Moving Beyond Raising Awareness: Addressing Barriers

Abstract

Awareness of issues and health concerns can prompt individuals to change their lifestyle behaviors. In fact, awareness is typically one of the first steps towards behavior change. However, awareness alone does not necessarily initiate or sustain behavioral changes. Specifically, many individuals experience significant barriers that prevent behavior change. Providers can address such barriers through ecological models of behavior change. Including concepts from an ecological model in health care settings can support positive lifestyle behavior change post-diagnosis. Moving beyond awareness alone and addressing barriers to change is an important goal that ultimately increases the probability of change for patients.

“Providers should aim to address barriers to behavior change as described in ecological models when providing treatment options to patients.”

Introduction

Many people believe that becoming aware of an issue or health concern will prompt behavior changes to address the concern. In this issue, Li et. al. reported that 84% of patients and 92% of providers believed that receiving a diagnosis of prediabetes would motivate patients to make healthy lifestyle changes. ¹ Unfortunately, multiple studies have found no association between awareness of prediabetes and lifestyle behavior change.^2-7 Despite this lack of association, many organizations, including the United States Department of Health and Human Services, continually ascribe a specific cause for raised awareness each month (e.g., “HIV Stigma and Hepatitis Awareness Month,” “National Physical Fitness and Sports Month”). ⁸ While awareness and education are needed to engage in behavior change, awareness alone is insufficient to incite change. Li et. al. found that following the diagnosis of prediabetes, providers’ most common suggestions were to increase physical activity, improve diet, and lose weight. Actionable suggestions for how to engage in these behaviors was less commonly recommend with 68% of providers reporting time to provide counseling on lifestyle modifications an extreme barrier for them. ¹

Referring patients to programs, such as the Diabetes Prevention Program (DPP), an evidenced-based intervention specifically designed to help people engage in lifestyle behavior change, could help overcome the lack of time barrier experienced by providers. Such programs will also provide patients actionable assistance following a prediabetes diagnosis. ⁹ Yet, only 55% of providers were aware of the DPP and of these, only 52% knew how to refer a patient. ¹ A natural response to this problem is to develop an intervention or campaign to raise providers’ awareness of the DPP and educate them on how to refer patients. This type of awareness strategy may not be sufficient to help providers change their behaviors and start referring patients to DPP. Other strategies may also need to be implemented to continue patient education and support. ¹⁰ In this article, we argue that health care needs to move beyond our ingrained reaction to raise awareness and instead focus on addressing barriers to behavior change.

Motivation is Dynamic

Behavior change is a challenging endeavor that has led theorists to develop over 100 different theoretical explanations.^11,12 While motivation is a common factor among many of these behavioral theories,^12-14 the distinction between behavior change initiation and behavior change maintenance is unclear. ¹³ Given this, the type or source of motivation needed is likely to change between the initiation and continued adherence to behavior change. ¹⁵ Consistent with the patient and provider beliefs reported by Li et al, a diagnosis of prediabetes may be sufficient motivation for an individual to make dietary or physical activity changes. ¹ However, the diagnosis alone is unlikely to motivate patients to sustain behaviors overtime. For example, if a patient’s behavior changes are not positively reinforced or if they continually experience too many barriers they may not maintain the behavior change.^11,16 Follow-up appointments following diagnosis may help to identify motives and barriers for behavior change maintenance. ¹⁷

In other instances, a diagnosis may not motivate patients to change their lifestyle behaviors at all. For example, diagnosing a patient with obesity and recommending that they move more and eat less is not likely to raise the patient’s awareness. Most patients with obesity will already recognize that they are carrying excess weight and that their activity levels and food intake contribute to their weight. For awareness of a condition to translate into behavior change, it has to actually raise awareness and carry meaning to the patient. ¹⁸ Providers should not assume that a diagnosis in and of itself sufficiently raises a patient’s awareness to motivate behavior change.

Motivation is one of the more difficult issues for providers to address. Ultimately, multiple factors play crucial roles in determining if an individual engages in behavior change. This area has been studied extensively.^11,15,18-20 One clear message from this research is the need to address the factors that are modifiable for the patient. ²¹ Having a direct conversation with patients about not only the factors that can promote change but also about the factors that detract from change can provide valuable information for the provider in developing a personalized plan for the patient.

Context Matters

Barriers and facilitators of lifestyle behavior change are often outlined with ecological models.^22,23 This approach is helpful in explaining the complexity of the context in which individuals try to make behavior changes, including individual, interpersonal, organizational, community, and policy level factors. ²⁴ Importantly, these factors are dynamic with considerable interaction across all levels. ²⁵ For this reason, many behavior change approaches aim to intervene at multiple levels. ²⁶ Although providers largely interact with only their patient (individual level), there are many ways in which providers can encourage intervention across the ecological model. ²⁷ At the interpersonal level, providers may consider involving family members in the patient’s treatment or assessing how family members may have positive or negative influences on patient behavior change. At the organizational level, providers could consider the patient’s work or school environments. At the community level, it is important to consider factors like safety, the built environment, transportation, and accessibility of healthy food. For example, if a patient experiences unstable nutrition security, the provider could refer them to a food assistance program or provide fruit and vegetable vouchers. Using an ecological perspective will allow providers to assess meaningful areas and develop appropriate interventions to aid their patients in making lifestyle changes. ²⁸

Another strategy for providers to integrate consideration of their patients’ contexts is to include community health workers as members of the care team. Community health workers are trained in behavior change, and, because they are respected members of the same community as patients, understand the context in which patients are trying to make behavior change. As such, they are often able to support behavior change in ways that providers are not.

Habits are Hard to Break

Similar to looking at factors across the ecological model that impact patient behavior change, changing the behavior of providers will also require examination of internal and external contextual factors. ²⁹ When individuals are stressed, tired, or under pressure they are unlikely to make goal-oriented behavior change. For example, in stressful situations providers are unlikely to be able to change their habits during patient care. ²⁰ Providing awareness educational materials to patients has likely become routine or habit for many providers. To break this habit it is important to create systems that can interrupt the context cues that activate. ¹⁹ For example, when alerts in a patient’s chart require a provider’s response it may prove beneficial to incorporate questions during the patient’s visit that address factors across the ecological model. Ideally disruptions would also make it easier to provide alternative care while making it more difficult to only provide awareness-based education.

Conclusion

Awareness is one of the first steps to behavior change. Raising awareness by itself is sufficient for some individuals to engage in change; however, for most, additional supports are needed. Specifically, providers should aim to address barriers to behavior change as described in ecological models when providing treatment options to patients. ³⁰ This will provide ongoing support and motivation for a patient implementing positive behavior changes. Addressing barriers to behavior may be avoided for multiple reasons. For example, a discussion of barriers may bring about an uncomfortable discussion that may feel like the patient is being discouraged to change. However, a realistic conversation about actual barriers that patients will experience increases the likelihood that these barriers can be addressed when the patient leaves the office. Additionally, patients may view this discussion as a focus on “weaknesses” instead of “strengths,” which may also be uncomfortable. Despite these difficulties, establishing a relationship with a patient that allows for these discussions to occur in earnest can have a profound impact on the behavior change process.