Strategies for Behavior Change in Patients With Heart Failure

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Strategies for Behavior Change in Patients With Heart Failure
Sara Paul and Nancee V. Sneed
Am J Crit Care 2004;13:305-313
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STRATEGIES FOR BEHAVIOR CHANGE IN PATIENTS WITH HEART FAILURE
By Sara Paul, RN, MSN, FNP, and Nancee V. Sneed, RN, PhD, ANP. From the Heart Function Clinic, Hickory Cardiology Associates, Hickory, NC (SP) and the College of Nursing, Heart Failure Clinic, Medical University of South Carolina, Charleston, SC (NVS). Appropriate management of chronic heart failure and its signs and symptoms requires a considerable amount of participation by patients. Behavioral changes that prevent or minimize signs and symptoms and disease progression are just as important as the medications prescribed to treat the heart failure. The most dif?cult lifestyle changes include smoking cessation, weight loss, and restriction of dietary sodium. The Transtheoretical Model is a framework for assessing and addressing the concept of readiness for behavior change, which occurs in a 6-step process. The model consists of 3 dimensions: the stages of change, the processes of change on which interventions are based, and the action criteria for actual behavior. The stages of change are discussed, and interventions are presented to assist patients with heart failure in progressing through those stages toward maintenance of changed lifestyle behaviors. Methods for measuring the level of readiness for change of patients with heart failure are also presented, because correct staging is required before appropriate interventions matched to a patient’s stage can be delivered. (American Journal of Critical Care. 2004;13:305-313)

hronic heart failure is a significant health problem in the United States; 5 million patients are affected, and 550 000 new cases are diagnosed each year.1 Appropriate management of the disease and its signs and symptoms requires a considerable amount of participation by patients. Unfortunately, heart failure remains a terminal illness in which patients’ conditions decline progressively. Medications for treating heart failure such as angiotensin-converting enzyme inhibitors and β-blockers have improved the mortality and morbidity statistics for the disease in recent years. Although important, medications for heart failure constitute only half of the treatment program. Behavioral changes that prevent or minimize the signs and symptoms and progression of the disease are just as important as the medications that are prescribed. Nurses spend considerable time educating and counseling patients with heart failure so that the patients have the knowledge and tools to prevent signs and symptoms and manage the disease. Although this
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education typically addresses the lifestyle changes necessary to control signs and symptoms and to improve outcomes, failure of patients with decompensated heart failure to adhere to recommendations remains a frequent reason for hospital readmission.2-5 Despite interventions, many patients may not be ready to learn how to manage the illness, and consequently they do not make the necessary changes in health behaviors. The behavioral changes recommended for patients with heart failure are numerous (Table 1). Simply making one of these lifestyle changes is dif?cult, but healthcare providers expect patients with heart failure to value the treatment of the disease enough to make permanent changes. Usually, patients receive 1 or 2 teaching sessions in which they learn of these changes, and then they are expected to incorporate all of these changes into their behavior patterns from that day forward. However, as any healthcare provider will attest, this sequence of events is not what usually happens. The most dif?cult lifestyle changes include smoking cessation, weight loss, and restriction of dietary sodium. Additionally, ?nancial constraints may make it difficult for some patients to fill prescriptions regularly, preventing the patients from receiving the full
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Table 1 Lifestyle changes recommended for patients with heart failure
Reduce sodium in diet, ranging from 2000 to 4000 mg/d Restrict fluid intake (<2 L [<64 fl oz] daily) Get regular aerobic exercise Allow for periods of rest during the day between activities Monitor weight daily Quit smoking Lose weight if appropriate Eliminate alcohol and cigarettes Reduce fat and cholesterol in diet if coronary disease is present Report signs and symptoms of weight gain or worsening heart failure immediately

benefit of pharmacological therapy. Determining if a patient is compliant regarding smoking cessation and weight loss is relatively easy; however, conclusively determining whether a patient has eaten high-sodium foods or has taken his or her medications appropriately is almost impossible. Smoking cessation and weight loss are not only measurable but also relatively “black or white.” A person either smokes or does not smoke, and a person is either overweight or within normal weight parameters. The intake of sodium in the diet is not so clear. Sodium intake is a continuum; a person can consume as much or as little sodium as possible, ranging from zero sodium intake to enormous sodium intake of thousands of milligrams per day. Comprehending this concept and understanding how to remain at the low end of the sodium intake continuum is often difficult for patients initially. Implementing behavioral change in patients with heart failure is a challenging task. Traditional strategies such as educational classes, videos, and written instructions present the information to all patients in the same manner regardless of each patient’s readiness to make lifestyle changes. Some patients are more prepared than others to hear the information and make the necessary changes. For that reason, evaluating models that individualize the instructional program for lifestyle changes is important.

