iv. Patient Education and Counseling for Prevention

Today’s major health care problems are increasingly the result of chronic 
and acute conditions related to individual behavior.<1> A significant 
proportion of coronary disease and cancer can be attributed to use of 
tobacco or unhealthy diets, and the majority of sexually transmitted 
diseases and injuries are related to patient behavior. While mortality from 
some of these conditions is decreasing, morbidity from most chronic 
diseases continues to increase.<2,3> For these conditions, prevention at 
all levels-primary (preventing disease), secondary (early diagnosis), and 
tertiary (preventing or slowing deterioration)-requires active participation 
by the patient with guidance and support from the clinician. The patient 
must take responsibility for carrying out the day-to-day preventive 
behaviors, accurately reporting progress to the clinician, and discussing 
health-related problems. Effective patient participation requires education, 
motivation, and counseling. While busy clinicians cannot fill all the 
educational needs, they can be pivotal in starting and guiding the 
process.

Effectiveness of Clinical Counseling

Published evidence regarding counseling’s effectiveness in changing 
specific patient behaviors is reviewed in detail in Chapters 54 through 64. 
For a number of important health-related behaviors (e.g., smoking, 
problem drinking) there is good evidence from high-quality studies that 
clinicians can change patient behavior through simple counseling 
interventions in the primary care setting.<4-7> For many other behaviors, 
the effectiveness of clinician counseling has been demonstrated only over 
the short term<8> or in specialized settings involving relatively intensive 
counseling.<9-14> In many cases, the effects of counseling on specific 
behaviors have never been examined in appropriately designed studies. 
Small changes in behavior may be difficult to prove in prospective 
studies, yet they could have important health benefits if applied to large 
populations at risk. Given the safety and generally low cost of advising 
patients about health-related behaviors, the U.S. Preventive Services 
Task Force (USPSTF) recommends routinely addressing some health 
behaviors even when the long-term effectiveness of such counseling has 
not yet been definitively proven. In their updated recommendations, 
however, the USPSTF explicitly distinguishes between recommendations 
based on good evidence of the effectiveness of counseling per se (e.g., 
smoking cessation) and recommendations made primarily on the basis of 
the strong link between behavior and disease (e.g., sexually transmitted 
disease prevention). The USPSTF recognizes that determining the 
effectiveness of counseling interventions, especially ones that are 
feasible in the primary care setting, is a research priority. Studies that 
have demonstrated benefits from brief counseling (e.g., for smoking 
cessation) help identify critical components of clinician counseling that 
may apply to other target conditions. This chapter will discuss the 
objectives of patient education and counseling and provide strategies that 
can be used in day-to-day practice, offering some examples of how these 
strategies can be applied.

Objectives of Patient Education and Counseling for Prevention

There are two major objectives of patient education and counseling 
related to primary prevention: changing health behaviors and improving 
health status. In addition to the studies cited above, a number of other 
studies of patient education have demonstrated successful health 
behavior change in areas such as weight control,<15,16> exercise,<17-
19> and contraceptive use.<20> No area of behavior change has been 
studied more thoroughly than compliance with medication and with other 
preventive or therapeutic regimens.<21-24> Several general points have 
emerged from these and other studies of effective counseling to change 
behavior, which can be incorporated into strategies for effective patient 
counseling (see below).

A large range of health status changes can be achieved from well-
implemented patient education efforts.<25> Various programs have been 
reported to: lower blood pressure;<23,26> reduce mortality from 
hypertension,<27> melanoma,<28> hematologic malignancies,<29> and 
breast cancer;<30> reduce pain and disability from arthritis;<31-34> 
reduce the incidence of low birth weight babies;<35,36> and maintain 
better blood glucose levels in diabetics.<37,38> While many of these 
changes in health status are mediated by changes in health behaviors 
and better compliance with therapeutic regimens, it seems that some 
clinical benefits occur independent of these factors.<39> A growing body 
of evidence suggests that when people have confidence that they can 
affect their health, they are more likely to do so than those without such 
confidence.<40> This confidence has been termed “perceived self-
efficacy.”<41> Self-efficacy can be enhanced through skills mastery, 
modeling, reinterpreting the meaning of symptoms, and persuasion. 
Efficacy-enhancing strategies for use in clinical practice are included in 
the suggestions for patient education described below.

