Vol. 9, No. 4 Printed in Great Britain

Family Practice © Oxford University Press 1992

Key Factors in Health Counselling in the Consultation ELISABETH ARBORELIUS.* INGVAR KRAKAU" AND SVEN BREMBERG***

tion etc.4"1' Such advice from the physician seems to be more effective if it is associated with the patient's symptoms and his life situation, if it is concrete as to how to go about it, if the immediate short-term advantages are emphasized and if a follow-up visit is decided upon.6'7 There is little reported about the way the doctor's own health habits affect his health counselling. Stokes and Rigotti7 point out that doctors who smoke use less time on smoking counselling compared with nonsmoking doctors. Demak and Becker12 emphasize that doctors have given up smoking to a greater extent than other people i.e. they have succeeded in affecting their own health but not in communicating such knowledge to their patients. Most GPs regard lifestyle as very important, but few perceive efficacy in influencing the patient.6-7'12-13 Only 3-18% of doctors have reported that they feel effective/successful in influencing habits such as diet, exercise, smoking and alcohol.7-12-13 Stokes and Rigotti hold that the obstacles are due to the physicians' lack of adequate training. Other obstacles experienced are lack of time, pessimism about the effectiveness of their advice and about the patient's ability to change and fear of alienating the patient. Demak and Becker12 point out that many doctors do not look upon prevention as an adequate issue in public health service.

BACKGROUND Previous Studies Prevention, in practice, is a complex phenomenon. We know that lifestyle is a determinant for morbidity and mortality, but to spread this knowledge so as to make people change their lifestyle involves a number of problems, e.g. people's need for self-determination, integrity, etc. Ethical issues are also raised. Previous studies deal mostly with doctors' health counselling. There are few, if any, studies concerning nurses' health counselling despite the great extent of their prevention work. A GP has extraordinary opportunities to influence people's life habits.1 The frequency of interventions in health counselling ranges from 9 to 77 per 100 consultations in different studies.1'2 In a Swedish study with the starting-point in videotaped consultations3 15 interventions were found per 100 consultations. Several studies demonstrate that counselling in life habits significantly influences people to enhance health activities, e.g. quit smoking, reduce alcohol consump• National Institute for Psychological Factors and Health, Box 60210, S-10401 Stockholm and SoDentuna Health Centre, PO Box 164, 191 23 Sollentuna, •• Department of Family Medicine, Uppsala University, 751 85 Uppsala and Sollentuna Health Centre, PO Box 164, 191 23 Sollentuna and • • • Department of Community Medicine, Karolinska Institute, DiagnosvSgen 8, 141 54 Huddinge, Sweden.

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Arborelius E, Krakau I and Bremberg S. Key factors in health counselling in the consultation. Family Practice 1992; 9: 488-493. To design an effective course in behaviour influence all GPs and general nurses at two health care centres were interviewed concerning procedure and perceived barriers to prevention. The results demonstrated that most doctors and nurses regarded health counselling as important in medical hearth service. They also maintained that they have time and space for this activity. However, most doctors and nurses were hesitant and/or disappointed concerning their perceived efficacy in affecting people's life habits. The explanation may be that the personnel lack an effective methodology to handle these issues. Few had a more developed educational theory where the starting-point was the patient. Another explanation may be that many doctors and nurses had a non-patient-centred style, which previous studies demonstrate to be less successful in affecting people's behaviour. This was expressed in the notion that the doctor/nurse has to be a model from which the patient can learn the 'righf life habits. It was also expressed in the notion that the reasons why patients do not change behaviour were mostly psychological, but no importance was attached to the role of different values. The results point out the need for education in patient-centred pedagogics.

KEY FACTORS IN HEALTH COUNSELLING

METHOD Population In the Sollentuna community, north-west of Stockholm, with about 50000 inhabitants, there are three primary health care centres, all with a stable staff. All permanent GPs (total 16, median age 45, range 37-52) and general nurses (total 14, median age 49, range 34-62) at two of these health care centres were interviewed. Among the doctors there was a broad competence over and above their medical qualification: engineer, welfare officer, psychologist, priest. Some doctors have also defended their theses. None of the general nurses had education beyond their nurse's exam. Six, however, had long experience of antidotal treatment for smokers and/or treatment for weight reduction.