The Transtheoretical Model of Behavior Change
In the early 1980s, James O. Prochaska and his associates first proposed the Transtheoretical Model (TTM) as a framework for assessing and addressing the concept of readiness for changes in behavior.6-8 This framework has been the basis of their research for more than 2 decades. On the basis of data from studies of persons who did not change high-risk health behaviors, Prochaska and Velicer8 proposed a general rule of thumb: 40% of persons with at-risk behaviors
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are in a stage of change marked by resistance and denial and have no intention of changing the behavior. Another 40% have thought about changing some time in the next 6 months, and only 20% are actually preparing to make serious change. Clearly, action-oriented interventions, such as education programs that stress strategies for behavior change, do not match the needs of at-risk persons who do not believe change is needed. The TTM is based on a set of critical assumptions about the nature of behavior and the interventions that can best facilitate change, including the following: ? No single theory can account for all the complexities of behavior change. ? Behavior change is a process that unfolds over time and occurs in stages. ? Without planned interventions, populations with high-risk behavior remain stuck in early stages marked by no movement toward change. ? Speci?c processes and principles of change should be applied at speci?c stages. ? Chronic behavioral patterns are under some combination of biological and social in?uence and self-control. Interventions designed within the TTM are targeted to enhance self-control.8 The TTM has been applied to a broad range of behaviors and a wide variety of populations, but it has been used to assess behavior change in patients with heart failure in only a single study.9 The TTM consists of 3 dimensions: 1. the various stages of change, which is the central organizing construct and temporal variable of the model, 2. the processes of change on which interventions are based, and 3. the action criteria for actual behavior (the dependent dimension or outcome). Decisional balance (pros and cons of changing) and self-efficacy (situation-specific confidence that change can be maintained without relapse) and temptation vary in predictable ways throughout the stages of change. The TTM emerged from an analysis of the leading theories of psychotherapy and behavior change (thus the name Transtheoretical Model), and many components of this model were adapted from such theories as freudian, skinnerian, and rogerian traditions.8
The Stages of Change

In the TTM, behavior change is viewed as a 6-stage process that may progress in a linear fashion but most often progresses in a spiral pattern that includes relapse to prior stages, recycling through the stages, and learning from mistakes before changed behavior becomes stable. The stages of change within the TTM are as follows: 1. Precontemplation: The person is perhaps unaware or underaware that a problem exists and has no inten-

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Table 2 De?nitions of the processes of change8,12,13
Process Experiential Consciousness raising Explanation

Increased awareness of causes, consequences, and cures for a problem; increasing information about self and the unhealthy behavior Experiencing and releasing feelings about the possible consequences of the behavior; using feelings to help motivate change Cognitive and affective assessments of one’s self-image with and without the behavior in order to change how one thinks about oneself in relation to the behavior Cognitive and affective assessments of how the presence or absence of the behavior affects one’s social environment; becoming aware that one can serve as a positive or negative role model to others Recognizing changes in the environment or social changes that influence personal change

Dramatic relief

Self-reevaluation

Environmental reevaluation

Social liberation Behavioral Self-liberation

Recognizing choices related to available actions and making a commitment to change a behavior Seeking and accepting support from others in the form of caring, trust, acceptance, and openness Applying consequences in the form of rewards to oneself for making change Learning new and healthier alternative behaviors to substitute for the unhealthy behavior Avoiding or removing environmental cues for unhealthy behavior and adding cues for healthier alternatives