Patient Education/Counseling Strategies

An underlying principle of patient education and counseling is that 
knowledge is necessary but not sufficient to change health behaviors. If 
knowledge alone could accomplish changes in health behavior, there 
would be many fewer smokers and more exercisers. Patient education 
involves more than simply telling people what to do or giving them an 
instructional pamphlet.

Few studies compare the efficacy of different types of counseling. The 
following recommendations have been chosen because they each have 
been found to be useful in changing certain health behaviors. Most of the 
suggested strategies can be incorporated into the practice setting without 
changing existing practice patterns. Many can be implemented in brief 
periods of time during routine health visits.

1. Frame the teaching to match the patient’s perceptions. When 
counseling patients, the clinician should consider and incorporate, where 
possible, the beliefs and concerns of the patient. Research suggests that 
people have only a few important beliefs about any one subject.<42> To 
persuade patients to change their behavior, it is first necessary to identify 
their beliefs relevant to the behavior and to provide information based on 
this foundation.<43> The clinician can elicit important beliefs by asking 
such questions as “When you think of heart disease, what do you think 
of?” and “What gets in the way of your eating a low-fat diet?” Once the 
patient’s concerns and understanding of the issues are apparent, 
teaching can then be focused appropriately. In considering a patient’s 
belief system, the provider is challenged to facilitate the bridging of cross-
cultural gaps as well. Culturally sensitive education and counseling 
requires that clinicians assess their own cultural beliefs and be aware of 
local ethnic, regional, and religious beliefs and practices.<44> Such 
knowledge aids the development of culturally specific health teaching. A 
fixed message will not be effective for all patients. By fitting teaching and 
recommendations to patients’ perceptions of their own health and ability 
to change, clinicians can enhance self-efficacy, which has been shown to 
improve health behaviors and health status.<41> If a patient with morbid 
obesity complains that he or she is not able to exercise, the clinician 
might reframe the patient’s conception of what is meant by “exercise.” 
One might initiate a very gentle and brief exercise program, such as 1 
minute of physical activity each hour.

2. Fully inform patients of the purposes and expected effects of 
interventions and when to expect these effects. Telling the patient when 
to expect to see beneficial effects from the intervention may avoid 
discouragement when immediate benefits are not forthcoming. When 
rheumatologists told patients about the purposes of their medications, 
79% of them were compliant 4 months later, compared with only 33% 
compliance for those patients who were not given clear information about 
the purpose of the drugs.<49> Informing patients that the beneficial 
effects of a low-cholesterol diet or regular physical activity may not 
become apparent for several months might increase the likelihood of 
long-term compliance. If side effects are common, the patient should be 
told what to expect, and under what circumstances the intervention should 
be stopped or the provider consulted.

3. Suggest small changes rather than large ones. Patients can be asked 
to do slightly more than they are doing now: “It is great that you are 
walking 10 minutes in the morning; could you add an additional 5 
minutes?” When someone is very overweight, losing 100 pounds might 
seem like an impossible task, whereas losing 3-4 pounds in the next 
month seems reachable. By achieving a small goal, the patient has 
initiated positive change.<41> The rationale for this suggestion comes 
from self-efficacy theory. Successful persuasion involves not only 
increasing a patient’s faith in his or her capabilities, but also structuring 
interventions so that people are likely to experience success.<45>

4. Be specific. Specific and informational instructions will generally lead to 
better compliance.<46> For example, when suggesting a physical activity 
program, it is helpful to ask the patient how much he or she can 
comfortably do now.<47> The patient can then be asked to perform this 
activity 3 times a week and then add to it by 10-25% per week, until the 
person is doing some type of aerobic exercise 20-30 minutes 3-4 times a 
week. Behavior change is enhanced if the regimen and its rationale are 
explained, demonstrated to the patient (if appropriate), and written down 
for patients to take home.