Since 1980 there has been a primary care research unit of family medicine attached to these health care centres i.e. there have been many research and development projects in progress. On the whole, there has been a great interest in preventive intervention. For some years now, there has been a major cardiovascular programme going on in which all GPs and general nurses were involved. The Interviews The interviews (made by one of the authors, EA) were structured and consisted of 35 questions. They lasted for 45-60 minutes. All GPs and general nurses agreed to be interviewed. The interviews covered the following issues: 1) the frequency of health counselling discussions about diet, smoking, exercise and alcohol; 2) the attitude to prevention; 3) the procedure of counselling; 4) patient-centred and doctor/nurse-centred style; 5) ideas of the patient's attitude to preventive counselling; 6) perceived efficacy in working with prevention; and 7) conflicts, if any, with one's own lifestyle. The procedure of the health counselling and the style were judged from the interviewed person's own story about his/her way of discussing smoking, diet, exercise and alcohol. Perceived efficacy was judged partly upon a direct answer to the question. "What do you think the result of counselling will be?", but also upon the answers to the other questions. The other issues were judged by the answers to direct questions. In this study, we processed qualitative data.24 At first, all the answers in a special area were classified according to the real content. After that, we searched for and named more comprehensive categories which appeared to elucidate interesting similarities and differences between the comments. Such an analysis means that patterns, themes and categories of analysis come from the data; they emerge out of the data rather than being imposed on them prior to data collection and analysis.24 A doctor/nurse-centred style was defined such that the GP/general nurse behaves as if he/she knows what is best for the patient and directs the patient towards this goal. It is expressed by moralizing over the patient or by statements implying 'right' and 'wrong' behaviour. The definition of a patient-centred style was that the GP/general nurse attempts to understand the patient's starting-point, rather than to direct the patient. It is expressed by statements that emphasize respect for the patient, the importance of not moralizing or 'running over' the patient, of being sensitive etc. After the first six interviews, some questions were added. That means that all persons did not get all questions. On some occasions it also happened that lack of time prevented our asking all questions.

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Pedagogics and Prevention In health counselling—as in consultation as a whole— the doctor/nurse may have a patient-centred or a doctor/nurse-centred style.14 Demak and Becker12 point out that the doctor in health counselling should be a teacher and an adviser but not a substitute parent or a policeman. The medical approach is very apparent in health counselling and is expressed by an authoritarian style, where the patient is asked to change his lifestyle in a special way.12 Willms et al. emphasize the importance of the patient's own decision to change his life habits. Studies demonstrate that a patient-centred style is more effective in this way.12*15'16 Patient-centred methods involving techniques where the doctor/nurse encourages and supports the patient's internal motivation are more successful with regard to giving up smoking,17'18 losing weight,19 lowering diastolic blood pressure and getting better glucose control.20 In the 'health belief model'21 the doctor's/nurse's ability to discuss perceived barriers—a calculation of the advantages and the disadvantages of changed behaviour—is a determining factor in healthenhancing behaviour. Key factors in social learning theory22*23 are recording of the patient's real behaviour, supporting the patient to make his own decision, helping the patient to find out strategies for realizing a change and giving him feedback on his new (or modified) behaviour. Health counselling involving such factors is more effective than consultations without these factors.3 Using videotaped consultations it has been demonstrated that if the doctor lacks these techniques, the result may be that he directs and moralizes over the patient's behaviour.3 To design adequate education in effective health counselling, pedagogical knowledge is needed, but also knowledge about the barriers doctors and nurses perceive in their actual health counselling. The previous few studies deal with separate aspects and comprise only GPs. The aim of this investigation was to study a number of aspects in perceived barriers and benefits among both GPs and general nurses.