Helping relationship

Reinforcement management Counterconditioning Stimulus control

tion of taking action in the foreseeable future (usually measured as the next 6 months). 2. Contemplation: The person is aware that a problem exists in relation to a behavior, has thought about changing, and intends to change at some time in the future, usually within the next 6 months. 3. Preparation: The person has taken some preliminary steps toward change and intends to change in the immediate future (usually measured as the next 30 days). 4. Action: The person has made a speci?c, overt modi?cation in lifestyle within the past 6 months. 5. Maintenance: The person has worked for more than 6 months to prevent relapse and to be less tempted and more con?dent that change can persist.7 6. Termination: The person has no temptation and 100% self-ef?cacy. During the termination phase, regardless of whether they are depressed, bored, anxious, lonely, angry, or highly stressed, persons are sure they will not give in to the temptation to return to their old unhealthy habit.8 Snow et al10 found that only 20% of former smokers and alcoholics ever reached this stage. For the majority, termination may not be a practical reality, and a more realistic goal for dealing with most unhealthy behaviors may be a lifetime of maintenance.8 Termination is

not typically assessed for purposes of research or clinical applications. These stages of change suggest that before overt action is taken to change an unhealthy behavior, persons must successfully pass through 3 stages in which they continue the behavior. During these stages, the concept of decisional balance generally has the cons of making the change outnumbering the pros. Before progressing to action, the pros and cons must cross over, and when the pros outweigh the cons, it is a sign that a person is prepared for action. In the TTM, progress from precontemplation to action is accompanied by the pros of change increasing twice as much as the cons decrease. This assertion suggests that perhaps twice as much emphasis should be placed on raising bene?ts of change as on reducing the costs or barriers.8
The Process of Change

Any activity that a person initiates to help modify thinking, feeling, or behavior is a change process. How can healthcare providers promote lifestyle changes in such a way that patients will adhere to the changes? The primary determinants of behavior and behavior change have been enumerated by Fishbein et al11 as follows:
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Table 3 Stages of change in which particular change processes are most useful
Precontemplation Contemplation Preparation Action Maintenance

Consciousness-raising Dramatic relief Environmental reevaluation Self-reevaluation Self-liberation Counterconditioning Stimulus control Reinforcement management Helping relationships

? Intention: Does the patient have a commitment to perform the behavior? ? Environmental constraints: What external conditions could facilitate or be a barrier to the behavior (eg, economics, insurance carrier, caregiver issues, social isolation, living with a smoker)? ? Ability: Does the patient have the necessary capabilities to make permanent change (depression, elderly, frail, homebound)? ? Anticipated outcome: Do the pros for performing the behavior outweigh the cons? Does the patient feel bad enough to want to change? ? Norms: What are the social pressures to perform the behaviors (eg, repeated hospitalizations, impact on the family)? ? Self-standards: Is the new behavior consistent with the patient’s self-image (eg, men who are forced to take on dependent roles or are no longer working)? ? Emotion: Does the patient have a positive reaction to performing the behavior? Is the patient emotionally invested in making the behavior change? ? Self-ef?cacy: Does the patient perceive that he or she is capable of performing the behavior? Ten distinct processes of change (Table 2) have been identi?ed: these are the covert and overt activities that people use to progress through the stages of change, speci?cally, how people change.12,13 The assumption of the TTM is that this common set of change processes can be applied across a broad range of behaviors, and that each process needs to be emphasized at different stages of change.8 Table 3 illustrates how these processes may occur. These processes are a guide for interventions to assist patients in progressing in readiness for behavioral change, and the processes encompass a variety of techniques and methods. The amount of progress a person makes after an intervention tends to be a function of the stage of change before treatment.6 Consequently, it is important to measure a patient’s stage of readiness
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to change before implementing appropriate stagebased interventions for lifestyle changes. Prochaska et al6 found that persons who were in the preparation and action stages were more successful in making permanent change than were persons in the precontemplation or contemplation stage. If a patient progresses through just a single stage in the ?rst month of treatment, his or her chances of taking action double during the initial 6 months of the program.6 The processes of change result in modi?cations of behavior and support the transition from stage to stage. These processes can be divided into 5 experiential processes that are internally focused on emotions, values, and cognitions and 5 behavioral processes that are focused on behavioral changes. Experiential processes include consciousness-raising, dramatic relief, environmental reevaluation, social liberation, and self-reevaluation. Behavioral processes include counterconditioning, helping relationships, reinforcement management, stimulus control, and self-liberation. These processes are primarily used in the action and maintenance stages and are de?ned in Table 2.
Measurement: Determining a Patient’s Stage of Change

Correct staging is required before appropriate interventions matched to a patient’s stage can be delivered. Reed et al14 suggest that a good staging algorithm should include a clear de?nition of the behavior to be changed and a 5-choice response format that includes the operational definitions of each of the stages. For example, they recommend that the de?nition of exercise include the frequency, duration, and intensity of exercise, taking into account the capabilities of the population of patients. Definitions and a consistent response format to determine stage of change for each of the behaviors that may require change in patients with heart failure are suggested in Table 4.

