Brief interventions

Every time a person is at the clinic, talk with them about issues or concerns they have about healthy lifestyle, or other health business. These short chances (as little as a couple of minutes) are ‘brief interventions’

Brief interventions work — people are more likely to consider changing if health care workers talk with them about their issues and concerns
Talk about any behaviour (good or bad) that affects health

Eating well, being more active
Drug use (eg smoking, marijuana, alcohol)
Looking after a chronic disease
Home problems (eg family violence)

Person needs to want to change before any steps will be taken. You can’t force people to change but you can raise awareness, share information, get person thinking about making changes, and support good choices and attempts to change
The type of brief intervention provided depends on how ready person is to change
Have printed material to support what you talked about — they may look at this at home
If problem is severe — probably need more than a brief intervention, may need specialist services (eg counselling)

Communicating with clients

The way that practitioners communicate with their clients is an important part of brief interventions and helping people change behaviour

Try to gain the person’s trust and establish a relationship. Particularly important when working with pregnant women as this is a very sensitive time
Conversational approach is best as lecturing and telling people what to do will not help to get the message across
Important not to judge person — makes it harder to talk with them

Stages of change

Determining stage of change

There are 4 steps to use when doing a brief intervention about any issue

Step 1 — Raise issue you want to talk about
Step 2 — Ask if they have thought about changing
Step 3 — Decide on their stage of change based on what they tell you in step 2 — Table 11.2 — do brief intervention to suit. Record in file notes — stage of change and advice given
Step 4 — Next time you see them, ask how they are doing. Reinforce positive changes, do another brief intervention if you think stage of change different

Relapse

Going back to previous behaviour (relapse) is common
Help person not to be down on themself, not to see this as a big failure
Encourage person to learn from setback and get back to positive behaviour again

Table 11.2 Stages of change and brief interventions to suit — using alcohol as example

Stage of change	Type of brief intervention
Not ready to change OR Not worried	Strategies to try I won’t hassle you, but if you want to talk about it, I’m here Can we talk about making sure you’re safe when you drink
Thinking about changing	Strategies to try Talk with person about What they see as good things about drinking What they see as ‘not so good’ things about drinking What happens when they drink, when they don’t drink While they think about it some more, maybe they could try cutting down a bit, or drinking light beer
Ready to change OR Doing it	Strategies to try So you’ve decided to give up/cut down on alcohol (grog) — can we talk about your ideas Reinforce small steps Talk about choices, support available Promote local groups (eg quit smoking, walking, exercise) Help develop a plan. Find out about concerns, give information and any support you can Invite them to come back
Sticking to it	Strategies to try Ask how they are going. Check file notes for earlier discussions and activities Find out what is going well How are they avoiding triggers Talk about benefits of change — congratulate Offer support, invite them back

FRAMES

FRAMES is a set of 6 elements shown to make brief interventions more effective. FRAMES provides a useful checklist for planning how to do brief interventions better. The elements are

Feedback — provide assessment results to person in positive way
Responsibility — talk about person’s responsibility for making changes
Advice — give clear relevant advice about reducing harm, improving health and wellbeing
Menu — work with person to create range of alternatives, options
Empathy — use empathy as a counselling style
Support self-efficacy — encourage person to be optimistic, and to believe that they can change

Other important ways of supporting change

Goal setting — need to set realistic goals for changing problem behaviour
Follow-up — reinforce behaviour change, make sure strategies are appropriate
Timing — very important. Motivation is there when person thinking about change. People make changes when time is right for them

5As approach — Ask, Assess, Advise, Assist, Arrange

Table 11.3 5As approach — using smoking as example

Ask	About smoking If smokes or ever smoked — ask how many, how long If ex-smoker — when they stopped If smoker — ask about quitting Tried to stop, want to stop, quitting now, thinking about it, previous attempts Check file notes to see what has been talked about or happened recently so you know what to ask. Record what you ask, are told, offer them materials. If non-smoker — remind them about passive smoking and the need to keep smoke away from children, adults and pregnant women
Assess	Readiness to quit. See Stages of change — Table 11.2 Level of nicotine dependence Ask How long after waking do you have your first cigarette How many cigarettes do you smoke a day If tried to quit — did you have cravings or withdrawal symptoms Smoking within 30 minutes of waking, smoking more than 10 cigarettes a day, history of withdrawal symptoms in previous quit attempts are all markers of nicotine dependence If first cigarette less than 30 minutes after waking — moderate to high dependence If first cigarette 30 minutes or more after waking — low to moderate dependence
Advise	Give advice in a positive way to all people who smoke "Stopping smoking is the most important thing you can do to protect your health now and in the future — I know it’s hard to quit, but if you want to, I can help" Give advice that means something to person — talk about how it makes their health problems worse, how it affects their children Use additional information such as flip charts, pamphlets, other written or pictorial materials Let person know that giving up smoking may cause cravings or nicotine withdrawal symptoms — but that these usually stop in a couple of weeks Symptoms can include feeling anxious, edgy, restless, down, hungry, trouble concentrating or sleeping Tell them to drink more water as it helps to lessen withdrawal symptoms Talk about what symptoms they had last time and then brainstorm ways to address these if they happen again *Remember:* People often try to quit a few times before stopping for good.
Assist	Offer support and treatment based on readiness to quit and level of nicotine dependence Offer all people trying to quit Quit plan Counselling and support (eg Quitline) If dependent — also offer medicine to help quit Nicotine replacement therapy (NRT) Urge reduction medicines (eg varenicline)
Arrange follow-up	Congratulate and be positive about decision to quit, remind them of good things about not smoking Review progress, problems, medicine use, and encourage to them continue to be smoke free Talk about strategies to deal with situations where there would be pressure to smoke If they do have a cigarette, don’t treat it as a failure. Talk about reasons and what they can learn from it. Encourage them to keep trying

Getting messages across in other ways

Display information about healthy lifestyles in clinic. Try to use local language in displays
Keep and display useful phone numbers and/or addresses for people to find help for themselves
Consider clinic policies that promote healthy lifestyle — smoke-free areas, dog-free clinics
Consider example you set for people you work with and in community