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RESULTS If only one type of intervention was discussed in every counselling, the frequency of interventions was 18 per 100 GP visits and 22 per 100 general nurses visits. If there were more interventions for every visit, the figures are lower. The majority (27/30) of those interviewed considered that this type of counselling belongs to the public health service and that they have enough time for these discussions. The Procedure of Counselling The pedagogical activities, spontaneously named, in the health counselling about diet, exercise, smoking and alcohol were:

Counselling Style About half (16/30) of those interviewed could be categorized as having a patient-centred style. Some (5/30) had a doctor/nurse-centred style. Another (6/30) persons could be categorized as having both a patient-centred and a doctor/nurse-centred style. In three cases, it was not possible to categorize the style. Examples of expressions of a doctor/nurse-centred style: "I think the patient likes a person who eventually tells him/her off." "Why doesn't the patient do as I say when I have done all that was humanly possible". "I'm not a fanatic, but there are no advantages to smoking". Examples of expressions of a patient-centred style: "These questions are very tactful, you have to be very careful not to run over with pointers. Then you will scare them away. We are not moral watchmen". "You have to respect the patient when he says "I want to continue smoking". It's important not to build barriers". Ideas of the Patient's Attitude Towards Health Counselling Twenty-four of those interviewed answered the question: "What do you think is the reason why people, despite all information etc., don't manage to

1) psychological needs; 2) external stress; 3) society's attitude of acceptance; 4) lack of knowledge; 5) lack of will-power; 6) physical dependence; 7) disparate values (in the case of elderly patients); and 8) inadequate pedagogics.

17/30 5/30 5/30 5/30 3/30 3/30 2/30 1/30

The predominant perceived reason seems to be psychological needs; relief from fear, consolation, pleasure, desire etc. Almost all (21/23) perceive no fear of alienating the patient if lifestyle is discussed in the right way. But two doctors—both with a doctorcentred style—differ from this opinion and point out that the discussion has to be on the nursing staffs terms: "I never feel fear of alienating the patient. I usually tell them about my disappointment with them. I'm not interested in whether they take it or leave it, it has to be somewhat on my terms". Perceived Efficacy The interviewees answered the following questions: "What do you think the discussion will result in i.e. do you think you can affect the patient? What concrete behaviour changes have you recorded?" The answers were classified in one of the following categories: 1. Doubt if there are any results (9/25). Examples: "1 have to believe that there will be results because I'm working with it. But when I'm talking to a patient, I seldom feel that he will change". "I get very much involved, I put a lot into it. Why doesn't the patient do what I want him to do? I do everything that is in my power". 2. Some result with some patients in the long run (9/25). Examples: "I have been a bit hardened over the years. My expectations are not so high". "Perhaps not immediate effects, but sometime. One consultation is not enough. But every little bit helps". 3. Good results (13/25). Example: "I'm astonished that people are so good. I'm impressed to see how patients can change, especially with reference to diet. It's easy to check by measuring lipids. But many changes last only for some time".

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1) inform about risk factors; 30/30 2) record the patient's behaviour; 18/30 3) give practical advice on how to change; 18/30 4) suggest that the patient think it over; 10/30 5) ask for the patient's ideas; 6/30 6) ask for the significance of the behaviour for the patient 2/30 7) discuss perceived barriers and benefits of changing behaviour; and 1/30 8) discuss life habits as an environmental risk where the patient has to make up his/her mind. 1/30

change their behaviour?" Most people mention two or more possible reasons:

KEY FACTORS IN HEALTH COUNSELLING Of the 14 district nurses interviewed, six had previously had weight-reducing and/or antidotal group treatment for smokers. At the interview (October-November 1991) all these had shelved these treatments because they had lost the desire and felt disappointed over bad results. A frequent reason was that the nurses spend time and energy in the groups while the participants failed to come or did not change their behaviour.

