
at dinner
Group-based
exercise
Incidental
activities
Select leaner
meat serves
Hi-fibre breads,
pasta and rice
Manage night
time eating
Other...
Other...
Other...
Other...
Other...
© 2012 Health Change Australia
(G Appendix J p.151)
Slide 140
Step 6: choose & refine an option
• Help the client to choose a personal goal option and
state it as a personal goal in one or two sentences:
• What
• How much
• How often
• When to start
• When to complete or review
© 2012 Health Change Australia
(G131)
Slide 141
Step 7: create an action plan
Include only as much detail as necessary for the client
to feel confident:
• Actions or tasks
• Memory prompts
• Support mechanisms
• Thinking strategies
• Emotion management strategies
• Backup plans
• Tracking and monitoring strategies
• Review and referral details
© 2012 Health Change Australia
(G135 & Appendix K p.153)
Action plan video Slide 142
Step 8: identify & address barriers
Behaviours
Emotions
B
S
E
T
Situations
Thinking
© 2012 Health Change Australia
(G139)
Cathy video Slide 143
Common below the line barriers
Behaviours & situations
• Not understanding
• Not remembering
• Poor planning
• Strength of old habits vs. creating new ones
• Recurring or cyclical situations: disease episodes,
depression, travel, seasons etc.
• Lack of support from partner/friends/family
• Lack of access to services
• Pain & disability
© 2012 Health Change Australia
Asthma Slide 144
Relapse prevention
• Normalise lapses and emphasise trial & error
• Identify potential triggers for lapses and strategies to get back
on track
• Change ANNTs into PETs (I have busted, I am back at the
beginning again, what’s the point?)
• Use metaphors to stay on track (e.g. going on a journey,
tortoise & hare)
• Average no. of relapses for people changing habits: 5 to 7
• Ave days to create habit: 66 (range 18-254)
(EJSP 2010)
© 2012 Health Change Australia
Slide 145
Step 9: ask RICk again
To check that the client’s personal goal and action plan
are appropriate
RICk tip:
If confidence is low, adjust the personal goal
and/or identify relevant barriers and add
necessary steps into the action plan
© 2012 Health Change Australia
(G143)
Slide 146
Step 10: consider review and referral
• Review consultation scheduling: the lower the
client’s overall confidence, the sooner the next
consult should be
• Check RICk for attending referral appointments
• Track client actions and clinical indicators to review
progress over time
• Reinforce trial and error
© 2012 Health Change Australia
(G145)
Slide 147
Conducting review consultations
Options:
Develop
personal goal/s
and action
plan/s
1. Continue with the
same personal goal
Extend goals &
add new
categories &
goals when
ready
2. Move to a new
personal goal
Give it a Go!
3. Move on to the next
lifestyle or treatment
category and add
personal goals for
that category
© 2012 Health Change Australia
(G149)
Keep using the
strategies that
work and
change the
ones that don't
Track your
progress &
review goals
regularly
(Duncan)
Slide 148
Practising step 5
Generate personal goal options within a category
• Choose a treatment or lifestyle category from the
personal self-management plan (PSMP)
• Generate a list of personal goal options relevant to
that category
• 5 minutes to create a list
Which practice principles and techniques would you use if
doing this with a client?
© 2012 Health Change Australia
Slide 149
Practising step 6
Create a personal goal for a client
• Choose one option from the list you just created
• Formulate a client goal in 1 or 2 sentences including:
• What they are going to do
• When or how often (frequency per
day/week/month) the action will be carried out
• Quantity/duration/intensity of behaviour as
appropriate
• Start date, review date &/or completion date
© 2012 Health Change Australia
(G133-134)
Slide 150
Phrasing for steps 7-10 – small group exercise
Normalising and addressing barriers to action
Identify barriers
1. How do you raise the
topic that it’s normal
for things to get in the
way of your plans?
2. Create a menu of
barriers from BEST to
help the client to
identify their own
below the line barriers.
© 2012 Health Change Australia
(G140-141)
Address barriers
1. What questions can you
ask to get the client to
come up with the
solutions?
2. How could you use a menu
of options to suggest
strategies to address the
barriers?
Slide 151
Share your phrasing examples:
1.
2.
3.
4.
•
Normalising and client first for barriers
Menu of options for barriers
Client first for strategies
Menu of options for strategies
Invite the client to write
© 2012 Health Change Australia
(G137, 140, 144, 147)
Slide 152
Documenting Steps 6-10
Treatment category: Regain and maintain mobility
Personal goal: Do my rehab exercises 3 times per day starting from tomorrow at
home and continue doing them until I see the physio again
Tick when
completed
Actions required to achieve this goal:
1.
2.
3.
4.
5.
6.
7.
8.
9.
Put my next rehab appointment on my calendar in the hallway
Put my rehab exercise handout and rolled up towel on the bedside table
Set an alarm to take my pain meds before the exercises
Do my exercises before I eat breakfast, lunch and dinner
Prepare my meals before I do my exercises
Label a pack of frozen peas with a texta and use as an ice pack
Put a damp towel around the peas & apply to my knee during my meals
Make sure I put the packet of peas back in the freezer after use
Remind myself that even though it hurts while I do my exercises, the
pain will settle afterward and it’s not causing damage









How much do you want to achieve this goal?
(Not at all) 1 2 3 4 5 6 7 8 9 10 (Very much)
How confident are you that you can achieve this goal?
(Not at all confident) 1 2 3 4 5 6 7 8 9 10 (Very confident)
© 2012 Health Change Australia
X
Page 153
Client case demonstration
Video – Young Geoff
Consultation showing the whole
framework in 13 minutes
© 2012 Health Change Australia
Young Geoff 13 minute video
Slide 154
How can you adapt your clinical practice?
