American Journal of Critical Care. 2004;13: 305-313
Strategies for Behavior Change in Patients With Heart Failure
By
Sara Paul, RN, MSN, FNP and
Nancee V. Sneed, RN, PhD, ANP.
From the Heart Function Clinic, Hickory Cardiology Associates, Hickory, NC (SP) and the College of Nursing, Heart Failure Clinic, Medical University of South Carolina, Charleston, SC (NVS).
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Abstract
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Appropriate management of chronic heart failure and its signs and symptoms requires a considerable amount of participation by patients. Behavioral changes that prevent or minimize signs and symptoms and disease progression are just as important as the medications prescribed to treat the heart failure. The most difficult lifestyle changes include smoking cessation, weight loss, and restriction of dietary sodium. The Transtheoretical Model is a framework for assessing and addressing the concept of readiness for behavior change, which occurs in a 6-step process. The model consists of 3 dimensions: the stages of change, the processes of change on which interventions are based, and the action criteria for actual behavior. The stages of change are discussed, and interventions are presented to assist patients with heart failure in progressing through those stages toward maintenance of changed lifestyle behaviors. Methods for measuring the level of readiness for change of patients with heart failure are also presented, because correct staging is required before appropriate interventions matched to a patient’s stage can be delivered.
Chronic heart failure is a significant health problem in the United States; 5 million patients are affected, and 550000 new cases are diagnosed each year.1 Appropriate management of the disease and its signs and symptoms requires a considerable amount of participation by patients. Unfortunately, heart failure remains a terminal illness in which patients’ conditions decline progressively. Medications for treating heart failure such as angiotensin-converting enzyme inhibitors and ß-blockers have improved the mortality and morbidity statistics for the disease in recent years. Although important, medications for heart failure constitute only half of the treatment program. Behavioral changes that prevent or minimize the signs and symptoms and progression of the disease are just as important as the medications that are prescribed.
Nurses spend considerable time educating and counseling patients with heart failure so that the patients have the knowledge and tools to prevent signs and symptoms and manage the disease. Although this education typically addresses the lifestyle changes necessary to control signs and symptoms and to improve outcomes, failure of patients with decompensated heart failure to adhere to recommendations remains a frequent reason for hospital readmission.2–5 Despite interventions, many patients may not be ready to learn how to manage the illness, and consequently they do not make the necessary changes in health behaviors.
The behavioral changes recommended for patients with heart failure are numerous (Table 1
). Simply making one of these lifestyle changes is difficult, but healthcare providers expect patients with heart failure to value the treatment of the disease enough to make permanent changes. Usually, patients receive 1 or 2 teaching sessions in which they learn of these changes, and then they are expected to incorporate all of these changes into their behavior patterns from that day forward. However, as any healthcare provider will attest, this sequence of events is not what usually happens.
The most difficult lifestyle changes include smoking cessation, weight loss, and restriction of dietary sodium. Additionally, financial constraints may make it difficult for some patients to fill prescriptions regularly, preventing the patients from receiving the full benefit of pharmacological therapy. Determining if a patient is compliant regarding smoking cessation and weight loss is relatively easy; however, conclusively determining whether a patient has eaten high-sodium foods or has taken his or her medications appropriately is almost impossible. Smoking cessation and weight loss are not only measurable but also relatively "black or white." A person either smokes or does not smoke, and a person is either overweight or within normal weight parameters. The intake of sodium in the diet is not so clear. Sodium intake is a continuum; a person can consume as much or as little sodium as possible, ranging from zero sodium intake to enormous sodium intake of thousands of milligrams per day. Comprehending this concept and understanding how to remain at the low end of the sodium intake continuum is often difficult for patients initially.
Implementing behavioral change in patients with heart failure is a challenging task. Traditional strategies such as educational classes, videos, and written instructions present the information to all patients in the same manner regardless of each patient’s readiness to make lifestyle changes. Some patients are more prepared than others to hear the information and make the necessary changes. For that reason, evaluating models that individualize the instructional program for lifestyle changes is important.
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The Transtheoretical Model of Behavior Change
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In the early 1980s, James O. Prochaska and his associates first proposed the Transtheoretical Model (TTM) as a framework for assessing and addressing the concept of readiness for changes in behavior.6–8 This framework has been the basis of their research for more than 2 decades. On the basis of data from studies of persons who did not change high-risk health behaviors, Prochaska and Velicer8 proposed a general rule of thumb: 40% of persons with at-risk behaviors are in a stage of change marked by resistance and denial and have no intention of changing the behavior. Another 40% have thought about changing some time in the next 6 months, and only 20% are actually preparing to make serious change. Clearly, action-oriented interventions, such as education programs that stress strategies for behavior change, do not match the needs of at-risk persons who do not believe change is needed.
The TTM is based on a set of critical assumptions about the nature of behavior and the interventions that can best facilitate change, including the following:
- No single theory can account for all the complexities of behavior change.
- Behavior change is a process that unfolds over time and occurs in stages.
- Without planned interventions, populations with high-risk behavior remain stuck in early stages marked by no movement toward change.