Conflicts, if Any, With One's Own Lifestyle

1. "I do not always practise as I preach; there can be fat sauces, chips for the children that I buy in the shop, thinking: 'Oh, what if someone catches me!' I avoid buying wine, my husband has to do it. It's important that the district nurse is a model". 2. "I behave as I teach. I think it's an advantage. It'd be crazy if I should go on preaching and at the same time have yellow fingers (from smoking)". 3. "I think I rather good behave as I teach. I mean that the doctor has to be a model and that it's an advantage that you don't smoke yourself. If you are a regular smoker it must be more difficult to discuss smoking with patients. It must be harder to discuss risk factors which are your own". 4. "It deals with professional distance and if I can conceal it, it's OK. But it's doubtful if the doctor just sit smoking or has alcohol in front of the patient or if the chair is too small for him when he talks to the patient." Some (8/22) state that it is difficult to behave as they teach; as expressed in these comments: 1. "Perhaps I'm not the right person to discuss diet because I'm not as a thread myself'.

2. "Because I'm a smoker I will not have antidotal group treatment for smokers". Another outstanding dimension in the answers (pointed out by 9/30) is that it is easier to understand the patients if you have own experience of the difficulty to change life habits: 1. "I am a smoker—it's difficult. But at the same time it's easier to understand the patients. I recognize them as smokers at once. I'm not so dogmatic as others are. I nuance very much, I think the patients are more open towards me." 2. I can preach everything with a good conscience because I practise as I preach. But we could have meet in another way if I had had own experience". 3. "I'm rather moderate with exercise myself, I really make an effort to get 2 times a week. So therefore I understand that it's not so easy". In all above variables there were no clear differences between general nurses and GPs. DISCUSSION The frequency of the reported interventions covering diet, exercise, smoking and alcohol is in agreement with the study where interventions were registered from ordinary videotaped consultations3 i.e. 15 interventions per 100 consultations. The GPs have, with the exception of diet, signficantly more health counselling than general nurses. Taking the district nurses' traditional direction of preventive work into account, this may seem remarkable. One possible explanation may be the special concentration on cardiovascular prevention in Sollentuna which to a considerable degree engaged the GPs. Moreover the GPs have about twice as many scheduled visits as the general nurses. The majority of those interviewed believed that health counselling is a very important part of the public health service. They also consider themselves as having time and space for this activity. Most of them, however, were hesitant and/or disappointed concerning their perceived efficacy in affecting people's behaviour. One explanation might be that the personnel have no effective methodology to discuss these issues with the patients. The results showed that giving information was the predominant behaviour. Other frequent pedagogical skills were recording the patient's real behaviour and giving practical advice. Much rarer were skills where the starting-point was the patient e.g. the significance of the behaviour for the patient, barriers and the benefit of change, asking about the patient's beliefs, making up one's own mind about a change, factors from the 'health belief model' and social learning theory. Another explanation would be that the personnel usually have a doctor/nurse-centred style. Studies

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All those interviewed answered the questions: "Do you ever come into conflict with your own habits when you discuss these issues with the patients? Does your own lifestyle affect the way you discuss these issues?" The answers were classified into one of the following categories: 'practising as you preach' and teaching and behaviour are two different things. The majority (25/30) considered it desirable to behave as you teach. A smaller group (5/30) held that these two things are disparate. With regard to 'practising as you preach' there are some dimensions in the answers. One element is that it deals with trustworthiness; that the message you give to the patients is something you yourself regard as true. But another element deals with the idea of being a model who shows the patients 'the right behaviour'. This option also implies that a person who does not behave as he teaches is unsuitable to discuss these issues with patients. Examples of these dimensions:

