Helping women to change their behaviour is not something that can be achieved overnight, or by one person advising them to change their unhealthy habits. A collaborative approach is required, women need to be constantly reminded of ways to be healthier. Health professionals are in a unique position to do this and with the help of services and products available from CABOOLTURE mums and little ones, together we can make a real difference in the lives of women in Caboolture.
The 'CABOOLTURE mums and little ones team' have developed the Pregnancy Pocketbook to help. The Pregnancy Pocketbook to available to pregnant women via the Caboolture hospital antenatal clinic has further details of how to use the Five A's approach to discuss smoking, physical activity and nutrition with your pregnant patients.
CABOOLTURE mums and little ones also has many other features and services available to women in Caboolture - check out the activities and services section of this site for other strategies or opportunities you can refer women to for further assistance.
The Five A’s of Behaviour Change – a framework for health professionals to support patients through health behaviour change
Behavioural counselling interventions in clinical settings are an important means of addressing health-related behaviours. The Five A’s counselling approach evolved from the U.S National Cancer Institutes four A’s construct (ask, advise, assist, arrange), to guide physician counselling about smoking cessation (Glynn and Manley, 1989).
The Five A’s approach emphasises a collaborative approach to setting goals and monitoring behaviour change. It has been used effectively by health professionals to assist patients to change other health behaviours including, physical activity and diet. More information of the Five A's approach is provided below, including two examples of using it to counsel pregnant or postnatal women. It is as simple as taking an interest in the behavioural choices women make and advising them on the correct guidelines and opportunities available to them in their local area.
Using the Pregnancy Pocketbook to guide health behaviour change with the 5As
The Five A's approach involves 5 steps:
1. Assess
Ask about/assess behavioural health risk(s), beliefs and knowledge and the patient’s current situation. The purpose of this is to identify those in need of intervention for a given behaviour (public health focus) and to gather data needed to target the intervention.
Use the health behaviour screening questions in the ‘Your first antenatal visit’ section of the Pregnancy Pocketbook to assess your pateints current behaviour. This will helpyou to identify those who would benefit from a behaviour change intervention. Encourage each woman to complete this herself or assist her in its completion.
2. Advise
The main aim of this step is to motivate change through personalised advice, by providing clear, specific and personalised advice and information about health risks and the benefits of change.
Use the information provided in the Pregnancy Pocketbook about health behaviour recommendations. This should be adapted to current health status and behaviours of each woman.
Activities are contained within the ‘Your health goals’ section of the Pregnancy Pocketbook may help as they ask each woman identify current behaviours and to monitor changes in these behaviours. Some women may need guidance and support as they make these changes.
3. Agree
Collaboratively agree on treatment goal(s) based on the patient’s motivation and confidence about the behaviour change. This is an important step because patients who are actively involved in healthcare decisions have a greater sense of personal control, adherence and compliance, a key factor for successful behaviour change.
Activities in the Pregnancy Pocketbook can assist in goal setting.
4. Assist
Help the patient to achieve the set goals by identifying personal barriers, providing appropriate strategies/problem solving techniques and social/environmental support. These behaviour change techniques may be through counselling and/or self help and may need to include adjunctive medical treatments where appropriate.
5. Arrange
Specify a plan for follow up (e.g. in person, telephone, email etc.) to provide ongoing support to the patient and adjust the treatment plan as needed. This step is needed to evaluate the behaviour change plan, prevent relapses and support behaviour change maintenance.
Using the Pregnancy Pocketbook to support pregnant women to stop smoking
1. Assess
Use the smoking status screening questions in the ‘Your first antenatal visit’ section of the Pregnancy Pocketbook to assess your patient’s current smoking behaviour. This multi-choice format supports greater disclosure of current smoking behaviour.
What is her current quitting stage? ‘Not smoking’, ‘Ready’, ‘Unsure’, ‘Not ready’ or ‘Relapse’? Record her answers on the sheet provided, along with her partner’s smoking status and, if relevant, her average daily cigarettes smoked.
Assess your patient’s knowledge of general and pregnancy smoking risks. Assess her reasons for quitting. Congratulate her if she’s an ex-smoker or has never smoked.
2. Advise
If your patient does smoke, direct her to the Fresh Start™ to stop smoking program in the Pregnancy Pocketbook. Information is contained within the Pregnancy Pocketbook is evidence-based and supports the process of smoking cessation.
