Commitment to a healthy lifestyle is based on personal, environmental and other factors that contribute to the behavior of individuals and the health decisions they make. Personal factors affecting lifestyle choices include belief systems, personality, previous health education and financial status.
Personal factors are influenced by family, friends, peers and health care workers. If family, friends and peers have a cavalier approach to healthy living, there is little motivation to make changes toward healthy behavior. When an individual is surrounded by couch potatoes, junk-food addicts and smokers, there is little incentive to change. If a patient has been discouraged from seeking health care or health information from a chiropractor by a family doctor or other health care worker, the patient might not follow through even when others recommend they visit a chiropractic office. Fear is a powerful motivating factor and can provoke avoidance of help, as well as promoting motivation to prevent disease and disability.
Institutional factors, including health insurance and availability of health care, also can have a devastating impact on healthy behavior. If an area is not served by a chiropractic health and wellness practitioner, or if the patient cannot afford services outside their insurance plan, the patient might not see a chiropractor for health promotion, even if they want to. Community norms and socioeconomic status can heavily influence motivation for change.1
Arguably the most potent factor is the individual's readiness and personal commitment to change. This article will discuss the use of the health contract as a tool for motivating patients and promoting compliance with healthy lifestyle changes.
The Chiropractor as Health Educator and Lifestyle Coach
Not all chiropractors choose to provide health promotion and wellness counseling, yet the job analysis survey conducted by the National Board of Chiropractic Examiners (NBCE)2 indicates that the great majority of chiropractors offer some form of counseling for a healthy lifestyle. Not all patients are receptive to acting on the counseling provided, as the NBCE survey shows. Advice on general fitness and exercise promotion is given regularly by greater than 98 percent of chiropractors to 65 percent of their patients. Ninety seven percent of the chiropractors surveyed provided advice on ergonomic and postural advice to 70 percent of their patients. More than 90 percent of the respondents reported they provide counseling on nutrition and give dietary recommendations to 52 percent of their patients, while 97 percent reported counseling over half their patients on changing risky and unhealthy behaviors. Ninety six percent teach self-care strategies to 60 percent of their patients. Relaxation and stress recommendations are made by 97 percent of chiropractors to half of their patients. Ninety one percent present disease prevention and early screening advice to 40 percent of all patients.
One of the dilemmas encountered in offering health promotion and wellness care in primary practice is determining who desires this service. In the majority of cases, the patient presents to the chiropractic office with some form of musculoskeletal complaint (most commonly back pain, neck pain or headache). As the patient recovers from the presenting complaint, the chiropractor who wishes to offer health promotion and wellness counseling commonly introduces recommendations for a healthier lifestyle. The initial overture should not be overwhelming, and with a gradual introduction of strategies to improve the patient's health, the chiropractic physician can readily determine if a patient is interested in pursuing this course.
We know that health education can promote activities that alter behavior, which impacts health. To minimize the time chiropractic physicians devote to non-manipulable interventions, the use of various clinical information and motivational aids are helpful,3 including health management contracts, screening and handouts. The following discussion presents the health contract as a motivational tool to maintain patient commitment to healthier behavior.
Health Promotion Contract
The health promotion contract can be an efficient and effective measure for health promotion when coupled with patient education.4 Health promotion contracts are the result of negotiations between the patient and the practitioner. Once a contract has been agreed to, the role of the chiropractor becomes one of facilitator. The practitioner acts as a health educator, lifestyle coach and cheerleader in times of discouragement, and promotes active participation on the part of the patient.
There are a number of considerations involved in formulating the health management contract. The contract process includes readiness to change, assessment, planning, implementation and evaluation. A health contract is most effective when coupled with monitoring and reinforcement of healthy behavior.2 A number of factors included in the health management contract help to develop motivation and compliance on the part of the patient. (Table 1)
| Table 1: Components of the Health Management Contract |
| Definition of what "optimal health means to the patient |
| Health status assessment (based on screening) |
| Disease risk assessment (minimizing risky behaviors) |
| Delineation and ranking the patient's personal health goals |
| Strategies for attaining goals |
| Identification of helpful others |
| Provision for ongoing evaluation by patient and practitioner |
Active Participation
Patients should be actively involved in the formulation of their own program. Health promotion and wellness is an active process, and patient compliance is fostered by empowerment of the patient in setting realistic goals. The collaboration of chiropractor and patient is a partnership arrangement that encourages patients to act responsibly for their health. The patient-centered, patient/doctor relationship avoids the need to "take charge" attitude that turns patients into passive players in their own health programs.
The doctor of chiropractic works together with patients to develop practical, lifelong plans that encourage healthy lifestyles.5 Shared decision-making ensures that patients choose effective and economically feasible goals that promote health and develop wellness.
Individualization of the Program
The individualized health management contract assists patients in developing a clear understanding of their personal definition of health. Patients should be able to answer the question, "What is 'health' and what does optimal health and wellness mean to you?" Questionnaires and health screening tools can identify areas of weakness in patients' lifestyles and establish health risks they are most prone to, providing a specific direction for their health promotion focus.6
Prioritization of Personal Goals
Delineation and ranking of personal health goals is an important part of health management contracts. It's the starting point from which a rational and individualized program can be developed. Too many goals can overwhelm a patient at the start; small steps with incremental changes work best when lifestyle changes are contemplated. After the patient lists their goals, the goals should be discussed, with any changes agreed to by both the patient and the doctor of chiropractic. Changes might be necessary based on the resources of the patient and the health care system. The health plan outlined in the contract should be modified to suit personal habits and preferences.
