Helen: Welcome to the 100^thepisode of Health Literacy Out Loud. In honor of this special occasion, we have new music to open and close this podcast series. It is my favorite song and so appropriate to health literacy. It is the old Shaker hymn “‘Tis the Gift to be Simple.”

I’m Helen Osborne, president of Health Literacy Consulting, founder of Health Literacy Month and your host of Health Literacy Out Loud. In these podcasts, you get to listen in on my conversations with those in the know about health literacy.

Today I’m talking with Drs. James (Jim) and Janice (Jan) Prochaska. Dr. Jim Prochaska is a clinical psychologist and one of the originators of the Transtheoretical Model of Behavior Change. He is founder of Pro-Change Behavior Systems, director of the Cancer Prevention Research Center, and professor of psychology at the University of Rhode Island.

Jim Prochaska is the author of hundreds of articles and many books, including the classic Changing for Good. Deservedly so, he has won numerous awards for his innovative work about behavior change for health promotion and disease prevention.

Dr. Jan Prochaska is one of the most published authors in the field of social work. As president and CEO of Pro-Change Behavior Systems, she leads a team of experts in health behavior and organizational change, applying the Stages of Change model to issues that include weight management, bullying prevention, and helping people be proactive about their health and healthcare.

Welcome to you both.

Dr. James Prochaska: It’s good to be with you.

Helen: I have been your fan for years, starting with my days as an occupational therapist working on a psychiatric unit. Now, in health literacy, I continue to see the relevance of behavior change as we work to improve health communication.

For our listeners who come from all backgrounds, can you put this into context? What is this Stages of Change behavioral model?

Dr. James Prochaska: The stage model begins with assessing what stage of change people are in. We have pre-contemplation, contemplation, preparation, action and maintenance. Then we can match our communications to where the patient or client is at to help them progress from one stage to the next.

Helen: Can you give us an example of that?

Dr. James Prochaska: Yes. In pre-contemplation stage, this is where folks are not intending to make significant changes in the foreseeable future. They’re often misunderstood as being noncompliant, resistant and unmotivated. In fact, we now know that one of the things we need to communicate to them is the benefit of regular exercise, for example.

That’s very different from somebody who has already taken action. There we want to encourage them to reinforce themselves, get support from others, and other processes that will help them move to long-term maintenance.

Helen: I love the example. As I learned about your work initially, it was a lot about smoking cessation, but also just those everyday behaviors we need to change.

If you never even though about doing this, you need a very different type of information than if you’ve been doing this for a while or thinking about doing it. Is that correct?

Dr. James Prochaska: Yes indeed. The health communications get tailored to the stage that the individual is in.

Helen: I’m curious. Since I have the luxury of talking to you for this podcast, how did this get started?

Dr. Janice Prochaska: It’s really fascinating how it all got started. Jim and some of his students were trying to understand how people change on their own. They went out and talked to people who had been smokers and had stopped smoking on their own. When they asked the smokers who had quit, “How did you do it and what were you doing?” they responded by saying, “It depends when.”

Helen: That was the crux of it? It depends?

Dr. James Prochaska: It depends on when we’re talking about, yes.

Dr. Janice Prochaska: They’d been teaching the Stages of Change to Jim and his graduate students.

Dr. James Prochaska: One of the reasons we’re convinced it has been important is because we were taught it by ordinary people who had found a way to get through stages. We would listen with the third ear, and we heard them talking about doing different things at different times in their quitting process.

Helen: There are two concepts you raised about listening and the real value of that. This behavioral model to me and so many people worldwide is a real underpinning of understanding human behavior. You took that from listening.

The other part that I gathered from your story is that it was ordinary people.

Dr. James Prochaska: Yes.

Dr. Janice Prochaska: What they taught us is that wherever they’re at, we can work with that if we listen and adapt our interventions to where they are at in their readiness to change.

Dr. James Prochaska: That’s very important because, historically, there was one model, the action model. Health professionals were basically stuck with communicating action messages such as, “You have to quit smoking, start exercising and change your diet.” Then they were so frustrated that the patients were seen as noncompliant, not motivated and not ready.

We discovered that it was us who were not ready for them and had not motivated our communications to match where they were at.

Helen: I’ve been doing this health literacy work for quite a while and I’m hearing the same issues. People aren’t following the information that we’re telling them. Why is that? I just got an email about that this morning.

Please correct me if I don’t have this right, but when I talk about this, I say that health literacy and good, clear communication will get us to one level because people need to know what to do. However, the way I consider it is that behavior and understanding how and why people change is the next level.

I’m not sure we can have successful interventions without the clear communication and understanding of why people change. What are your thoughts about that?

Dr. Janice Prochaska: We realized that it’s not just clear, simple information that’s important. People have to be ready to do something with it. For many years, people just figured that the doctor would tell them what to do or that the doctor knows best.

What we’re really changing is that we’re encouraging people to take more responsibility for their health and healthcare needs. We’re encouraging people to be more proactive about their health and to become a proactive health consumer.

Everybody’s not ready to do that, so we actually built a program at Pro Change to assess people’s readiness to be a proactive health consumer, which means being able to make an informed decision and working with your provider about making some shared decisions.