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Clinicians should be aware that a patient’s perception of his or her stage of readiness may not always match the patient’s actual behavior. One of the most dif?cult and arguably the most important behaviors requiring change in many patients with heart failure is the reduction of sodium in the diet. Povey et al15 suggest some fundamental problems with using the TTM for dietary behaviors. They note that generally a discrepancy exists between objective assessment of diet and self-rated, subjective dietary intake. Further, for more general, widely interpreted dietary behaviors such as “eating healthy,” patients are less likely to perceive accurately whether they are actively engaging in the behavior than they are for more speci?c behaviors such as eating 5 fruits and vegetables a day. This discrepancy may result in a mismatch between perceived and actual diet and thus lead to overrepresentation of patients in the action and maintenance stages. Low-sodium diets can be widely interpreted by patients. In a sample of patients with heart failure, Sneed and Paul9 noted a discrepancy between objective assessment of sodium intake and self-rated assessment of consistently avoiding salty foods. These findings suggest that use of the TTM to stage patients with heart failure in relation to adherence to low-sodium diets may be a problem, and determining actual intake of salty foods may be necessary to stage patients accurately. Actual intake can be determined in several ways: 24-hour dietary recall, assessment of a food diary recorded for up to a week before a clinic visit, or use of a food checklist that patients could fill out while in the waiting room. To create such a list, consult a nutrition book to ?nd the highest sodium foods typically eaten by that group of patients and ask patients to respond yes or no to whether they have eaten any of the foods on the list in the last 24 hours. If they report themselves to be in the action or maintenance stages and have eaten high-sodium foods in the past 24 hours, they should be restaged according to their actual behavior into the preparation, contemplation, or even the precontemplation stage (if they appear to be unaware of their risky behavior). It may be better to view patients who eat high-sodium foods or add salt to their food but see themselves in the maintenance stage as a separate group and design interventions for them accordingly.15 Actual behavior may have to be assessed for other behaviors as well. For example, actual exercise behavior may have to be assessed by using such things as an activity log or journal, a pedometer, or a list of examples of common behaviors that exceed the action criterion and behaviors that do not. Keep in mind, however, that these, as well as all self-reported measures of behavior, are subject to social desirability bias.

Table 4 Questions about stage of change and response options
Questions with definitions Do you exercise 3 times a week for at least 20 minutes each time? Exercise includes brisk walking, riding a stationary bicycle, swimming, or other exercise of similar intensity advised for you. Activities that are primarily sedentary, such as bowling or playing golf with a cart, would not be considered exercise. Do you drink 2 L (2 qt) or less of fluid a day (water, sodas, coffee, tea, juice)? Have you eliminated high-sodium (salty) foods from your diet? High-sodium foods include canned vegetables; processed foods such as deli meat, prepared gravy and sauces, frozen dinners; “fast food” (such as pizza, fried chicken, burgers, french fries), and snacks (such as potato chips, corn chips, salted nuts). Foods also become high in sodium when salt is added to them during cooking or at the table. If applicable: Have you quit smoking cigarettes (or other tobacco products)? Have you quit drinking alcohol (beer, wine, liquor)? Have you been trying to lose weight by dieting (eating fewer foods, smaller portions, or less fattening foods)? Response options14 Maintenance: Action: Preparation: Yes, I have been for more than 6 months. Yes, I have been for less than 6 months. No, but I am planning to start in the next 30 days. No, but I am planning to start in the next 6 months.

Contemplation:

Precontemplation: No, and I don’t plan to start in the next 6 months.

