Using Teachable Moments to Encourage Lifestyle Change in Urology
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Dr Alyssa Lee's presentation at the SCPN Conference, Wednesday 4th February 2015.
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Using Teachable Moments to Encourage Lifestyle Change in Urology
- 1. OPPORTUNITIES FOR LIFESTYLE CHANGE USING “THE TEACHABLE MOMENT” - A PROOF OF CONCEPT PILOT IN THE UROLOGY SERVICE Dr Alyssa Lee, Health Psychologist Mr Steve Leung, Consultant Urological Surgeon
- 2. Background Funding from Detect Cancer Early - proposal highlighted the Urology site as for a proof of concept pilot Collaborative project to introduce a Health Psychologist into the Urology team to capitalise on the ‘teachable moment’ for behavioural change Increasingly utilise ‘teachable moments’ to improve patient outcomes through timely, evidence-based interventions in testing, screening and treatment for cancer
- 3. Why this work is needed Fits with health promoting health service and priority to improve cancer services Many cancers can be prevented through lifestyle change 1 Patients in secondary care are likely to have risk factors for other cause of mortality/morbidity 2 1. Parkin et al, 2010; World Cancer Research Fund, 2014 2. Schmitz et al, 2010
- 4. Why this work is needed In absence of lifestyle change advice and support negative tests/screens could be seen as endorsing current behaviour ‘health certificate effect’ 1 Improved symptom management and quality of life can accompany and follow lifestyle change 2 Can play a significant role in cancer reoccurrence, staging and cancer survival rates 3 1. Larsen et al, 2007 in Anderson 2014 2. Demark-Wahnefried et al., 2005 3. Moreira et al, 2013
- 8. What is a ‘teachable moment’? 1. an opportunity arising between a ‘patient’ and ‘health professional’ during consultations to mention and encourage change. 2. a specific event/context, which can predictably be associated with an increased desire, willingness or capacity for change in patients 3. a cueing event in which an individuals’ perceptions change and make them more favourable for change.
- 9. Teachable moments interventions Risk communication e.g. Endorsement of importance of lifestyle change by credible source like a nurse/doctor Motivational approaches e.g. Raise intention to change through motivational interviewing, exploration of pro/cons, ambivalence, values for health etc. Implementation approaches e.g. Develop action plans for change, signpost to relevant services, introduce self-monitoring aids etc.
- 10. What is notable, and supported by the wider behaviour change literature is that all of the above require a supportive system to be effectively utilised to increase motivation, and to enact change.
- 11. Progress What have we done so far...
- 12. Setting up of the service Identifying where TM interventions can be implemented Review of clinical pathways for cancer patients Observation of consultant and nurse-led clinics Developing materials to identify lifestyle behaviours Flyer and lifestyle survey collaboratively developed and piloted for routine TRUS clinic Baseline assessment of behaviours started
- 13. Setting up of the service What does the service look like? Focusing on patients with a negative results following biopsy of the prostate Clinics for one-to-one consultations Close relationship with cancer nurse specialists Generating clinic letters to GPs Looking at supporting men on active surveillance Prospectively auditing the service
- 14. Delivering the service Developing a culture to effectively utilise “TMs”: Staff survey: motivation, intention, skills to discuss lifestyle change Raising awareness of TM opportunities with staff Support and training in communication approaches and behaviour change techniques Clinical case study presentation at unit meetings Inclusion of lifestyle factors in follow up reviews
- 15. Other cancer areas Could this approach be more widely implemented in cancer services? Lessons learned will provide valuable insight into opportunities in other secondary care cancer settings But...approach likely depend on contextual factors in each cancer service
- 16. Key messages TM work is implementable at this early stage Identifying a large cohort with both negative and positive results CNS support is pivotal to the work Requires buy-in from other staff to reinforce messages
- 17. Questions? For more information please contact alyssalee@nhs.net steve.leung@nhs.net
Notas del editor
- 1. This collaboration involved psychology, Public health from NHS Fife, along with health psychology input from School of Medicine at St Andrews university. The urology team – in particular Steve Leung have been excellent partners in this – shown a real commitment to improving services for patients. 2. This proposal t focuses on the role of secondary care sites in relation to supporting and motivating changes in patient outcomes – we will look at why this might be a useful approach in the next slide. 3. I’ve used the word increasingly here on purpose to demonstrate that the secondary care cancer settings is obviously already doing elements of ‘teachable moment’ work as part of routine practice. For example, advice to stop smoking, cut down on caffeine or lose weight will be given by clinical staff where viewed important/relevant. Evidence of awareness and promotion of services for signposting to increase PA to improve fatigue – Move More Fife. What we will look at in the next slide is whether improvements to patient care can come about with more attention paid to enhancing the TM through delivery of timely evidence-based interventions.