5. It is sometimes easier to add new behaviors than to eliminate 
established behaviors.<48,49> Thus, if weight loss is a concern, 
suggesting that the patient begin moderate physical activity may be more 
effective than suggesting a change in current dietary patterns.

6. Link new behaviors to old behaviors. For example, a clinician might 
suggest to patients that they exercise before eating lunch, use an 
exercise bike while watching the evening news, or take prescribed 
medications twice daily when brushing the teeth.

7. Use the power of the profession. Patients see clinicians as health 
experts, and they regard what the clinician says as important. The 
clinician need not be afraid to tell a patient, “I want you to stop smoking,” 
or “I want you to cut half the fat out of your diet.” These direct messages 
are powerful, especially if they are simple and specific.<5> It is important 
to recognize that some patients lack confidence in their ability to make 
lifestyle changes. The clinician can be sympathetic and supportive while 
providing firm, definite messages.

8. Get explicit commitments from the patient. Asking patients to describe 
how the intended regimen will be followed encourages them to begin to 
think about how to integrate this new behavior into their daily schedule. 
Clinicians should ask patients to describe what specifically they plan to 
achieve this week (i.e., what, when, and how often). For example, the 
patient can be asked to describe what physical activity he or she will 
undertake, when it will be done, and how often. The more specific the 
commitment from the patient, the more likely it is to be followed. After 
getting the commitment, the clinician can also ask the patient how sure he 
or she is that he or she will carry out the commitment, for example using a 
scale of 0 (not at all sure) to 10 (totally sure). A patient with a high degree 
of certainty that he or she will carry out the commitment is more likely to 
follow through.<41> If a patient expresses uncertainty, the clinician can 
explore the problems that might be encountered in carrying out the 
regimen. This is best done in a nonjudgmental manner, e.g., “Many 
people have problems starting or continuing an exercise program; do you 
think you may have any problems? How will you begin?” The clinician and 
patient can then seek solutions for potential problems.

9. Use a combination of strategies. Educational efforts that integrate 
individual counseling, group classes, audiovisual aids, written materials, 
and community resources are more likely to be effective than those 
employing a single technique.<5> Programs can be tailored to individual 
needs; for example, some patients will not attend group classes, and 
others may have inflexible work schedules. Written materials strengthen 
the message<50> and may be personalized by jotting pertinent comments 
in the margins; this will help to remind patients later of the clinician’s 
suggestions. The clinician should ensure that printed materials are 
accurate, consistent with their views, and at a reading level appropriate to 
their patient population. Printed materials cannot, however, substitute for 
verbal communication with patients. Multiple studies have demonstrated 
that clinicians’ individual attention and feedback are more useful than the 
news media or other communication channels in changing patient 
knowledge and behavior.<51>

10. Involve office staff. Patient education and counseling is a 
responsibility that is shared among physicians, nurses, clinical nurse 
specialists, health educators, dietitians, and other allied health 
professionals as appropriate. A team approach facilitates patient 
education. The receptionist can encourage patients to read materials that 
the clinician has reviewed, approved, and placed in the reception area. 
Staff members and the office environment can communicate consistent 
positive health messages.<52> Forming a patient education committee 
can help to generate program ideas and promote staff commitment.<52>

11. Refer. In a busy practice, it may not be possible to do complete 
patient education and counseling. In some situations, patients are best 
served by appropriate referrals. There are four major referral sources: 
community agencies, national voluntary health organizations such as the 
American Heart Association and the American Cancer Society, 
instructional references such as books and video tapes, and, finally, other 
patients. One of the best ways to change health behavior is to connect 
the patient with a role model, someone with the same problem who has 
made changes and is doing well.<41> An up-to-date, written list of 
specific referral sources (including name, address, and telephone 
number) can be prepared for each of the 10 or so most common 
counseling topics and given to patients who need referral. Clinicians 
should check the credibility and appropriateness of an agency, 
organization, or other references before referral.