Selected strategies are then decided upon and included in the personalized health management contract. If the program is too strenuous or unrealistic, changes to the contract can be made by including more realistic intermediary goals. Patient inconvenience should be minimized.
Helping Relationships
Involvement of significant others in a health promotion program can help to motivate the patient and serve as an additional source for identification of health goals. Not all personal relationships will be supportive of patients seeking positive changes. Involvement in an individual's health care program can encourage family acceptance of the program. The impact of the family on the health and the potential contribution of the family to high-level wellness, both for the individual and the family, increasingly are being acknowledged.3
Timeline for Evaluation of Outcomes
Provision for ongoing evaluation by both patient and doctor should be based on a practical monitoring system. Realistic timelines for assessment of progress should be included in the contract. Adherence to the program is reinforced by regular monitoring, with both objectives and strategies that can be changed to suit the individual patient's needs.
Readiness for Change
Any program aiming to promote the health and wellness of patients can only be successful when the patient is ready to make changes toward healthier behavior. An effective patient education program alone does not ensure compliance, and information alone has limited motivational properties.3 Understanding the stages of change can be helpful in identifying those patients willing to enter into a health management contract and move forward toward better health and wellness.
Stages of Change
A model based on stages of change for moving toward healthier behavior was developed in 1983.7-9 This model identifies five specific stages of susceptibility to health behavior change.
- Precontemplation
Stage one is characterized by precontemplation. In this stage, there is no intention to change behavior in the foreseeable future. Individuals in this stage are unaware or under-aware there is a need for change. Families, friends, neighbors and peers, however, might see that the precontemplators have problems. If a patient indicates they are not contemplating change in the next six months, they are classified as a precontemplator. They might make statements such as, "As far as I'm concerned, I don't have any problems that need changing" or "I guess I have faults, but there's nothing that I feel really needs changing." Patients who display these attitudes are unlikely to enter into a health management contract or be open to behavior modification to promote their health and wellness. - Contemplation
Contemplation is the stage in which people are aware a problem exists and are seriously thinking of addressing it. However, they have not made a commitment to take action. Patients frequently remain stuck in the contemplation stage for long periods, not making a move to make any changes. If patients state they are seriously considering making changes in their behavior in the next six months, they are classified as contemplators. Indicative of this stage are statements such as, "I've been thinking I should work on my problems," or "I have a problem, and I think I should do something about it." Providing these patients with health information might move them into the next stage, since they are aware and acknowledge they have a problem that needs to be addressed. - Preparation
Patients in the stage of preparation combine intention with evaluation of behavioral criteria. They are intending to take action in the near future (next month) and might have unsuccessfully taken action in the past year. Individuals in this group are prepared to take "baby steps" and are prepared to attempt small behavioral changes. A health management contract can move these patients into a stage of compliance with significant behavioral change. - Action
The action stage is the stage in which patients modify their behavior in order to overcome their problem. The health management contract can facilitate commitment and encourage overt behavioral changes. In this stage, patients successfully have altered the unhealthy behavior for a period of one day to six months. They might make statements such as, "I am really working hard to change" or "You can talk about changing, but I am actually doing it." - Maintenance
Maintenance is the stage of change in which patients work to prevent relapse and to consolidate the gains attained during action. Monitoring the behavioral change and evaluation of their health status is characteristic of this stage. Patients might state, "I need encouragement right now to maintain the changes I've already made" or "I'm looking for help to keep me from having a relapse of my problem." The timelines established in the health management contract for monitoring progress come into play at this stage.
The health management contract can help to develop skills necessary for behavior modification and foster commitment and compliance in moving the patient toward a healthier lifestyle. Compliance is a significant clinical management problem. The health management contract can significantly increase patient motivation to change behaviors risky to health and wellness. Health promotion lacks the motivation created by pain and discomfort. Changing habitual behaviors is seldom easy, and because the health management contract is highly individualized, it can target patients' strengths that motivate them to make healthier choices.
References
- Evans MW. Health Theory and Chiropractic Practice: What Makes Your Patients Tick? J American Chiropractic Association, June 2003:42-4.
- Christensen MG. Job Analysis of Chiropractic. A Project Report, Survey Analysis, and Summary of the Practice of Chiropractic Within the United States. Greeley, CO: National Board of Chiropractic Examiners, 2005.
- Jamison JR. Health Promotion for Chiropractic Practice. Gaithersburg, MA: Aspen, 1991, pgs 25-31.
- Van Dover LJ. "Health Promotion Through the Use of Nurse-Client Contracts." Presented at the annual meeting of the APHA (113th). Washington, D.C., Nov. 17-21, 1985.
- Gatterman MI. A Patient-centered Paradigm: A Model for Chiropractic Education and Research. J Alternative and Complementary Medicine 1995;1:371-86.
- Gatterman MI. Chiropractic, Health Promotion and Wellness. Boston, Jones and Bartlett, 2007
- Prochaska JO, DiClemente. Stages and Processes of Self-change of Smoking: Toward an Integrative Model of Change. J Consult Clin Psychol 1983;51:390-5.
- Prochaska JO, Norcross JC. Stages of Change. Psychotherapy 2001;38:443-9.
- Evans MW, Hawk C, Boyd J. Smoking Cessation for Chiropractic Interns: A Theory-driven Intervention. J American Chiropractic Association, July 2006:13-9.
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