Susan A. Flocke

Teachable moments for health behavior change: A concept analysis

OBJECTIVEnTeachable moments have been proposed as events or circumstances which can lead individuals to positive behavior change. However, the essential elements of teachable moments have not been elucidated. Therefore, we undertook a comprehensive review of the literature to uncover common definitions and key elements of this phenomenon.nnnMETHODSnUsing databases spanning social science and medical disciplines, all records containing the search term teachable moment* were collected. Identified literature was then systematically reviewed and patterns were derived.nnnRESULTSnAcross disciplines, teachable moment has been poorly developed both conceptually and operationally. Usage of the term falls into three categories: (1) teachable moment is synonymous with opportunity (81%); (2) a context that leads to a higher than expected behavior change is retrospectively labeled a teachable moment (17%); (3) a phenomenon that involves a cueing event that prompts specific cognitive and emotional responses (2%).nnnCONCLUSIONnThe findings suggest that the teachable moment is not necessarily unpredictable or simply a convergence of situational factors that prompt behavior change but suggest the possible creation of a teachable moment through clinician-patient interaction.nnnPRACTICE IMPLICATIONSnClinician-patient interaction may be central to the creation of teachable moments for health behavior change.

Initiation of health behavior discussions during primary care outpatient visits

OBJECTIVEnDespite the importance of health promotion, rates of health behavior advice remain low and little is known about how advice is integrated into routine primary care. This study examines how health behavior topics of diet, physical activity and smoking are initiated during outpatient visits.nnnMETHODSnAudio recording of 187 adults visit to five purposefully selected physicians. An iterative analysis involved listening to and discussing cases to identify emergent patterns of initiation of health behavior talk and advice that followed.nnnRESULTSnPhysicians initiated 65% of discussions and used two overarching strategies (1) Structured: a routine to ask about health behavior and (2) Opportunistic: use of a trigger to make a transition to talk about health behavior. Opportunistic strategies identified a greater proportion of patients at risk (50% vs. 34%) and led to a greater rate of advice (100% vs. 75%). Patients initiated one-third of health behavior discussions and were more likely to receive advice if they explicitly indicated readiness to change.nnnCONCLUSIONSnOpportunistic strategies show promise for a higher yield of identifying patients at risk and leading to advice.nnnPRACTICE IMPLICATIONSnEncouraging patients to be explicit about their readiness to change is likely to increase physician advice and assistance.

Making sense of primary care practices' capacity for change

A deeper understanding of the forces that shape the motivation and willingness of primary care practices to adopt and implement new procedures-their capacity for change-may better guide development of interventions to foster adoption and implementation of evidence-based care. This study applies and evaluates the utility of a previously described framework for making sense of this complex construct in a diverse sample of primary care practices. A multidisciplinary team of 3 analysts examined ethnographic field notes that describe 15 single-physician or multiphysician practices in different organizational settings. Examples of the 4 components within the framework (ie, staff motivations, resources, opportunities for change, and external influences) and their interactions were identified. Cross-practice comparisons identified emerging themes relevant to capacity for change. Not surprisingly, variation among examples of individual components of change capacity across practices was present. Patterns among these components, however, seemed less informative in making sense of practices capacity for change than patterns across component interactions. For example, the ability of practice members to recognize and act on opportunities for change seemed to be shaped by the extent to which motivations were broadly shared within the practice and by tangible and intangible resources (eg, leadership style, relationships among practice members, and financial resources of the practice). Revised operational definitions for framework components and careful reflection on the nature of their interactions helped make sense of practices capacity for change in our sample and will enable future hypothesis testing to refine our understanding of factors that influence the translation of scientific knowledge in primary care settings.

Physician Practice Patterns and Variation in the Delivery of Preventive Services

BackgroundStrategies to improve preventive services delivery (PSD) have yielded modest effects. A multidimensional approach that examines distinctive configurations of physician attributes, practice processes, and contextual factors may be informative in understanding delivery of this important form of care.ObjectiveWe identified naturally occurring configurations of physician practice characteristics (PPCs) and assessed their association with PSD, including variation within configurations.DesignCross-sectional study.ParticipantsOne hundred thirty-eight family physicians in 84 community practices and 4,046 outpatient visits.MeasurementsPhysician knowledge, attitudes, use of tools and staff, and practice patterns were assessed by ethnographic and survey methods. PSD was assessed using direct observation of the visit and medical record review. Cluster analysis identified unique configurations of PPCs. A priori hypotheses of the configurations likely to perform the best on PSD were tested using a multilevel random effects model.ResultsSix distinct PPC configurations were identified. Although PSD significantly differed across configurations, mean differences between configurations with the lowest and highest PSD were small (i.e., 3.4, 7.7, and 10.8 points for health behavior counseling, screening, and immunizations, respectively, on a 100-point scale). Hypotheses were not confirmed. Considerable variation of PSD rates within configurations was observed.ConclusionsSimilar rates of PSD can be attained through diverse physician practice configurations. Significant within-configuration variation may reflect dynamic interactions between PPCs as well as between these characteristics and the contexts in which physicians function. Striving for a single ideal configuration may be less valuable for improving PSD than understanding and leveraging existing characteristics within primary care practices.