Recognizing that everybody is not ready to do that, we’ve build a program to assess their readiness and help them move through the Stages of Change to become a more proactive health consumer.

Helen: That’s fascinating. I keep hearing the terms proactive, patient engagement, the activated patient and informed decision-making. Like it or not, it seems like that’s where healthcare is today, at least in the United States.

Dr. James Prochaska: Yes, and increasingly so because of the changes happening in healthcare reform where practices and accountable care organizations are increasingly responsible for populations and need to be able to work with them wherever they’re at.

Helen: Can you give an example of how we can consider the Stages of Change with our patients who could be at all levels of readiness to participate?

Dr. James Prochaska: Honestly, if we don’t like the way our patients are behaving, the old rule was that we would first have to change our own behavior, but that starts changing our mental model of what behavior change is. We first need to have a model that will be for all people in a population, not just those who are ready or motivated.

Frankly, we need to have a simply way of communicating that to patient populations. We often use a traffic light as a nice symbol. Red light means not ready, yellow light means getting ready and green light means ready. Ready or not, we can be of help.

We need to let patients know that because their mental model is action. If they’re not ready to take action, they think, “I’m not going to talk about exercise, smoking or diet or make decisions about healthcare because I’m not ready and I’ll just fail,” versus “Wherever you’re at, you can be part of this process and we can help you to move ahead.”

Helen: Can you give an example? We’re talking about being an activated patient, so perhaps it’s making that decision with your provider. Is that a good example to use?

Dr. James Prochaska: Let’s use an example in terms of medication. A nurse practitioner prescribes a medication and takes care to choose the biology that will be most helpful.

Let’s say they prescribe them a statin for cholesterol management. They don’t recognize that they’re also prescribing a behavior. “Are you prepared to take this pill every day for the rest of your life?” They may pressure the patient to go on the medication, but if the patient is in contemplation, they’re going to be very ambivalent.

Their pros and cons of taking that action are tied, so the provider can assess where they’re at and say, “We need to help you appreciate the multiple benefits that come with this medication, and we need to help you to lower some of the cons of this. We want to share the process with you.” If it’s not a shared process, then the patient will often act out where they’re at. They may start and then have some negative.

That throws them in a negative balance, so they discontinue and the physician says, “Look at that. They’re a noncompliant patient,” versus, “I prescribed and pushed action when they weren’t ready. I could help them to be part of that. If they share that with me, I can share with them the best kind of guidance to move them toward taking action.”

Helen: What a great example. What would you recommend that a clinician should do to create that alliance and meet the person where he or she is at?

Dr. Janice Prochaska: The provider needs to understand what stage that individual might be in. For example, if they’re in pre-contemplation for taking that medication, they need to share what the benefits of taking that medication would be and also help reduce some of the cons that they might be experiencing around that.

Also, they need to help them understand the impact that them being adherent would have on their family or peers. It’s important to articulate a lot to that person who is not ready to start being adherent to the prescribed situation.

Helen: What about someone who’s at that yellow-light stage and thinking, “Maybe or maybe not”?

Dr. James Prochaska: That’s the contemplation stage. That is marked by profound ambivalence. We know that one of the things we need to do with them is bring down the cons.

For example, the number-one con for regular exercise in Taiwan, Mexico and amongst retired Americans in the US is time. They will keep putting it off and say, “I don’t have enough time.”

We can help them to appreciate that this is the bargain basement of behaviors and there’s nothing they could do with their time that could give them as many benefits. We can say, “Do you like bargains? That’s great. This is a behavior for you.”

Helen: I like “bargain basement.” What about someone who is a champion and says, “Yes! I want to do this”?

Dr. Janice Prochaska:  We really encourage someone in preparation to not just jump right away to that action criteria, but to develop a plan, have a start date, share their plan with others to gain some support, and create the surroundings around them to be receptive to that new behavior.

For example, if they’re a smoker, get rid of the ashtrays, clean out the car, freshen up the clothes, and get ready to be in an environment that’s going to be clean and healthier for them.

For that person in preparation, we encourage them to take some small steps and be successful at those small, manageable steps to give them confidence to go on and actually stop the negative behavior or start doing the very healthy behavior.

Helen: I know from your model that you have the other person who’s been doing it for a while and might be getting a little sick and tired of this.

Dr. James Prochaska: Yes, and exercise is clearly one of those. You see a lot of relapse. We call it recycling where they go back to an earlier stage. If they’ve built up a nice list of pros, and we let them know that there are over 60 regular benefits, then they make a to-do list.

It may say, “Today, I’m walking for my heart. Tomorrow, I’m walking for my weight. The next day, I’m walking for my stress. Then I’m walking for my brain and bones.”

Then they say, “Oh my gosh! Look at all the benefits. I am walking to affirm so much of my body and myself. I’m walking for my grandkids.” We shouldn’t think of these as physical exercises but as vitality exercises.