12. Monitor progress through follow-up contact. Scheduling a follow-up 
appointment or telephone call within the next few weeks-to evaluate 
progress, reinforce successes, and identify and respond to problems-
improves the effectiveness of clinician counseling.<5,6> In one study, a 
monthly call to older persons with osteoarthritis reduced their reported 
pain and utilization of services.<53> A study in which calls were made to 
internal medicine patients between visits reduced visits by 19% and 
hospital days by 28%.<54> Provider-initiated contact may be more 
effective than patient-initiated phone calls.<55> Proactive calls (calls 
made by the provider to the patient) have been shown to reinforce 
behavior change effectively.<56-59> It is also important for the clinician to 
followup on referrals to monitor progress and support continued 
compliance.

Implementing Patient Counseling in the Practice Setting

As described in Chapter i, clinicians face important barriers to 
implementing counseling interventions, such as insufficient 
reimbursement, provider uncertainty about how to counsel effectively, 
varying interest on the part of patient or staff, and lack of 
organizational/system support to facilitate the delivery of patient 
education. Many of these barriers are addressed by “Put Prevention into 
Practice” (PPIP), the Public Health Service’s prevention implementation 
program.<60> PPIP provides tools that can assist the provider in 
delivering appropriate counseling to change patients’ personal health 
practices every time patients are seen. Other publications also provide 
useful information on the effective delivery of prevention-related 
education and counseling.<61>

The clinician and public health community are faced with substantial 
morbidity and mortality from chronic, infectious, and traumatic conditions 
that are related to personal behaviors. With a large and growing body of 
literature demonstrating its effectiveness in promoting healthier behavior, 
patient education and counseling has become an increasingly important 
part of the delivery of clinical preventive services.

The draft update of this chapter was prepared for the U.S. Preventive 
Services Task Force by Kate Lorig, RN, DrPH.

