Using Action Plans to Help Primary Care Patients Adopt Healthy Behaviors: A Descriptive Study

Margaret Handley; Kate MacGregor; Dean Schillinger; Claire Sharifi; Sharon Wong; Thomas Bodenheimer

doi:10.3122/jabfm.19.3.224

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Figure 1.
Participant Flow. Eligible patients with CHD risk factors defined as having a diagnosis of diabetes, CHD, hyperlipidemia, or hypertension; a clinical note indicating the patient was obese or overweight or a smoker; elevated blood pressure (diastolic ≥90 mm Hg or systolic ≥140 mm Hg), or laboratory evidence of elevated low-density lipoprotein cholesterol (>100) or diabetes (elevated hemoglobin A1C >7.0) in the previous 3 months. Ineligible patients were those planning to leave the area or to change clinicians during the next 6 months, or who lacked access to a telephone. Patients were excluded following chart review and consultation with study clinicians if they had evidence of drug or alcohol addiction, serious mental illness, end-stage renal disease or cancer.

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Table 1.

Description of Patients Enrolled in the Action Plan Project (N = 274)

Variable/Definition	Mean or % (SD)
Variable/Definition	All enrolled patients (%) (n = 274)	Patients making action plans (%) (n = 228)	Patients not making action plans (%) (n = 46)
CHD risk factors^*
Diabetes	31	32	22
Hyperlipidemia	48	49	44
Hypertension	63	61	70
Overweight	62	64	48^†
Coronary heart disease	7	7	9
Smoking	27	28	20
Multiple CHD risk factors^‡	86	86	87
Age (mean years, SD)	52 (12.7)	52 (13.1)	54 (10.8)
Race/ethnicity
African American	33	35	24
White	30	29	35
Latino/a	10	10	7
Asian American	16	14	28^†
Other	11	12	6
Education
High School or less	42	43	39
Clinic setting
Public	47	46	50
Private	53	54	50
Health status^§
Fair or poor	36	36	36
Good	39	38	43
Very good or excellent	25	26	21
Health risk factors^‖
Physical inactivity (none)	15	15	17
Skipped medication (1+ times/week)	19	20	13
Few fruits/vegetables (<2 per week)	31	33	22
Stage of change^¶
Precontemplative	7	6	13
Contemplative	2	2	2
Preparation	22	23	17
Action/maintenance	69	69	68
Self-efficacy^** (mean score, SD)
Health confidence	8.5 (2.2)	8.6 (2.1)	8.2 (2.5)
Diet confidence	7.6 (2.6)	7.5 (2.7)	7.8 (2.6)
Exercise confidence	7.0 (2.7)	6.9 (2.8)	7.5 (2.5)
Worry confidence	5.7 (3.1)	5.6 (3.1)	6.1 (3.1)
Stress confidence	6.6 (3.1)	6.5 (3.1)	6.8 (3.2)
Help confidence	8.0 (2.4)	8.0 (2.3)	7.8 (3.1)
Overall confidence	8.1 (2.6)	8.1 (2.6)	8.1 (2.6)

* Based on chart review prior to study enrollment using the following criteria: (1) diagnosis of diabetes, hypertension, coronary heart disease, hyperlipidemia; (2) clinical note indicating patient is overweight or a smoker; (3) recent laboratory report indicating elevated blood pressure (dystolic >90 or systolic >140), elevated low-density lipid (>100) or hemoglobin A1c value >7.0.
† P < .05 for comparisons between patients making action plans (n = 228) and patients not making action plans (n = 46).
‡ Presence of 2 or more CHD risk factors in chart review.
§ Based on the Risk Factor Surveillance System survey.10
‖ In the previous month.
¶ Based on the transtheoretical model.11 Precontemplative: have not made a behavior change in the past 6 months to improve health and are not planning any such changes in the next 6 months. Contemplative: have not made any changes in the past 6 months but are planning to in the next 6 months. Preparation: have made no changes in the past 6 months but plan to in the next 30 days. Action/maintenance: have made changes in the past 6 months to change health-related behaviors.
** Scale 0 to 10. Higher score is better. Responses to: How sure are you that you can (behavior)? Health confidence: do the different tasks and activities needed to manage your illness? Diet confidence: make changes in your diet to improve your health? Exercise confidence: make and stay with a regular exercise program. Worry confidence: keep tiredness, pain, or worry from interfering with things you want to do? Stress confidence: remain calm when faced with difficulties related to your health? Help confidence: find the help you need when having problems with your health or your life? Overall confidence: solve most of your problems if you try hard enough?

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Table 2.

Description of Baseline Action Plans (N = 228)

Action Plan Domains and Subtopics	N	%
Exercise (38%)	86
Walk a specific distance or specific amount of time	46	53
Use gym more, more of any exercise	37	43
Buy a pedometer	3	4
Diet (30%)	68
Eat more good food, substitute good food for bad	24	35
Portion control of bad foods	27	40
Lose weight/go on a diet	6	9
Other (eg, see nutritionist, track eating, change others’ behaviors)	11	16
Combined diet and exercise^* (4%)	9	4
Medication (7%)	16
Take specific medication	5	31
Take all meds	6	38
Take meds at specific time	3	19
Take vitamins, etc	2	12
Other^† (9%)	21
Make/keep appointments	5	25
Socialize or join group	3	15
Initiate positive action	9	45
Increase self-monitoring	3	15
Smoking (8%)	19
Reduce smoking frequency (episodes or no. of cigarettes)	11	58
Quit smoking/patch to quit	7	37
Track smoking	1	5
Stress (4%)	9
Time with others	2	22
Structured relaxation exercises	4	45
Reading	2	22
Time by self for self	1	11

* A combined diet/exercise domain was added during the coding process. Most patients making action plans reported a high level of confidence that they could complete their plan—79% had a confidence score >7.
† One Action Plan is illegible in this category and not coded.