Use this information to advise your patient of the antenatal, postnatal, and long-term maternal risks of continued smoking. Advise your patient to stop smoking. Personalise the risk factors and discuss and address barriers.
The activities contained within the Fresh Start™ section will allow your patient to identify her current behaviours and to monitor changes in these behaviours. ‘The FIRST day’ and ‘The next few days’ sections provide structure and guidance through your patient’s initial stages of smoking cessation.
Discuss her quitting concerns. Encourage major reductions in cigarettes smoked (at least 50%).
3. Agree
Collaboratively identify a day for your patient to stop smoking. Following the ‘first day’/’next few days’ sections is a contract page. You can both sign and date this page to strengthen your patient’s decision to stop smoking. Your patient may also like to fill out the next page with her partner or support person.
4. Assist
Encourage your patient to revisit the activities on ‘the next few days’ pages of the Pregnancy Pocketbook and the 5Ds page (behavioural tips) in the weeks following her decision to stop smoking.
Research shows that continuing to ask your patient about her smoking progress over subsequent visits assists behaviour change and is appreciated by patients.
5. Arrange
Encourage your patient to call the quitline if you think she needs extra support with quitting smoking. She may also benefit from a referral to a specialist health care worker, for example, a counsellor or psychologist.
Using the Pregnancy Pocketbook to encourage pregnant women to eat better
1. Assess
Use the health behaviour screening questions in the ‘Your first antenatal visit’ section of the Pregnancy Pocketbook to assess your patient’s fruit and vegetable intake. Encourage your patient to complete this herself or assist her, if necessary.
‘Serve’ equivalents are outlined below the screening questions, or refer to the information on the ‘fruit and vegetable planner page’.
2. Advise
If your patient does not meet the ‘Go for 4 fruit & 5 vegetables’ during pregnancy guideline, refer her to the ‘Healthy Nutrition’ section within ‘Your health goals’.
Information is contained within this section of the Pregnancy Pocketbook relevant to a healthy diet during pregnancy, including increasing fruit and vegetable intake.
3. Agree
Collaboratively set a goal with your patient about fruit and vegetable intake - use the activities on the pages following the ‘fruit and vegetable planner’.
4. Assist
Encourage your patient to monitor her fruit and/or vegetable intake with the ‘fruit and vegetable planner’ at an agreed timeframe. Encourage and/or assist your patient to review her goals regularly, setting new goals once she’s met her old ones.
Refer your patient to the 'CABOOLTURE mums and little ones' website for further information on healthy eating during pregnancy.
5. Arrange
Refer your patient to a dietitian if you identify that she requires extra support in her behaviour change through the screening process or the self-monitoring process.
Using the Pregnancy Pocketbook to assist pregnant women to meet physical activity guidelines
1. Assess
Use the health behaviour screening questions in the ‘Your first antenatal visit’ section of the Pregnancy Pocketbook to assess whether your patient:
- does 30 minutes or more of physical activity on most, if not all, days, and
- whether she would like to be more active.
2. Advise
Use the table below the questions to guide the advice and support you provide to pregnant women about physical activity during pregnancy. Using your patient’s response to the above questions, identify the appropriate advice they require.
Encourage your patient to read the ‘Being Active’ section in the Pregnancy Pocketbook.
Activities are contained within the ‘Your health goals’ (‘Being Active’) that will help your patient identify her current physical activity level and to monitor changes in her behaviours. Some women may need guidance and support as they make these changes.
Refer your patient to the 'CABOOLTURE mums and little ones' website for further information on how to fit activty into her day.
3. Agree
Collaboratively set a goal with your patient about her physical activity levels. Base this on what she is doing now and what she likes to do. Be sure to include the planning of rewards, to reinforce the successful changes she does make.
4. Assist
Activities are contained within the ‘Your health goals’ (‘Being Active’) that will help your patient to monitor changes in her behaviours. Some women may need guidance and support as they make these changes.
5. Arrange
Refer your patient to an exercise physiologist or a physiotherapist if you identify that she requires extra support in her behaviour change through the screening process or the self-monitoring process.
References
Glynn, T. and M. Manley (1989). How to help your patients stop smoking: a manual for physicians. Bethesda, MD, National Cancer Institute.
Whitlock, E. P., T. Orleans, et al. (2002). "Evaluating Primary Care Behavioural Counselling Interventions." American Journal of Preventative Medicine 22(4): 267-284.