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可能可以通过改变个人健康行为来预防。初级保健医生为大多数美国人提供基本保健，他们提出的健康行为建议(HBA)有望成为改变癌症相关健康行为、降低发病率和死亡率的一项战略。然而，实施有效干预的主要障碍来自于将有效的HBA方法纳入日常实践的相互竞争的需求中的可行性，以及以疾病为主的提供保健的模式。一个已经得到推广的潜在有效策略是，利用就诊作为改变健康行为的“可教时刻”。然而，对于创造一个可教的时刻或这一方法对健康行为改变的有效性至关重要的具体沟通策略，我们知之甚少。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的方式，对于推动采用可教时刻方法改变健康行为既是基本的，也是至关重要的。因此，这项多方法研究的目标是描述可教时刻在医患互动中产生和构建的方式，并评估这一策略在患者回忆建议、改变行为的动机和改变健康行为方面的有效性。来自16名社区家庭医生的分层随机抽样的800名成年患者-临床医生的访问录音将为深入的定性分析提供丰富的数据。对话分析将被用来描述“可教的时刻”是如何产生的，它的结构和对话的内容；并找出访问的语境特征，可能促进或阻碍HBA的沟通。从定性分析中得出的关键变量，包括可教时刻的元素、建议的内容、提示、相互竞争的需求以及互动的以患者为中心，将为800次访问中的每一次进行编码。对患者进行为期1个月和6个月的电话跟踪调查的纵向跟踪将用于评估改变行为动机和改变健康行为的结果。将使用多变量模型来评估可教时刻策略对每个结果的影响，以包括上下文协变量，并将使用GEE方法来解释集群数据结构。这项研究的发现将把“可教的时刻”从一个吸引人的想法领域转移到一种基于经验的策略，以影响健康行为的改变，并将指导医生在可能对患者结局产生最大影响的时候，以一种可能对患者结局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.