Using Illness Visits to Provide Health Behavior Advice

描述（由申请人提供）：癌症发病率和死亡率的巨大负担是可以通过改变个人健康行为来预防的。为大多数美国人提供基本医疗保健的初级保健医生提出的健康行为建议（HBA），作为一种改变癌症相关健康行为和降低发病率和死亡率的策略，具有很大的前景。然而，实施有效干预的主要障碍源于将有效的HBA方法纳入日常实践的竞争性需求的可行性以及提供医疗保健的主要疾病护理模式。一项潜在的强有力的战略已经得到推广，那就是利用疾病访问作为改变健康行为的“教育时刻”。然而，对于创造一个可教育的时刻或这种方法对改变健康行为的有效性所必需的具体沟通策略知之甚少。了解如何通过沟通和评估这一战略的有效性来构建可教时刻，对于促进采用可教时刻方法来改变卫生行为的努力既基本又至关重要。因此，本多方法研究的目的是表征可教时刻在医患互动中产生和构建的方式，并评估该策略在患者回忆建议、改变行为动机和改变健康行为方面的有效性。对16名社区家庭医生进行分层随机抽样，800名成年患者与临床医生的就诊录音将为深入的定性分析提供丰富的数据。对话分析将用来描述“可教时刻”是如何产生的，它的结构和对话的内容；并确定访问的上下文特征，这些特征可能启用或阻碍HBA的通信。从定性分析中得出的关键变量，包括教学时刻、建议内容、线索、竞争需求和以患者为中心的互动等要素，将对800次就诊中的每一次进行编码。通过1个月和6个月的电话随访调查对患者进行纵向随访，以评估改变行为动机和改变健康行为的结果。可教时刻策略对每个结果的影响将使用包含上下文协变量的多变量模型进行评估，并将使用GEE方法来解释聚类数据结构。这项研究的发现将把“可教时刻”从一个吸引人的想法转变为一种基于经验的影响健康行为改变的策略，并将指导医生在可能产生最大影响的时候，以一种可能对患者结果产生重大影响的方式传达健康行为建议。

DESCRIPTION (provided by applicant): A large burden of cancer morbidity and mortality is potentially preventable by changes in personal health behaviors. Health behavior advice (HBA) by primary care physicians, who provide basic health care to most Americans, holds great promise as a strategy to alter cancer-related health behaviors and reduce morbidity and mortality. However, major barriers to implementing effective intervention stem from the feasibility of incorporating effective HBA approaches into the competing demands of every day practice and a predominately illness care mode of providing health care. One potentially powerful strategy that has been promoted is the use of illness visits as a 'teachable moment' for health behavior change. However, little is known about the specific communication strategies essential to creating a teachable moment or the effectiveness of this pproach for health behavior change. Understanding the way a teachable moment is constructed through communication and evaluation of the effectiveness of this strategy is both fundamental and crucial to efforts to promote adoption of a teachable moment approach for health behavior change. Therefore, the goal of this multimethod study is to characterize the way a teachable moment arises and is constructed within the patient-physician interaction, and to evaluate the effectiveness of this strategy on patient recall of advice, motivation to modify behavior and change in health behavior. Audio recordings of 800 adult patient-clinician visits from a stratified random sample of 16 community family physicians will provide the rich data for the in-depth qualitative analysis. Conversation analysis will be used to characterize how the 'teachable moment' arises, its structure and the content of the dialogue; and identify contextual features of the visit that may have enabled or impeded the communication of HBA. Key variables derived from the qualitative analysis including elements of the teachable moment, the content of the advice, cues, competing demands and the patient centeredness of the interaction will coded for each of the 800 visits. Longitudinal follow-up of patients with one- and six-month phone follow-up surveys will be used to assess the outcomes of change in motivation to modify behavior and change in health behavior. The effect of a teachable moment strategy on each of the outcomes will be evaluated using multivariable models to include contextual covariates and will use GEE methods to account for the clustered data structure. The findings from this study will move 'teachable moments' from the realm of an appealing idea into an empirically-based strategy for affecting health behavior change and will guide physicians to communicate health behavior advice when it is likely to have the most impact and in a way that is likely to have a significant impact on patient outcomes.