All patients may not need to lose weight, and this need can be determined by calculating the body mass index of each patient and then staging those patients who have an index greater than 25. Efforts at trying to lose weight can be accomplished by exercise, dieting, or both. Because exercise is important for patients with heart failure, independent of their need to lose weight, staging can be determined by evaluating dietary interventions. If patients report that they are in the action or the maintenance stage, yet show no downward trend in their weight or body mass index, there may be a mismatch between reported effort and actual
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Table 5 Educational plan based on level of readiness to change
LEVEL: Precontemplation – Having no intention of changing behaviors related to heart failure in the next 6 months Process of change Consciousness-raising Encourage patients to increase their level of awareness, seek new information, and gain understanding and feedback Have educational pamphlets readily available for patients to pick up and read Give a list of Internet sites with information on heart failure Encourage questions Invite patients to attend a heart failure support group Have patients describe heart failure in their own words Share information from investigational studies of heart failure, especially findings about quality of life Activity

鼓励病人增加意识水*,寻求新的信息, 获得理解和反馈

Dramatic relief Ask patients to consider ways in which heart failure affects the way they feel Have patients recall how they felt before they had heart failure versus how they are feeling now Have patients in the maintenance stage give testimonials 询问病人考虑心衰对他的感觉的影响 during a group session about how lifestyle changes have improved how they feel Environmental reevaluation Encourage patients to consider and assess how their heart failure affects the physical and social environment Have family members share their thoughts about the patient’s illness Have family members share experiences and emotions related to exacerbations of heart failure and hospitalizations Ask patients to describe physical and social changes in their life since their heart failure developed

鼓励病人考虑和评估 心衰是如何影响其身体和社会环境的

LEVEL: Contemplation – Seriously considering the need to change lifestyle behaviors, but having no plan to do so in the next month Process of change Consciousness-raising Encourage patients to increase their level of awareness, seek new information, and gain understanding and feedback Give patients pamphlets about heart failure to take home Provide a video about heart failure Give a list of Internet sites with information on heart failure Encourage questions Invite patients to attend a heart failure support group Have patients describe heart failure in their own words Activity

Dramatic relief Ask patients to consider ways in which heart failure affects the way they feel Have patients attend a support group with members giving testimonials about improvement in the way the members feel after making lifestyle changes Have patients express their feelings at a support group Have patients role-play situations in which they need to make choices between healthy and unhealthy lifestyle changes (eg, ordering low-sodium foods from a restaurant menu) Use psychodrama to role-play what body parts feel with heart failure (eg, what would swollen feet say if they could talk?) Have patients visualize the release of neurohormones rampant in their body if no lifestyle changes are made

Environmental reevaluation Encourage patients to consider and assess how heart failure affects their physical and social environment Have patients and family members reverse role-play an episode of exacerbation of the heart failure Have patients describe changes they have made in their physical environment since their heart failure developed Discuss patients’ personal cost of treating heart failure

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Table 5 continued
Self-reevaluation Encourage patients to assess how they feel and think about themselves with respect to heart failure and the need to exercise or decrease sodium intake Have patients describe the changes in their lives since heart failure developed (eg, activity level, hobbies, travel) Have patients ?ll out a questionnaire on the quality of life and review the results with them Have patients visualize what life would be like without signs and symptoms of heart failure Review patients’ diet records and point out inconsistencies between values and behaviors

LEVEL: Preparation – Planning to change behaviors related to heart failure in the next month Process of change Self-reevaluation Encourage patients to assess how they feel and think about themselves with respect to having signs and symptoms of heart failure Have patients write down 2 or 3 thoughts or beliefs about their heart failure; identify any items that are incorrect or inaccurate, and review corrected information with patients Help patients plan activities for after lifestyle is changed (eg, exercise plan, dietary choices to replace sodium, use of lowsodium recipes) Activity

Self-liberation Encourage patients to believe in their ability to change and make the choice and commitment to act on that belief Complete a written contract between nurse and patient about new behaviors Explain importance of self-care in managing heart failure Teach patients to read “Nutrition Facts” labels Have patients speak with a patient who is in the maintenance stage about the effects of the changes on quality of life Encourage patients to purchase equipment needed for lifestyle changes (eg, comfortable walking shoes)