REFERENCES
	1. McGinnis JM, Foege WH. Actual causes of death in the United 
States. JAMA 1993;270:2207-2212.
	2. Verbrugge LM. Longer life but worsening health? Trends in 
health and mortality of middle-aged and older persons. Milbank Mem 
Fund Q 1984;62:475-519.
	3. Rothenberg RB, Koplan JP. Chronic disease in the 1990’s. Annu 
Rev Public Health 1990;2:267-296.
	4. Lichtenstein EL, Glasgolo RE. Smoking cessation: what have we 
learned over the past decade? J Consult Clin Psychol 1992;60:518-527.
	5. Kottke TE, Battista RN, DeFriese GH, et al. Attributes of 
successful smoking cessation interventions in clinical practice: a meta-
analysis of 42 controlled trials. JAMA 1988;259:2882-2889.
	6. Bien TH, Miller WR, Tonigan JS. Brief interventions for alcohol 
problems: a review. Addiction 1993;88:315-336.
	7. Brief interventions and alcohol use. Effective Health Care 
Bulletin 7. Leeds, U.K.: Nuffield Institute for Health Care, University of 
Leeds, 1993.
	8. Bass J, Christoffel K, Widome M, et al. Childhood injury 
prevention counseling in primary care settings. Pediatrics 1993;92:544-
553.
	9. Caggiula AW, Christakis G, Farrand M, et al. The Multiple Risk 
Factor Interventions Trial (MRFIT). IV. Intervention on blood lipids. Prev 
Med 1981;10:443-475.
	10. The Writing Group for the DISC Collaborative Research Group. 
Efficacy and safety of lowering dietary intake of fat and cholesterol in 
children with elevated low-density lipoprotein cholesterol: the Dietary 
Intervention Study in Children (DISC). JAMA 1995;273:1429-1435.
	11. Ramsay LE, Yeo WW, Jackson PR. Dietary reduction of serum 
cholesterol concentration: time to think again. BMJ 1991;303:953-957.
	12. Dattilo AM, Kris-Etherton PM. Effects of weight reduction on 
blood lipoproteins: a meta-analysis. Am J Clin Nutr 1992;56:320-328.
	13. Hopkins PN. Effects of dietary cholesterol on serum 
cholesterol: a meta-analysis and review. Am J Clin Nutr 1992;55:1060-
1070.
	14. Wood PD, Stefanick ML, Williams PT, et al. The effects on 
plasma lipoproteins of a prudent weight-reducing diet, with or without 
exercise, in overweight men and women. N Engl J Med 1991;325:461-
466.
	15. Brownell KD, Kramer FM. Behavioral management of obesity. 
Med Clin North Am 1989;73:185-201.
	16. Brownell KD, Wadden TA. Etiology and treatment of obesity: 
understanding a serious, prevalent and refractory disorder. J Consult Clin 
Psychol 1992;60:505-517.
	17. King AC, Blair SN, Bild DE, et al. Determinants of physical 
activity and interventions in adults. J Med Sci Sports Exerc 1988;24(Suppl 
6):S221-S236.
	18. King AC, Martin JE. Exercise adherence and maintenance. In: 
Painter P, ed. Resource manual for guidelines and exercise testing and 
prescription. 2nd ed. Philadelphia: American College of Sports Medicine 
1988;93:443-454.
	19. Disman RK, ed. Exercise adherence: its impact on public 
health. Champaign, IL: Human Kinetics, 1988.
	20. Nathanson CA, Becker MH. The influence of client-provider 
relationships on teenage women’s subsequent use of contraception. Am J 
Public Health 1985;75:33-38.
	21. Haynes RB, Taylor DW, Sackett DL. Compliance in health 
care. Baltimore: Johns Hopkins University Press, 1979.
	22. Roter D. Which facets of communication have strong effect on 
outcome: a meta-analysis. In: Stewart M, Roter D, eds. Communicating 
with medical patients. Newbury Park, CA: Sage Publications, 1989.
	23. National Institutes of Health, Working Group on Health 
Education and High Blood Pressure Control. The physician’s guide: 
improving adherence among hypertensive patients. Bethesda: National 
Institutes of Health, 1987.
	24. Cramer JA. Optimizing long-term patient compliance. 
Neurology 1995;45:525-528.
	25. Mazzuca SA. Does patient education in chronic disease have 
therapeutic value? J Chronic Dis 1982;35:521-529.
	26. Levine DM, Green LW, Deeds SG, et al. Health education for 
hypertensive patients. JAMA 1979;241:1700-1703.
	27. Morisky DE, Levine DM, Green LW. Five-year blood pressure 
control and mortality following health education for hypertensive patients. 
Am J Public Health 1983;73:153-162.
	28. Fawzy FI, Fawzy NW, Hyun CS, et al. Malignant melanoma: 
effects of an early structured psychiatric intervention, coping and effective 
state on recurrence and survival 6 years later. Arch Gen Psychiatry 
1993;50:681-689.
	29. Richardson JL, Shelton DR, Krailo M, et al. The effect of 
compliance with treatment among patients with hematologic malignancies. 
