By Kathleen McNamara, PhD, School of Social Work, University of Nevada, Las Vegas, NV; Adriana Carpenter, DO, Family Medicine Residency Program, Nellis Air Force Base, Las Vegas, NV; Weston Williams, PhD, Public Health Analytic Consulting Services, Inc., Hillsborough, NC; Meredith Williamson, PhD, Texas A&M Family Medicine Residency, Bryan, TX

BACKGROUND 

Lifestyle behaviors are known to play an important role in individual health outcomes._1,2 Sustained behavior changes, such as implementing a lower-fat diet, adding aerobic exercise, and taking medications as prescribed, have been found to improve quality of life and life expectancy._3-5 A global systematic review found that family doctors can effectively facilitate targeted behavior change using interviewing tools to improve patients’ health behaviors._6,7 However, primary care physicians overwhelmingly report feeling ill-equipped to motivate their patients to engage in healthier habits when resistance or ambivalence is present.₈ This study sought to test the efficacy of a brief educational lesson, via video tutorial, in increasing family physicians’ self-assessed confidence in using behavior change tools in their clinical practice, as well as actual use of these tools.
  

METHODS

The first author, who serves as behavioral health faculty at a family medicine residency program, filmed four brief educational videos on behavior change tools: Change Talk, Importance and Readiness Rulers, Decisional Balance, and Chain Analysis. Each video was under three minutes in length and included: 1) Introduction to the tool; 2) Example of tool’s use; and 3) Practice Prompt. These videos were uploaded onto the free video sharing website YouTube on the channel Behavior Change Bootcamp (BCB). Providing the lessons in a familiar and easy-to-access format allowed for wide dissemination of the intervention.

Air Force physicians serving at a Family Medicine Residency Program (n=40) between August and December 2023 were invited to participate in this study. Participants were asked to watch the four educational videos which they accessed via a Quick Response (QR) code. They were asked to practice this behavior change tool with a colleague before using it in patient care. Evaluation of 1) the post-intervention changes in physician self-reported confidence and 2) use of four behavior change tools, was determined via an anonymous survey administered to the research participants two months after completing the intervention. The survey asked participants to report how confident they were in motivating patients to change their unhealthy behaviors (5-point scale ranging from “Not at all” to “Extremely”) and frequency using each of the four behavior change tools (3-point scale including “Never”, “A little bit”, and “Frequently”) before and after BCB. Participants were also asked whether the BCB protocol was useful for their clinical practice (Yes/No). 

The participants reported usefulness of the intervention was presented using descriptive statistics. Differences in confidence before and after the intervention were analyzed using a paired t-test after confirming a normal distribution. Differences in the frequency of using each of the four tools were analyzed using a Wilcoxon signed-rank test. 

RESULTS

The majority of invited participants took part in the study (7/10 Postgraduate Year 1 (PGY); 8/10 PGY2; 7/9 PGY3; 5/11 physician faculty; 27/40 total). The first author notes the anecdotal finding that physicians were more likely to participate if they were present during the didactic lecture or faculty meeting time set aside to complete the video and role play portions of this study.

The majority of physicians (22 of 26, 85%) found BCB to be useful to their clinical practice. Reported confidence in motivating patients to change their behaviors after BCB was significantly higher after the intervention, increasing from a mean of 2.52 (SD=0.89) to 3.48 (SD=0.70, p<.0001, Table 1). When analyzing by cohort, significant (p<.05) increases in confidence were found for each group (Table 1). Respondents reported significantly higher frequency of use for each behavior change tool (all p<.01, Table 2). The proportion that reported any increase in frequency ranged from 48% for the Decision Balance tool, to 69% for the Change Talk tool. 

Qualitative results revealed: “[Change talk] was more effective than me just talking at patients with medical advice.” Another participant was pleased by the relative brevity of the tool: “[Decisional balance] didn't require as much time as I thought it would.” Another found: “[Importance and Readiness Rulers] were great, easy, quick, motivating.” One participant appreciated how one of the tools prioritized the patients’ values and goals: “[Chain analysis] was useful in having patients identify what items they wanted to change.” Physicians showed an overall preference for using Importance and Readiness Rulers with patients.

IMPACT

BCB is an effective, brief educational program that harnesses modern technology to deliver impactful lessons that family physicians can immediately use in the clinic. Improving physicians' confidence in providing effective care is critical in physicians’ sense of meaning and efficacy in their work, which has been shown in the literature to reduce the risk of burnout.₉  

BCB was also utilized in the training of medical students rotating through the site featured in this study. Prior to their rotation with Primary Care Behavioral Health, medical students were instructed to view the four videos and be prepared to practice these tools in patient encounters. Such education was easy for the medical students to incorporate into their rotation preparation, and the first author can attest to the students’ effective use of these tools in patient encounters. 

Encouraged by the success of this initiative with medical students, residents, and fellow faculty, we encourage other residency programs to trial this approach. Brief video tutorials on any relevant topic, including physical health matters, provide low-investment, high-yield training to learners. Residencies are invited to trial this video-based “bootcamp” method featuring their own enthusiastic faculty members. Inspired by the positive feedback from students, residents and faculty, we are exploring opportunities to scale this “bootcamp” model within our residency as well, ensuring that more physicians gain confidence in using behavior change tools in their practice. 

 
REFERENCES
1. Li Y, Pan A, Wang DD, et al. Impact of Healthy Lifestyle Factors on Life Expectancies in the US Population. Circulation (New York, NY). 2018;138(4):345-355. doi:10.1161/CIRCULATIONAHA.117.032047

2. Centers for Disease Control and Prevention. Lifestyle Risk Factors. October 21, 2020. Accessed June 5, 2024. https://www.cdc.gov/nceh/tracking/topics/LifestyleRiskFactors.htm. 

3. Byrne DW, Rolando LA, Aliyu MH, et al. Modifiable Healthy Lifestyle Behaviors: 10-Year Health Outcomes From a Health Promotion Program. American journal of preventive medicine. 2016;51(6):1027-1037. doi:10.1016/j.amepre.2016.09.012

4. Rippe JM. Lifestyle Medicine: The Health Promoting Power of Daily Habits and Practices. American Journal of Lifestyle Medicine. 2018;12(6):499-512. doi:10.1177/1559827618785554

5. Leading health indicators. Healthy People 2030. Accessed June 5, 2024. https://health.gov/healthypeople/objectives-and-data/leading-health-indicators. 

6. Morton K, Beauchamp M, Prothero A, et al. The effectiveness of motivational interviewing for health behavior change in primary care settings: a systematic review. Health psychology review. 2015;9(2):205-223. doi:10.1080/17437199.2014.882006

7. Ball L, Brickley B, Williams LT, et al. Effectiveness, feasibility, and acceptability of behaviour change tools used by family doctors: a global systematic review. British journal of general practice. 2023;73(731):e451-e459. doi:10.3399/BJGP.2022.0328

8. Oshman LD, Combs GN. Integrating motivational interviewing and narrative therapy to teach behavior change to family medicine resident physicians. International journal of psychiatry in medicine. 2016;51(4):367-378. doi:10.1177/0091217416659273

9. Hiefner AR, Constable P, Ross K, Sepdham D, Ventimiglia JB. Protecting Family Physicians from Burnout: Meaningful Patient-Physician Relationships Are “More than Just Medicine.” Journal of the American Board of Family Medicine. 2022;35(4):716-723. doi:10.3122/jabfm.2022.04.210441