- Specific processes and principles of change should be applied at specific stages.
- Chronic behavioral patterns are under some combination of biological and social influence and self-control.
Interventions designed within the TTM are targeted to enhance self-control.8 The TTM has been applied to a broad range of behaviors and a wide variety of populations, but it has been used to assess behavior change in patients with heart failure in only a single study.9
The TTM consists of 3 dimensions:
- the various stages of change, which is the central organizing construct and temporal variable of the model,
- the processes of change on which interventions are based, and
- the action criteria for actual behavior (the dependent dimension or outcome).
Decisional balance (pros and cons of changing) and self-efficacy (situation-specific confidence that change can be maintained without relapse) and temptation vary in predictable ways throughout the stages of change. The TTM emerged from an analysis of the leading theories of psychotherapy and behavior change (thus the name Transtheoretical Model), and many components of this model were adapted from such theories as freudian, skinnerian, and rogerian traditions.8
The Stages of Change
In the TTM, behavior change is viewed as a 6-stage process that may progress in a linear fashion but most often progresses in a spiral pattern that includes relapse to prior stages, recycling through the stages, and learning from mistakes before changed behavior becomes stable. The stages of change within the TTM are as follows:
- Precontemplation: The person is perhaps unaware or underaware that a problem exists and has no intention of taking action in the foreseeable future (usually measured as the next 6 months).
- Contemplation: The person is aware that a problem exists in relation to a behavior, has thought about changing, and intends to change at some time in the future, usually within the next 6 months.
- Preparation: The person has taken some preliminary steps toward change and intends to change in the immediate future (usually measured as the next 30 days).
- Action: The person has made a specific, overt modification in lifestyle within the past 6 months.
- Maintenance: The person has worked for more than 6 months to prevent relapse and to be less tempted and more confident that change can persist.7
- Termination: The person has no temptation and 100% self-efficacy.
During the termination phase, regardless of whether they are depressed, bored, anxious, lonely, angry, or highly stressed, persons are sure they will not give in to the temptation to return to their old unhealthy habit.8 Snow et al10 found that only 20% of former smokers and alcoholics ever reached this stage. For the majority, termination may not be a practical reality, and a more realistic goal for dealing with most unhealthy behaviors may be a lifetime of maintenance.8 Termination is not typically assessed for purposes of research or clinical applications.
These stages of change suggest that before overt action is taken to change an unhealthy behavior, persons must successfully pass through 3 stages in which they continue the behavior. During these stages, the concept of decisional balance generally has the cons of making the change outnumbering the pros. Before progressing to action, the pros and cons must cross over, and when the pros outweigh the cons, it is a sign that a person is prepared for action. In the TTM, progress from precontemplation to action is accompanied by the pros of change increasing twice as much as the cons decrease. This assertion suggests that perhaps twice as much emphasis should be placed on raising benefits of change as on reducing the costs or barriers.8
The Process of Change
Any activity that a person initiates to help modify thinking, feeling, or behavior is a change process. How can healthcare providers promote lifestyle changes in such a way that patients will adhere to the changes? The primary determinants of behavior and behavior change have been enumerated by Fishbein et al11 as follows:
- Intention: Does the patient have a commitment to perform the behavior?
- Environmental constraints: What external conditions could facilitate or be a barrier to the behavior (eg, economics, insurance carrier, caregiver issues, social isolation, living with a smoker)?
- Ability: Does the patient have the necessary capabilities to make permanent change (depression, elderly, frail, homebound)?
- Anticipated outcome: Do the pros for performing the behavior outweigh the cons? Does the patient feel bad enough to want to change?
- Norms: What are the social pressures to perform the behaviors (eg, repeated hospitalizations, impact on the family)?
- Self-standards: Is the new behavior consistent with the patient’s self-image (eg, men who are forced to take on dependent roles or are no longer working)?
- Emotion: Does the patient have a positive reaction to performing the behavior? Is the patient emotionally invested in making the behavior change?
- Self-efficacy: Does the patient perceive that he or she is capable of performing the behavior?
Ten distinct processes of change (Table 2) have been identified: these are the covert and overt activities that people use to progress through the stages of change, specifically, how people change.12,13 The assumption of the TTM is that this common set of change processes can be applied across a broad range of behaviors, and that each process needs to be emphasized at different stages of change.8 Table 3 illustrates how these processes may occur.
