Evaluation of Physical Activity Counseling in Primary Care Using Direct Observation of the 5As

University of Rochester Medical Center, Rochester, New York, USA.
The Annals of Family Medicine (Impact Factor: 5.43). 09/2011; 9(5):416-22. DOI: 10.1370/afm.1299
Source: PubMed


The 5As (ask, advise, assess, assist, arrange) are recommended as a strategy for brief physical activity counseling in primary care. There is no reference standard for measurement, however, and patient participation is not well understood. This study's objectives were to (1) develop a coding scheme to measure the 5As using audio-recordings of primary care visits and (2) describe the degree to which patients and physicians accomplish the 5As.
We developed a coding scheme using previously published definitions of the 5As, direct-observation measures, and evaluation of audio-recorded discussions of physical activity. We applied the coding scheme to 361 audio-recorded visits by patients reporting low levels of physical activity and 28 physicians in northeast Ohio.
The coding scheme achieved good inter-rater agreement for each of the 5As (κ = 0.62-1.0). A total of 135 visits included discussion of physical activity. Although ask tasks occurred in 91% of visits, it infrequently elicited sufficient detail about current activity. Patient readiness to change physical activity (assess) was infrequently directly elicited by the physician (24%), but readiness was commonly expressed by the patient in response to an assessment of current level of physical activity (53%). Ambivalence was infrequently followed by physician assistance (49%).
Our newly developed measure showed that (1) physicians infrequently assess patient readiness to change, (2) patient expressions of ambivalence are common, and (3) specific mention of recommended guidelines for exercise is nearly absent. Future work should increase clinician skills in exploring ambivalence and readiness to change, as well as improve explicit mention of recommended guidelines for physical activity.

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Available from: Susan A Flocke, Mar 06, 2015
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    • "Patient-centered health behavior counseling strategies, such as motivational interviewing emphasize engaging the patient to identify, examine, and resolve ambivalence about change.[19] [20] Pragmatically adapting aspects of motivational interviewing to the primary care setting, specifically, communication skills for eliciting the patient's perspective, adapting to resistance, and partnering to encourage behavior change [21] [22] [23] [24] [25], could complement the TM approach and improve skills for negotiating patient resistance and ambivalence to change. "
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    ABSTRACT: Objective Teachable moments (TM) are opportunities created through physician-patient interaction and used to encourage patients to change unhealthy behaviors. We examine the effectiveness of TMs to increase patients’ recall of advice, motivation to modify behavior, and behavior change. Method A mixed-method observational study of 811 patient visits to 28 primary care clinicians used audio-recordings of visits to identify TMs and other types of advice in health behavior change talk. Patient surveys assessed smoking, exercise, fruit/vegetable consumption, height, weight, and readiness for change prior to the observed visit and 6-weeks post-visit. Results Compared to other identified categories of advice (i.e. missed opportunities or teachable moment attempts), recall was greatest after TMs occurred (83% vs. 49%-74%). TMs had the greatest proportion of patients change in importance and confidence and increase readiness to change; however differences were small. TMs had greater positive behavior change scores than other categories of advice; however, this pattern was statistically non-significant and was not observed for BMI change. Conclusion TMs have a greater positive influence on several intermediate markers of patient behavior change compared to other categories of advice. Practice implications TMs show promise as an approach for clinicians to discuss behavior change with patients efficiently and effectively.
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    Full-text · Article · Jul 2015 · BMJ Open
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