Stimulus control Encourage patients to identify cues to remind them to increase positive behavior Have patients remove items from their home that are temptations and potentially harmful (eg, salt, cigarettes, alcohol, high-fat foods) Have patients purchase a low-sodium cookbook Have patients place the bathroom scale next to the commode for daily measurement of weight Have patients place their medication schedule on the refrigerator door Have patients keep 2-L bottle of water in the kitchen and pour out an equivalent amount of water whenever drinking another liquid Provide patients with 1-week pillbox Help patients develop a shopping list of healthy snacks to keep in the house

LEVEL: Action – Engaged in changing behaviors related to heart failure for less than 6 months Process of change Self-liberation Encourage patients to believe in their ability to change and make the choice and commitment to act on that belief Update the contract between the nurse and the patient Have patients record weight, blood pressure, and heart rate daily Allow patients to self-adjust amount of diuretic as needed Have patients keep a diet and activity journal Activity

Counterconditioning Encourage patients to substitute healthier alternatives in conditions that normally elicit signs and symptoms of heart failure Have patients identify situations that increase noncompliance and suggest substitute activities Review information on low-sodium diet; share low-sodium recipes; give a list of low-sodium cookbooks Develop an exercise plan with patients or have patients join cardiac rehabilitation or ?tness center Help patients identify low-fat and low-cholesterol foods; share heart healthy recipes; give a list of low-fat cookbooks

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Table 5 continued
Stimulus control Encourage patients to identify cues to remind them to increase positive behavior Have patients remove items from their home that are temptations and potentially harmful (eg, salt, cigarettes, alcohol, high-fat foods) Have patients purchase a low-sodium cookbook Have patients place the bathroom scale next to the commode for daily measurement of weight Have patients place their medication schedule on the refrigerator door Have patients keep 2-L bottle of water in the kitchen and pour out an equivalent amount of water whenever drinking another liquid Encourage patients to avoid entering restaurants that serve high-sodium food (eg, McDonald’s, Taco Bell, any Chinese restaurant) Have patients post their daily exercise plan on the refrigerator

Reinforcement management Encourage patients to acknowledge and reward positive behavior changes Help patients identify specific rewards such as a new dress after losing 4.5 kg (10 lb) or a nice dinner out after 2 weeks of carefully following a low-sodium diet Encourage patients to take a vacation out of town

Helping relationships Encourage patients to use support system of family, friends, and clinic healthcare providers Help patients identify at least 1 person who is committed to helping them change and get support from that person Get patients involved in a support group Encourage patients to join Weight Watchers, cardiac rehabilitation, and so forth

LEVEL: Maintenance – Actively engaged in changing behaviors related to heart failure for past 6 months Process of change Counterconditioning Encourage patients to substitute healthier alternatives in conditions that normally elicit signs and symptoms of heart failure Have patients identify situations that increase noncompliance and suggest substitute activities Share low-sodium recipes with patients; give patients a list of low-sodium cookbooks Develop an exercise plan with patients or have them join a cardiac rehabilitation or fitness center Share heart healthy recipes with patients; give patients a list of low-fat cookbooks Activity

Stimulus control Encourage patients to identify cues to remind them to increase positive behavior Have patients remove items from their homes that are temptations and potentially harmful (eg, salt, cigarettes, alcohol, high-fat foods) Have patients purchase a low-sodium cookbook Have patients place the bathroom scale next to the commode for daily measurement of weight Have patients place their medication schedule on the refrigerator door Identify foods to order that are within the patients’ dietary guidelines when they eat out at restaurants Have patients repeat quality-of-life questionnaire and compare responses with previous results

Reinforcement management Encourage patients to acknowledge and reward positive behavior changes Help patients identify specific rewards, such as a new dress after losing 4.5 kg (10 lb) or a nice dinner out after 2 weeks of carefully following a low-sodium diet Encourage patients to take a vacation out of town

