Communication study
Identifying teachable moments for health behavior counseling in primary care

https://doi.org/10.1016/j.pec.2010.11.009Get rights and content

Abstract

Objective

Situations with potential to motivate positive change in unhealthy behavior have been called ‘teachable moments’. Little is known about how they occur in the primary care setting.

Methods

Cross-sectional observational design. Audio-recordings collected during 811 physician–patient interactions for 28 physicians and their adult patients were analyzed using conversation analysis.

Results

Teachable moments were observed in 9.8% of the cases, and share three features: (1) the presence of a concern that is salient to the patient that is either obviously relevant to an unhealthy behavior, or through conversation comes to be seen as relevant; (2) a link that is made between the patient's salient concern and a health behavior that attempts to motivate the patient toward change; and (3) a patient response indicating a willingness to discuss and commit to behavior change. Additionally, we describe phenomena related to, but not teachable moments, including teachable moment attempts, missed opportunities, and health behavior advice.

Conclusions

Success of the teachable moment rests on the physician's ability to identify and explore the salience of patient concerns and recognize opportunities to link them with unhealthy behaviors.

Practice implications

The skills necessary for accomplishing teachable moments are well within the grasp of primary care physicians.

Introduction

Teachable moment is a colloquially term in health care to describe opportunities to stimulate patient action, particularly with regard to health behavior change [1], [2], [3], [4], [5], [6], [7]. Conceptual work defining the phenomenon and empirical testing of its effect is limited [8], [9], [10], [11]. Most research retrospectively identifies circumstances in peoples’ lives associated with behavior change [8], [9], [10], [11]. McBride et al. have proposed a conceptual model for the teachable moment [1], [12] and empirically tested it [13]. They define teachable moments as “cueing events”: naturally occurring health events or circumstances that lead individuals to make health behavior changes. Drawing significantly from the Health Belief Model [14], this definition of a teachable moment informs research examining the effect of cueing events, such as a cancer diagnosis, on rates of smoking cessation [1], and the impact of worry about cancer on patients’ participation in a behavioral intervention [13].

McBride et al. acknowledge the important social and interactional dimensions of teachable moments [1], [13]. People do not experience health events in isolation, but make sense of experiences through social interaction and communication with friends, family members, and health professionals [15]. Yet, little is known about how teachable moments occur through social interaction and communication. Understanding this process fills an important gap and could improve health behavior counseling by helping physicians stimulate behavior change through brief, well-timed counseling.

The purpose of this study is to explore the discourse between physicians and patients and examine the social building blocks of the teachable moment for health behavior change during primary care visits. The primary care setting provides unique opportunities to discuss important health events with the majority of the population [16], [17]. Many patients seen in primary care have multiple health behavior risks [18] and counseling that prompts behavior change could make a difference in patients’ lives [16], [19], [20], [21], [22], [23], [24], [25], [26]. Thus, examining primary care visits with patients at risk for unhealthy behaviors where health behavior counseling is observed provides a prime environment for observing this phenomenon as it may occur naturally.

Section snippets

Methods

Given the limited knowledge about how teachable moments unfold naturally in primary care, we conducted an observational study and used conversation analysis (CA) to answer the following research questions: (1) is there evidence for teachable moments arising during primary care visits and (2) if so, how are teachable moments enacted through the communication between physician and patient?

Results

Among the 811 patient participants, 733 were at risk for at least one unhealthy behavior: 21% were smokers, 68% overweight or obese, 45% inactive and 57% reported poor fruit and vegetable consumption. Among patients who self-identified as at risk for an unhealthy behavior, 451 of those visits included talk about a health behavior for a total of 548 discussions of health behavior (mean number of discussions = 1.2, std dev 0.45). Table 1 shows the characteristics of these 451 patients.

Discussion

This study establishes that teachable moments occur in primary care visits and shows how they are enacted through communication between physician and patient. By recognizing a patient's salient concern and linking that concern with a relevant health behavior, physicians attempt to motivate patients and, when successful, may elicit patient's commitment to health behavior change. To do this effectively, physicians need to identify and explore the salience of patient concerns and recognize

Acknowledgements

This study was funded by a grant to Susan A. Flocke by the National Cancer Institute (R01 CA 105292). The authors would like to acknowledge the work by Leslie Cofie and Antje Daub to code the cases. Mary Step, PhD and William L. Miller, MD, MA provided helpful comments on a draft of the manuscript. Preliminary findings were presented at the North American Primary Care Research Group November, 2008. The authors do not have any conflicts of interest to report.

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