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Transtheoretical Model (Prochaska and DiClemente, 1982) of readiness to change has received considerable attention in practice. Specific questions are asked to determine a patient’s stage of readiness with the intent of targeting strategies to shift a patient from one stage to the next (i.e., to move toward ‘‘preparation’’ and ‘‘action’’ and then ‘‘maintenance’’ of the desirable behavior. Self-efficacy, a concept first proffered by Bandura (1977), is considered an important determinant of readiness to change and one’s capacity to effect and maintain a behavioral change (Meland, Maeland, and Laerum, 1999). When stage of readiness to change is considered in promoting healthy lifestyles, health coaching can be successful even when brief (Steptoe, Kerry, Rink, and Hilton, 2001). Although this model has been critiqued on the basis of the argument that health behavior change is more likely a continuous rather than discrete variable and that its validity has been queried, the model remains compelling from a practical and clinical perspective. Patients receiving care, particularly those who are hospitalized, can be a receptive and captive audience for positive health messages and advice. The impact of the physical therapist as an agent of change may reflect her or his capacity to serve as a role model. Health care providers (e.g., physicians) who exercise are more likely to recommend that patients exercise as well as advocate other health behaviors (Abramson et al, 2000; Wells, Lewis, Leake, and Ware, 1984). Thus, practicing what one preaches may have a powerful effect on increasing adherence of patients to health and lifestyle change recommendations. When patients are in the preparation and action stages of the Prochaska and colleagues’ model, the physical therapist can teach a range of self-monitoring skills and strategies along with know-ledge about circulatory and heart disease, risk factors, and disease prevention. Blood pressure self-monitoring can be taught provided the equipment is calibrated and checked, standardized procedures are used, and the patient’s measurement proficiency is evaluated (Mengden et al, 2000).
Health education for people in the pre-contemplative stage of readiness to change warrants being targeted differently than those in other stages of readiness. The Canadian Cancer Society (1999a,b), for example, has two publications regarding smoking cessation: one for those who are not yet ready to quit (pre-contemplative stage) and one for those who are (contemplative stage). The former publication focuses on what can be expected when the individual feels at a contemplative or higher stage of readiness and what resources would be available. This publication can serve as a prototype for education related to other health behaviors for individuals at the pre-contemplative stage of readiness to change.
The theories and models of health behavior and health behavior change counseling support a role for a range of approaches. One or more approaches, however, may be indicated, dependent on the individual, the context, the conditions, and their stages and severity, motivational factors, and readiness. These theories and models do not suggest that any one approach will elicit a given outcome. In some instances, for learner engagement, brief counseling can be effective, whereas others require a systematic targeted approach with a consideration of enabling and dis-enabling factors, and in others greater dependence on the expertise of other team members (e.g., nutritionist or psychologist).
Follow-up
The challenge of health promotion and risk factor reduction is targeting those in need and then implementing healthy lifestyle practices that are sustained. Follow-up is essential to ensure that health behavior change is occurring and to determine when the program needs to be progressed or maintained. An analysis of the individual’s facilitators and barriers to health behavior change will enable the physical therapist to build sustainability into the program. The degree of health benefit from a given behavior change or the clinical effect size needs to be considered to establish a time frame. For example, to what extent does an observed clinical change (e.g., 3 mmHg reduction in systolic blood pressure or 10-pound weight reduction) for a given individual translate into health benefit and reduced risk for a given lifestyle condition?
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