Clinical tasks
Description
Set-up & introduction
Assessment
Lifestyle & treatment recommendations
Passive treatment
Broad macro level education
Prioritisation of recommendations
Targeted micro level education
Personal goal setting
Personal action planning
Treatment planning/referral/other
© 2012 Health Change Australia
(G Appendix A, p. 15-16)
Slide 155
Skills development exercise:
Group exercise
Discussion topic: Will you work on developing your
skills to apply the HCA approach in your workplace?
• Work through decisional balance as a group
• If you cross the decision line write down strategies
that might help you to address any challenges and
implement the approach
© 2012 Health Change Australia
Slide 156
HCA generic behaviour change pathway
Knowledge & understanding
Motivation & expectations
Decision
Line
Decision & commitment
Planning
Action
Self-regulation
Build Motivation
© 2012 Health Change Australia
Build Confidence
Slide 157
Troubleshooting with clients
Difficult clients: client is above the decision line
Chronic and complex clients:
• client is above the decision line
• client has significant BEST barriers
• messy head syndrome for clinicians and clients
When you are feeling stuck, ask yourself:
• Is the client above or below the decision line?
• What is the sticking point?
• Which course of action is appropriate?
© 2012 Health Change Australia
Slide 158
HCA skills development pathway
HCA core training for
clinicians
Organisational
capacity building
options
HCA Core Training Part 1
(2-day workshop)
HCA Core Training Part 2
(1-day workshop)
HCA Core Training for
Managers
(1/2-day workshop)
HCA Peer Leader Support
Package
HCA Peer Trainer Program
(Train the trainer option)
© 2012 Health Change Australia
Slide 159
How confident are you that you can use the HCA
approach in your work?
1. Practice principles
2. Essential techniques:
a. For use with all clients:
1) Client first technique
2) Menu of options technique
3) Using your RICk radar
b. Optional use to identify & address barriers:
1) Asking RICk
2) Decisional balance technique
3) Turning ANNTs into PETs
4) Tracking and monitoring strategies
3. 10 step decision framework
© 2012 Health Change Australia
Slide 160
© 2012 Health Change Australia
(G 25)
Slide 161
Thank you for your participation!
Download case studies, session records,
practice guides and worksheets from
the Resources Library at
www.healthchangeaustralia.com
Our tools can be used freely in clinical practice
and programs as long as HCA intellectual property
is visibly acknowledged
© 2012 Health Change Australia
Slide 162
Client case – ‘toxic wasteland’
• Male, mid-30’s, BMI = 34 (96 kg), elevated BP, BGLs & Chol.,
married, 2 children, manager in hospitality industry
• Told to change diet, lose weight, start exercising, reduce alcohol
and caffeine dramatically, quit smoking:
• 18-24 shots per day espresso per day
• 1 bottle of wine per night, plus multiple martinis
• 15 cigarettes/day
• Low energy, poor sleep, frequent waking, needed naps on
days off
• Very little water – doesn’t like it
• No exercise, poor diet, hardly any fruit and vegetables
© 2012 Health Change Australia
Slide 163
Client case – 1 x 20 minute intervention
Reaction to Dr’s advice: “What can I do? I would have to quit my job!”
•
1 x 20 minute impromptu conversation in Nov 2009:
• High importance, but low readiness due to very low confidence in
making any changes
• One thing at a time, one step at a time, adding up over time
• Client chose alcohol reduction as a priority
• Planned to eat dinner early with family (doesn’t drink when
children are up and drinks less if he eats first), and not keep any
chilled wine in the house
• No review consultation
© 2012 Health Change Australia
Slide 164
Client case – behavioural changes
1.5 years:
• 5 alcohol free days/week, 1 bottle of wine over 2 nights, no martinis
• No more than 2 x skinny lattes per day
• 2-3 cigarettes per day, work days only
• 1.9 lt jug of water/day (hot water + ice + touch of cordial)
• 1 x vegetarian meal per week, aims for daily vegetables + 2 x fruit per
day
• 3 x per week on exercise bike, plus conscious use of (many) stairs at
work
• No longer takes naps on days off
2.5 years:
• 5 serves vegetables plus 2 serves of fruit per day
• 5 x exercise sessions per week
© 2012 Health Change Australia
Slide 165
Client case – physiological outcomes
Results at 1 & 1.5 years:
• BMI 29 (82 kg) - previously 34 (96 kg)
• BP, BGLs and Chol. in normal range – previously all
elevated
• No longer gets daily headaches
• Sleeps through the night and reports increased
energy
Results at 2.5 years:
• 76 kg
• Waist circumference 88 cm (previously 110 cm
• BP, BGLs and Chol. All in normal range
© 2012 Health Change Australia
Slide 166
Client case – intrinsic motivators
• Dreamt he had to watch his daughter’s wedding on video due
to ill health – used this mental imagery to motivate himself
• “I couldn’t be there for her on her happiest day”
• Can feel and see the difference that his healthy choices have
made and wants to maintain these benefits
• Work colleagues have commented on the visible changes
• He reports that he doesn’t miss his old habits
• The first 3 months were the hardest
© 2012 Health Change Australia
Slide 167
Client case – client reflection
“What the Dr told me to do was impossible”
“I am thankful that she told me (about the critical nature of
my health issues) but I expected more help with how to do it”
“The Dr doesn’t know why I do what I do and why it is hard
to change. Health professionals need to know why!”
“I was in a nasty evil cycle”
© 2012 Health Change Australia
Slide 168
Teach a man to fish
© 2012 Health Change Australia
Slide 170