Article
Interactive behavior change technology: A partial solution to the competing demands of primary care

https://doi.org/10.1016/j.amepre.2004.04.026Get rights and content

Abstract

Background

Primary care practices are faced with the challenge of having too much to do in too little time. As a result, behavioral counseling is often overlooked, especially for patients with multiple health behaviors in need of change.

Methods

This paper describes recent examples of the application of interactive behavior change technologies (IBCTs) to deliver health behavior change counseling before, during, and after the office visit to inform and enhance patient–clinician interactions around these issues. The 5A's framework (assess, advise, agree, assist, arrange follow-up) is used to consider how interactive technology can be used to implement behavior change counseling more consistently.

Results

A variety of IBCTs, including the Internet, clinic-based CD-ROMs, and interactive voice-response telephone calls have been shown to be feasible and potentially valuable adjuncts to clinic-based behavioral counseling. These technologies can both increase the effectiveness of behavioral counseling and extend the reach of these services to patients with barriers to face-to-face interactions.

Conclusions

If appropriately developed with the context of primary care in mind and integrated as part of a systems approach to intervention, IBCT can be a feasible and appropriate aid for primary care. Recommendations are made for the types of IBCT aids and research that are needed to realize this potential.

Introduction

P rimary care physicians and healthcare systems face substantial barriers to providing preventive services. Given the competing demands for management of acute illnesses and chronic health conditions, Stange et al.1 have concluded that 1 minute is the realistic average amount of time that primary care providers can devote to prevention during a typical office visit.1 Rather than argue that more time should be devoted to prevention, they argue that this “1 minute for prevention” should be leveraged, supported, and informed by activities outside the face-to-face encounter. Another recent paper demonstrates that to deliver all the preventive services recommended by the U.S. Preventive Services Task Force2 (USPSTF) to an average panel of patients, family physicians would need to spend 7.5 hours of every working day on prevention.3 These articles demonstrate the impossibility of relying on primary care physicians to deliver personally all the recommended and guideline-concordant preventive services. They also provide a sobering juxtaposition to the series of articles in this issue describing the prevalence, importance, and effectiveness of methods to assist patients to change multiple health risk behaviors.4, 5 Given the complexity and challenges of behavior change for patients who have multiple behaviors to change or multiple chronic illnesses,6, 7 thoughtful use of interactive behavior change technology (IBCT) might provide a partial solution to the otherwise overwhelming problem of addressing prevention effectively in primary care.

By IBCT we mean computer-based tools and systems, including hardware and software that can be used to address health behavior change. Examples include, but are not limited to, Web-based behavior change programs; CD-ROM interventions using touchscreen kiosks or similar methods; interactive voice response (IVR) technologies, also known as automated telephone disease management; personal digitial assistants (PDAs) or other handheld devices, electronic medical records or registries that include behavioral and behavior change information, and a variety of emerging “convergence” devices that merge or combine the characteristics of these different technologies.8

The purposes of this article are to (1) describe a model of how IBCT can inform, deliver and support behavior change counseling; (2) discuss recent applications of IBCT; (3) illustrate innovative ways that IBCT can be use to leverage the “1 minute for prevention”1; and (4) propose future directions for research and application. It is not our intent to provide a systematic review of the literature on IBCT; this is worthy of a separate paper. The article by Goldstein et al.5 in this issue provides evidence from IBCT (as well as many other interventions) and reviews of IBCT are available.9, 10, 11 The American Journal of Preventive Medicine has published a series of articles on the development and status of IBCT,12, 13, 14, 15 and entire books have been written on the potential for integrating IBCT into health care and on the evidence supporting IBCT.9, 10 This article focuses on the narrower question of how IBCTs can be integrated within primary care practices to address the challenge of multiple behavior change.

As described in accompanying articles4, 16 and recommended by the USPSTF on health behavior counseling,17 the 5A's model (assess, advise, agree, assist, arrange follow-up) provides a helpful framework for conceptualizing and delivering evidence-based behavior change interventions. These sequential and ongoing activities include assessing current patient health behaviors, advising them in personally relevant ways to change health behaviors that put them at risk, agreeing with patients on collaboratively set, specific behavior change goals, assisting them with problem-solving strategies to overcome barriers to attaining these goals, and arranging follow-up support so that achieved behavior changes are maintained over time.17, 18, 19

Interactive behavior change technologies can be used to deliver the 5A's consistently within the context of primary care. Our primary thesis is that modern IBCT can be used effectively and efficiently to provide behavior change support before, during, and after primary care office visits—and sometimes instead of such visits (Figure 1). If appropriately constructed to draw on the strengths of primary care,20, 21 and to use patient-centered principles,22, 23 IBCT can inform, leverage, and support patient–provider communication and enhance behavior change.1

Table 1 provides a summary of the purpose of each of the 5A's of behavior change, and our estimation of the relative strengths and limitations of each of the more widely used IBCT platforms (as typically constructed and used in 2004) on these categories.24 We also encourage readers to think about creative ways that these various technologist can be combined to support primary care and to assist patients and healthcare teams to address multiple behavior risk factors.

Section snippets

Using IBCT before an office visit

Interactive behavior change technology can be particularly useful before the clinic visit to promote assessment, the first of the 5A's. Primary care practices can take advantage of IBCT to assess and promote behavior change even before a client steps into the office. Patients may use the telephone, a clinic Website, or a CD-ROM in the office before the visit to complete a health behavior risk assessment (HRA). HRAs have been effective in facilitating behavior change when coupled with feedback

Use of IBCT after the visit

After a clinic visit, many primary care encounters require arranging follow-up for successful behavior change. Unfortunately, this follow-up seldom occurs.45 IBCTs are well adapted to this task. While IBCT applications often serve multiple clinical goals, it is useful to appreciate the distinct care processes that IBCT can support.

Luse of IBCT to arrange patient reminders and administrative supports

For many patients, particularly those with multiple behavioral risk factors or chronic illnesses, medical care involves a complex array of visits with multiple clinicians, laboratory tests, and medication refills. Not surprisingly, patients frequently have difficulty adhering to these schedules. Many miss appointments, and large numbers have difficulty adhering to their medication regimen.60 IBCTs are well suited to providing reminders. Such reminders consistently increase follow-up medical

Discussion

The efficacy of many of the IBCT applications described above has been demonstrated by rigorous trials in motivated clinical practices. Some of the other IBCT applications we have proposed are more visionary, although all are feasible using current technology. If established and innovative IBCT interventions to enhance prevention are to become even a partial solution to the competing demands of primary care, they must be designed in recognition of several realities of clinical practice. IBCT

Acknowledgements

Preparation of this paper was facilitated by a grant from the Robert Wood Johnson Foundation. We are grateful to Elliott Coups, PhD, and Nicolaas Pronk, PhD, for their helpful feedback on an earlier version.

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