Helen: I’ve been a walker for years. I live up in Massachusetts. The weather can be pretty rotten some mornings. It’s not quite as thoughtful as what you’re talking about, but what keeps me going is that I keep listening to podcasts. It’s not just mine. I have all of my favorite ones. If I need to hear the end of Ira Glass’s This American Life, I’m walking. Maybe that’s my little treat out there.

Dr. Janice Prochaska: You’re giving yourself a stimulus which really gets you to go out and keep walking.

Dr. James Prochaska: Jan, like a lot of others, always has a pedometer on so she can monitor herself. She can say, “I need to get another 1,000 steps in today,” and off she goes.

Helen: It sounds like there are little prizes or rewards we give ourselves.

We’re not all clinicians. There are public health folks, librarians, teachers and everybody communicating health information. What we have in common is that we’re all somehow interested in health literacy, but we’re at very different places.

I always hear the issue about time when I give workshops and things. They say, “That’s a great idea, but I don’t have time to put this into my practice.”

Can you think of how this behavioral stage model might apply to people building health literacy into what they do as they communicate?

Dr. James Prochaska: Let me start in terms of building change literacy into their programs. With Pro Change, you can have dashboards. You can have questions on the screen to assess what stage the person is in.

Helen: When you say Pro Change, are you referring to the business?

Dr. James Prochaska: Yes.

Helen:  Can you give us the website for that, please?

Dr. Janice Prochaska: It’s www.ProChange.com

Helen: Thanks.

Dr. James Prochaska: It can help the professional assess what stage a person is in. If they’re going to be helping them with particular behaviors, it can also give them nice bullets that say, “Here are one or two things that you could say to help them progress.”

You can also recommend programs that the person can do at home in between contacts. If you have somebody who was in pre-contemplation around informed and shared decision-making, Pro Change’s program would give you as a professional nice feedback on what you could do, but it also has a program that the client can use.

As a professional, you can see on your dashboard that they’re progressing. When they come in, you say, “Congratulations. You’ve progressed one stage since we last met. You have just about doubled the chances that you’re going to be taking effective action in the next few months.”

Both get reinforced because the professional and the client can see progress.

Helen: That’s wonderful. I will put that URL on the Health Literacy Out Loudweb page.

I have actually used the Stages of Change model as I advocate and talk about Health Literacy Month. That’s about raising awareness. When people ask me, “What should I do for Health Literacy Month?” I go back to where you started and say, “It depends. Where are you?”

It depends. Have they ever heard about health literacy? Is this a brand new concept and I have to present information one way, or is this something they’ve been thinking about doing but don’t quite know what to do? Have they been doing this for a while and need to justify continuing to do this? I found that model so helpful.

Dr. James Prochaska: That’s great. Jan was talking about increasing the pros, whether it’s mass communication or person-to-person communication. What are all the benefits? As a group, folks can contribute. You can have a site where you write, “Here’s a pro that I found with an individual,” and share more benefits that folks are finding they can help people with.

Helen: I love that idea. You’ve been doing this for quite some time, but I still hear the enthusiasm about all the work you’re doing and all of the benefits of considering behavior change. What keeps you excited to go to work each morning?

Dr. Janice Prochaska: What keeps me excited is applying the model in new ways. You were pointing out earlier how I work with being a proactive health consumer, but also in bullying prevention and with the perpetrators of domestic violence. Right now we’re working with the juvenile justice program to help kids who are on probation stay out of trouble with the law.

We’ve also applied it to organizational change in helping people work more collaboratively in teams. It’s exciting to me to have people calling in and asking for new ways of applying the principles of change to a new content area.

Dr. James Prochaska: For me, I would say it’s that we continue having breakthroughs. Jan and I have been working on a whole new model called the Continuum of Patient Engagement. We know that’s such a high priority. We are putting together the phases of engagement and the factors that help people to become increasingly more engaged.

We’ve also had breakthroughs on how to help people change multiple behaviors. We know that folks with multiple risk behaviors are the highest risk and the highest cost. Now we’re finding we can have greater impact with fewer demands on the professional and the patient or client.

Helen: I want to thank you both for all of the work that you have done. It has made a profound difference. From you listening to ordinary people about how they change behaviors in their lives, I hope that listeners of the podcast will also learn from you about how to change their practice. I’m sure they will.

Thank you both so much for being guests on Health Literacy Out Loud.

Dr. Janice Prochaska: You’re most welcome.

Dr. James Prochaska: It was great to be on your 100^th broadcast.

Helen: I learned so much from talking with Drs. Jim and Janice Prochaska, and I certainly hope that you learned so much too.

But health literacy isn’t always easy. For help clearly communicating your health message, please visit my health literacy consulting website at www.HealthLiteracy.com. While you are there, sign up for the free enewsletter What’s New in Health Literacy Consulting.

NewHealth Literacy Out Loud podcasts come out every few weeks. Subscribe for free to hear them all. You can find them on iTunes, Stitcher Radio and the Health Literacy Out Loud website at www.HealthLiteracyOutLoud.com. You can also find links to written transcripts for all of the newer Health Literacy Out Loud podcasts.

Did you like this podcast? Even more, did you learn something new? If so, tell your colleagues and friends. Together, let’s let the whole world know why health literacy matters. Until next time, I’m Helen Osborne.