- What is the evidence out there. Lung cancer – smoking setting – dr brief advice or separate research – vs. this project integrating to the team. One-sided Drs to do it. 1. HPHS concept since 2008 focussed on acute care settings, with the aim of ensuring that “every healthcare contact is a health improvement opportunity”. - Improving survival and treatment for people with cancer in Scotland is a priority for the Scottish Government - Better cancer care document and recent efforts looking at transforming care after treatment 2. Estimates from CRUK – as many as 4 in 10 cancers can be prevented through not smoking keeping a healthy body weight cutting back on alcohol eating a healthy, balanced diet keeping active avoiding certain infections (like HPV) staying safe in the sun occupation (see chemicals in the workplace) Special issue of B J of Cancer devoted to this in 2010 plus other studies EPIC looking at effect on all cause mortality/morbidity – from engaging in 4 of these behaviours was extra 14 years of life. Recent WCF paper found strong evidence of obesity in relation to development of adv CaP. In CaP - In men with prostate cancer the leading cause of death is cardiovascular disease
- 3. Health certificate effect makes sense in the context – of media reports underplaying role of lifestyle factors 4. Improving outcomes requires concentrated efforts to promote earlier diagnosis and effective treatment – DEC purpose. Additionally, as with most health problems, a combination of primary, secondary and tertiary interventions are needed to achieve a meaningful degree of cancer prevention and protection. Example from research – CaP Pts undergoing radical prostatectomy, cigarette smoking is associated with an increased risk of metastasis, cancer reoccurrence and overall mortality4
- From research quoted here: http://www.nature.com/bjc/journal/v105/n2s/index.html On a page entitled Statistics on preventable cancers, you can peruse the estimated relative contribution to various factors, such as smoking, alcohol consumption, diet, sunlight, radiation, and others, to a wide array of different human cancers. Not surprisingly, by far the most common cause of preventable cancer is tobacco, causing an estimated 86% of cases of lung cancer, 65% of cases of esophageal cancer and cancers of the oropharynx and head and neck, 37% of cases of bladder cancer, and 29% of cases of pancreatic cancer. Diet is estimated to contribute to 31% of bowel cancers, 46% of esophageal cancer, 51% of stomach cancers, and 56% of head and neck cancers. Alcohol contributes to several cancers, including breast, bowel, esophageal, oral, and liver cancers, but the effects are much more modest. Sunlight contributes to 86% of cases of malignant melanoma,
- This research widely in news – contibutes to public beliefs about cancer as something that can be prevented or not. especially regarding obesity/overweight – CRUK risk perceptions survey 2008 found this. Only 3percent knew this increased risk. Note. breast and prostate – most common male/female not inc.
- The point isnt that people are criticing the science (but they area) but that the media coverage of the findings were out of step and disproportionate to the findings – plus the latest reports stating this is getting much less media attentions So how much cancer is down to random cell division error? The researchers say they've calculated that two thirds (65%) of "the differences in cancer risk among different tissues" is down to cell division gone wrong - "bad luck". Now many media reports have simply concluded that this means that two thirds of cancer cases are just the result of random haywire cell division. That's not correct. But on the other hand, a lot of people aren't quite sure exactly what the researchers mean. Statistical and scientific experts who have been blogging about the misreading of the research don't all agree about what the 65% figure refers to. The most likely explanation seems to be that the researchers were referring to the correlation between cell divisions in different types of tissue, and the tendency of those tissues to develop cancer.
- 1. Often seen as spontaneous and unpredictable, health professionals require specific skills to notice and hardness such opportunities during routine clinical practice; 2. Evidence suggests that events such as pregnancy, hospitalisation, and medical interventions for life threatening illnesses are more likely to act as ‘teachable moments’ (McBride et al, 2003); Patients in secondary care are likely to be more motivated to engage in lifestyle interventions. However, patients need to be aware of the relevant risk factors and relate these to current personal behaviours before the “teachable moment” opportunity can be perceived as relevant. 3. This includes an a) increase in the risks associated with continuation of the behaviour and/or an increase in expectations of positive outcomes of change; b) a strong emotional response; c) individuals experiencing a redefining of their self-concept/ social role. This model also takes cognizance of predisposing factors (e.g. age, skills, general self-efficacy, previous behaviour change attempts etc.). What is notable, and supported by the wider behaviour change literature is that all of the above require a supportive system to be effectively utilised to increase motivation, and to enact change.
- Appropriate resources on hand to support clinicians likely to help with implementing this in practice. TM should not be seen as a one-stage process, likely require revisiting with feedback to effectively implement changes. Likely only low-intensity interventions can be done in usual clinical time – brief advice led, raising the issue etc. But with a trained person delivering behaviour change interventions – is evidence of effectiveness in weight outcomes, diet and PA (for example Anderson et al BEWEL study – following screening for colorectal cancer) – highlighted risk of weight for adenoma reoccurrence to patients via a letter and invited to 12 month study – lifestyle counselling using MI.
- Highlight embedded nature into the team Programmes have shown that as little as 5.25 hours support can lead to 7% weight loss at 12 month compared with people receiving no support. Services are available for some behaviours – smoking cessation, weight management (only if BMI 35 with co-mor or 40 without)
- Mention evaluation here: Service evaluation proposal passed ethical considerations Regular audit of service (from March 2015) Staff impact evaluation Patient surveys – experience of service and decliners
- 1. As part of national screening programmes for breast, colorectal, cervical? As part of testing and treatment for cancer in other secondary care sites? CaP Incidence rates are high (89-116 per 100,000 persons) with a high number of negative screens (40% roughly) with a number of men lowgrade and on AS routes of treatment – could survival rates at 1-5yr As discussed likely benefits to CaP patients from lifestyle change Is this different from other cancers – arguably within urology – impact of smoking, obesity on bladder/kidney cancer Wider breast and colorectal obv benefits plus in lung with earlier detection and improved clinical outcomes from stopping smoking (prev work has looked at pts and families with mixed results for TM interventions at diagnosis of LC).
- Benefits to patient of integration into team – Potential for improved health outcomes Empower patients to take control of health Lifestyle/self-management concerns addressed Harness “health within illness” Asses the wider psychosocial determinants of health LINKS TO MAGGIES, FSLT etc.