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Table 5 continued
Helping relationships Encourage patients to use support system of family, friends, and clinic healthcare providers Help patients identify at least 1 person who is committed to helping them change and get support from that person Get patients involved in heart failure support group Ask patients to speak with other patients with heart failure who are at lower levels of readiness to change Get patients involved in local American Heart Association activities

behavior. As with sodium, use of 24-hour dietary recall, 3-day food diaries, or food checklists may help determine the problem. Portion size, as well as content of the diet, should be assessed.
Application of the TTM to Patients With Heart Failure

so, however, requires validation by research trials involving patients with heart failure before the model can be applied in clinical practice. With the appropriate activities to meet the patient’s stage of readiness for change, healthcare providers may facilitate a patient’s movement along the continuum of change to alter lifestyle behaviors that can affect the disease.
REFERENCES 1. American Heart Association. 2001 Heart and Stroke Statistical Update. Dallas, Tex: American Heart Association; 2000. 2. Ghali JK, Kadakia S, Cooper R, Ferlinz J. Precipitating factors leading to decompensation of heart failure: traits among urban blacks. Arch Intern Med. 1998;148:2013-2016. 3. Opasich C, Febo O, Riccardi G, et al. Concomitant factors of decompensation in chronic heart failure. Am J Cardiol. 1996;78:354-357. 4. Monane M, Bohn RL, Gurwitz JH, Glynn RJ, Avorn J. Noncompliance with congestive heart failure therapy in the elderly. Arch Intern Med. 1994;154:433-437. 5. Rich MW, Gray DB, Beckham V, Wittenberg C, Luther P. Effect of a multidisciplinary intervention on medication compliance in elderly patients with congestive heart failure. Am J Med. 1996;101:270-276. 6. Prochaska JO, DiClemente CC, Norcross JC. In search of how people change: applications to addictive behaviors. Am Psychol. 1992;47:1102-1114. 7. Prochaska JO, Norcross JC, DiClemente CC. Changing for Good: A Revolutionary Six-Stage Program for Overcoming Bad Habits and Moving Your Life Positively Forward. New York, NY: Avon Books Inc; 1994. 8. Prochaska JO, Velicer WF. The transtheoretical model of health behavior change. Am J Health Promot. 1997;12:38-48. 9. Sneed NV, Paul SC. Readiness for behavior change in heart failure. Am J Crit Care. 2003;12:444-453. 10. Snow MG, Prochaska JO, Rossi JS. Processes of change in Alcoholics Anonymous: maintenance factors in long-term sobriety. J Stud Alcohol. 1994; 55:362-371. 11. Fishbein M, Bandura A, Triandis H, et al. Factors In?uencing Behavior and Behavioral Change: Final Report of Theorist’s Workshop in AIDS-Related Behavior. Washington, DC: National Institute of Mental Health, NIH, October 3-5, 1991. 12. Greene GW, Rossi SR, Rossi JS, Velicer WF, Fava JL, Prochaska JO. Dietary applications of the stages of change model. J Am Diet Assoc. 1999;99:673-678. 13. Peipert JF, Ruggiero L. Use of the transtheoretical model for behavioral change in women’s health. Women’s Health Issues. 1998;8:304-309. 14. Reed GR, Velicer WF, Prochaska JO, Rossi JS, Marcus BH. What makes a good staging algorithm: examples from regular exercise. Am J Health Promot. 1997;12:57-66. 15. Povey R, Conner M, Sparks P, James R, Shepherd R. A critical examination of the application of the Transtheoretical Model’s stages of change to dietary behaviours. Health Educ Res. 1999;14:641-651.

As the understanding of the pathology of heart failure increases, it has become clear that excessive sodium intake is harmful. The effectiveness of medications such as diuretics and neurohormonal blocking agents is reduced if sodium intake is high; hence the importance of changing dietary patterns to include a low-sodium diet. Furthermore, exercise, weight loss, and smoking cessation are bene?cial in patients with heart failure. Yet how do we help patients incorporate the changes in their lives that will signi?cantly affect signs and symptoms and, indeed, the disease state? It is not realistic to expect patients to make changes that they are not prepared to make. A patient’s stage of readiness for change must be measured before a change program is implemented. Once the patient’s stage of readiness has been determined, appropriate strategies for applying the processes of change may be instituted. Table 5 presents a plan that offers speci?c activities for each of the processes of change to assist patients in moving through the stages of readiness for change.

Conclusion
Chronic heart failure remains a signi?cant health problem in the United States. Traditional methods of promoting behavioral lifestyle changes have been only marginally successful, as numerous studies on patients’ noncompliance have revealed. The application of the TTM to patients with heart failure offers an opportunity to improve patients’ compliance by individualizing the change process to meet the needs of each patient. Doing

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