These processes are a guide for interventions to assist patients in progressing in readiness for behavioral change, and the processes encompass a variety of techniques and methods. The amount of progress a person makes after an intervention tends to be a function of the stage of change before treatment.6 Consequently, it is important to measure a patient’s stage of readiness to change before implementing appropriate stage-based interventions for lifestyle changes. Prochaska et al6 found that persons who were in the preparation and action stages were more successful in making permanent change than were persons in the precontemplation or contemplation stage. If a patient progresses through just a single stage in the first month of treatment, his or her chances of taking action double during the initial 6 months of the program.6
The processes of change result in modifications of behavior and support the transition from stage to stage. These processes can be divided into 5 experiential processes that are internally focused on emotions, values, and cognitions and 5 behavioral processes that are focused on behavioral changes. Experiential processes include consciousness-raising, dramatic relief, environmental reevaluation, social liberation, and self-reevaluation. Behavioral processes include counterconditioning, helping relationships, reinforcement management, stimulus control, and self-liberation. These processes are primarily used in the action and maintenance stages and are defined in Table 2
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Measurement: Determining a Patient’s Stage of Change
Correct staging is required before appropriate interventions matched to a patient’s stage can be delivered. Reed et al14 suggest that a good staging algorithm should include a clear definition of the behavior to be changed and a 5-choice response format that includes the operational definitions of each of the stages. For example, they recommend that the definition of exercise include the frequency, duration, and intensity of exercise, taking into account the capabilities of the population of patients. Definitions and a consistent response format to determine stage of change for each of the behaviors that may require change in patients with heart failure are suggested in Table 4.
Clinicians should be aware that a patient’s perception of his or her stage of readiness may not always match the patient’s actual behavior. One of the most difficult and arguably the most important behaviors requiring change in many patients with heart failure is the reduction of sodium in the diet. Povey et al15 suggest some fundamental problems with using the TTM for dietary behaviors. They note that generally a discrepancy exists between objective assessment of diet and self-rated, subjective dietary intake. Further, for more general, widely interpreted dietary behaviors such as "eating healthy," patients are less likely to perceive accurately whether they are actively engaging in the behavior than they are for more specific behaviors such as eating 5 fruits and vegetables a day. This discrepancy may result in a mismatch between perceived and actual diet and thus lead to overrepresentation of patients in the action and maintenance stages. Low-sodium diets can be widely interpreted by patients. In a sample of patients with heart failure, Sneed and Paul9 noted a discrepancy between objective assessment of sodium intake and self-rated assessment of consistently avoiding salty foods.
These findings suggest that use of the TTM to stage patients with heart failure in relation to adherence to low-sodium diets may be a problem, and determining actual intake of salty foods may be necessary to stage patients accurately. Actual intake can be determined in several ways: 24-hour dietary recall, assessment of a food diary recorded for up to a week before a clinic visit, or use of a food checklist that patients could fill out while in the waiting room. To create such a list, consult a nutrition book to find the highest sodium foods typically eaten by that group of patients and ask patients to respond yes or no to whether they have eaten any of the foods on the list in the last 24 hours. If they report themselves to be in the action or maintenance stages and have eaten high-sodium foods in the past 24 hours, they should be restaged according to their actual behavior into the preparation, contemplation, or even the precontemplation stage (if they appear to be unaware of their risky behavior). It may be better to view patients who eat high-sodium foods or add salt to their food but see themselves in the maintenance stage as a separate group and design interventions for them accordingly.15
Actual behavior may have to be assessed for other behaviors as well. For example, actual exercise behavior may have to be assessed by using such things as an activity log or journal, a pedometer, or a list of examples of common behaviors that exceed the action criterion and behaviors that do not. Keep in mind, however, that these, as well as all self-reported measures of behavior, are subject to social desirability bias.
All patients may not need to lose weight, and this need can be determined by calculating the body mass index of each patient and then staging those patients who have an index greater than 25. Efforts at trying to lose weight can be accomplished by exercise, dieting, or both. Because exercise is important for patients with heart failure, independent of their need to lose weight, staging can be determined by evaluating dietary interventions. If patients report that they are in the action or the maintenance stage, yet show no downward trend in their weight or body mass index, there may be a mismatch between reported effort and actual behavior. As with sodium, use of 24-hour dietary recall, 3-day food diaries, or food checklists may help determine the problem. Portion size, as well as content of the diet, should be assessed.
Application of the TTM to Patients With Heart Failure
As the understanding of the pathology of heart failure increases, it has become clear that excessive sodium intake is harmful. The effectiveness of medications such as diuretics and neurohormonal blocking agents is reduced if sodium intake is high; hence the importance of changing dietary patterns to include a low-sodium diet. Furthermore, exercise, weight loss, and smoking cessation are beneficial in patients with heart failure. Yet how do we help patients incorporate the changes in their lives that will significantly affect signs and symptoms and, indeed, the disease state?
It is not realistic to expect patients to make changes that they are not prepared to make. A patient’s stage of readiness for change must be measured before a change program is implemented. Once the patient’s stage of readiness has been determined, appropriate strategies for applying the processes of change may be instituted. Table 5 presents a plan that offers specific activities for each of the processes of change to assist patients in moving through the stages of readiness for change.
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Conclusion
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Chronic heart failure remains a significant health problem in the United States. Traditional methods of promoting behavioral lifestyle changes have been only marginally successful, as numerous studies on patients’ noncompliance have revealed. The application of the TTM to patients with heart failure offers an opportunity to improve patients’ compliance by individualizing the change process to meet the needs of each patient. Doing so, however, requires validation by research trials involving patients with heart failure before the model can be applied in clinical practice. With the appropriate activities to meet the patient’s stage of readiness for change, healthcare providers may facilitate a patient’s movement along the continuum of change to alter lifestyle behaviors that can affect the disease.
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The Transtheoretical Model of...