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FAMILY PRACTICE—AN INTERNATIONAL JOURNAL a 'right' lifestyle should not discuss these issues with patients': "I practise as I preach. I think it's an advantage. It'd be crazy if I should go on preaching and at the same time have yellow fingers (from smoking)." Can the result be the influence of interview bias? The interviewer was, on the occasion of the interviews, newly employed at the primary care research unit and thus had no personal relationship to those interviewed. Her position as behavioural scientist included no managerial responsibility and therefore there was not a dependency relation to the subjects. Do the subjects behave as they say? This problem is handled by the procedure of letting the people describe in detail the procedure in their health counselling. Furthermore the results are in agreement with the study of videotaped health counsellings3 where most doctors, due to lack of methodology, assessed, moralized and directed the patients. In that study the focus was on the consultation as a whole i.e. the doctors did not know that their sequences of lifestyle issues would be analysed in detail. Therefore, bias in these sequences is negligible. Because of the connection to the primary care research unit, however, the results are probably more positive in comparison with ordinary health care centres. The results point out the need to educate GPs and general nurses in patient-centred health counselling with emphasis on behavioural models. Several studies have stressed the importance of such education to increase the efficacy in health counselling.3>25'26 CONCLUDING REMARKS Despite declaring a patient-centred style, there are many expressions that medical practice is mostly characterized by the opposite. Doctors and nurses direct the patients towards a more 'right' behaviour than the patients' actual behaviour. They consider themselves to be models for the patients and thereby teach them a better way of living. They seldom take the patients' values into consideration. Pedagogics with the patient as a starting-point are very seldom used. Most doctors and nurses express disappointment over the perceived bad result despite their arduous work. If the desire is to achieve greater efficacy—and increased satisfaction for the doctors and nurses—in the preventive work, it is necessary to educate GPs and general nurses in a more patient-centred style. Even in this study, in a primary health care centre with a rather strong concentration on prevention, many staff members showed a non-patient oriented approach. This may indicate an even stronger need for education in health orientated methods in primary health care in general.

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REFERENCES Mamon J. Paccagnella B. Patient counseling by general practitioners: Republic of San Marino's experience. Health Educ Q 1991; 18: 135-143.

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demonstrate that patient-centred methodology is more effective when it comes to affecting people's life habits.1213"20 From the interviewees' stories about the procedure of counselling, it was demonstrated that about half of them had a style that was more or less authoritarian. But a doctor/nurse-centred style is also expressed in other ways e.g. the ideas about the patient's attitude to preventive counselling. Concerning the reasons why patients despite information etc., do not change their behaviour, the majority of the personnel think that it is due to psychological mechanisms i.e. the need for desire, comfort, relief from fear etc. It is regarded as a complex phenomenon where an influence is also exerted by other factors, such as external stress, society's attitude of acceptance, the patient's inadequate knowledge about the consequences. What is remarkable is the dominance of reasons which cannot be affected by education in how to handle these issues with patients. One nurse states that the reason is pedagogical. She says: "They (the patients) have not met the right person; if they really did that I think that many people would manage to change their behaviour". It is notable that values are not mentioned as a reason why people do not change behaviour. Indeed, two people mention values as a possible reason, but only in the sense that it is very old people who want to continue with diet habits they have had for many years. Do public health service personnel regard their own values as a matter of course and not perceive that patients may have another opinion? The public health service personnel's values may have their startingpoint in the fact that a change of behaviour in the long-term will result in lower morbidity and mortality. This style is non-patient-centred because the personnel's opinion is in focus rather than the patient's. Patients may have another perspective and, from that,- make another decision. Another manifestation of a non-patient-centred style is the attitude to one's own lifestyle. Remarkably many persons have the opinion that you should be a model for the patients and 'practise as you preach'. There are two dimensions in these comments: trustworthiness and modelling. Trustworthiness entails believing in what you are talking about. Being a model seems to mean that you, by your own behaviour, show the patient the 'right' lifestyle. If you do not act as a good model, the patient can imitate the doctor's/ nurse's 'bad' behaviour: "Fat sauces, chips for the children that I buy in the shop, thinking: 'Oh, what if someone catches me?' I avoid buying wine, my husband has to do it." This approach characterizes a parent-child relationship instead of the relationship between two adult equals. This reflects a non-patientcentred style; by modelling, the idea is to get the patient to change his lifestyle from a 'bad' one to a 'good' and more healthy one. As a consequence of this opinion, it is apparent that a person who does not have

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Key factors in health counselling in the consultation.

To design an effective course in behaviour influence all GPs and general nurses at two health care centres were interviewed concerning procedure and p...
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