J Clin Oncol 1990;8:356-364.
	30. Spiegel D, Bloom JR, Kraemer HC, et al. Effects of 
psychosocial treatment on survival of patients with metastatic breast 
cancer. Lancet 1989;2:888-891.
	31. Lorig KR, Konkol L, Tronzalez V. Arthritis patient education: a 
review of the literature. Patient Educ Counsel 1987;10:207-252.
	32. Hirano PC, Laurent DD, Lorig KR. Arthritis patient education 
studies, 1987-1992: a review of the literature. Patient Educ Counsel 
1994;24:9-54.
	33. Mullen PD, Laville E, Biddle AK, et al. Efficacy of 
psychoeducational interventions on pain, depression, and disability with 
arthritic adults: a meta-analysis. J Rheumatol 1987;14:33-39.
	34. Parker JC, Iverson GL, Smarr KL, et al. Cognitive-behavioral 
approaches to pain management in rheumatoid arthritis. Arthritis Care 
Res 1993;6:207-212.
	35. Windsor RA, Cutter G, Morris J, et al. The effectiveness of 
smoking cessation methods for smokers in public health maternity clinics: 
a randomized trial. Am J Public Health 1985;75:1389-1392.
	36. Klaus MK, Kennel J, Berkowitz G. Maternal assistance and 
support in labor: father, nurse, midwife or doula? Clin Consult Obstet 
Gynecol 1992;4:211-217.
	37. Padgett D, Mumford E, Hynes M, et al. Meta-analysis of the 
effects of educational and psychosocial interventions in the management 
of diabetes mellitus. J Clin Epidemiol 1988;41:1007-1030.
	38. Brown SA. Studies of educational interventions and outcomes 
in diabetic adults: a meta-analysis revised. Patient Educ Counsel 
1990;16:189-215.
	39. Lorig KR, Laurin J. Some notions about assumptions 
underlying health education. Health Educ Q 1985;12:231-243.
	40. Schwarzer R. Self-efficacy, physical symptoms and 
rehabilitation of chronic disease. In: Schwarzer R, ed. Self-efficacy: 
thought control of action. Washington, DC: Hemisphere Publishing 
Corporation, 1992.
	41. Bandura A. Social foundations of thoughts and action: a social 
cognitive theory. Englewood Cliffs, NJ: Prentice-Hall, 1986.
	42. Miller GA. The magical number seven; plus or minus two: some 
limits on our capacity for processing information. Psychol Rev 
1956;63:81-97.
	43. Fishbein M, Ajzen I. Belief, attitude, intention, and behavior. 
Reading, MA: Addison-Wesley, 1975.
	44. Price JL, Cordell B. Cultural diversity and patient teaching. J 
Continuing Educ Nurs 1994;25:163-166.
	45. Bandura A. Self-efficacy mechanism: psychobiologic 
functioning. In: Schwarzer R, ed. Self-efficacy: thought control of action. 
Washington, DC: Hemisphere Publishing Corporation, 1992.
	46. Daltroy LH, Katz JN, Liang MH. Doctor-patient communications 
and adherence to arthritis treatments. Arthritis Care Res 1992;5:S19.
	47. Martin JE, Dubbert PM. Exercise applications and promotion in 
behavioral medicine: current status and future directions. J Consult Clin 
Psychol 1982;50:1004-1017.
	48. Tabak ER, Mullen PD, Simons-Morton DG, et al. Definition and 
yield of inclusion criteria for a meta-analysis of patient education studies 
in clinical preventive services. Eval Health Prof 1991;14:388-411.
	49. Mullen PD, Simons-Morton DG, Ramirez G, et al. A meta-
analysis of studies evaluating patient education for three groups of 
preventive behaviors. Presented at Prevention ‘93. St. Louis, MO, April 
17-20, 1993.
	50. Bernier MJ. Developing and evaluating printed education 
materials: a prescriptive model for quality. Orthop Nurs 1993;12:39-46.
	51. Mullen PD, Green LW, Persinger G. Clinical trials of patient 
education for chronic conditions: a comparative analysis of intervention 
types. Prev Med 1985;14:753-781.
	52. Vogt HB, Kapp C. Patient education in primary care practice. 
Postgrad Med 1987;81:273-278.
	53. Weinberger M, Tierney WM, Booher P, et al. Can the provision 
of information to patients with osteoarthritis improve functional status? 
Arthritis Rheum 1989;32:1577-1583.
	54. Wasson J, Gaudette C, Whaley F, et al. Telephone care as a 
substitute for routine clinic follow-up. JAMA 1992;267: 1788-1793.
	55. Sanson-Fisher R, Halpin S, Redman S. Notification and follow-
up of Pap test results: current practice and women’s preferences. Prev 
Med 1994;23:276-283.
	56. Weinberger M, Kirkman MS, Samsa GP, et al. A nurse-
coordinated intervention for primary care patients with non-insulin-
dependent diabetes mellitus: impact on glycemic control and health-
related quality of life. J Gen Intern Med 1995;10:59-66.
	57. van Elderen-van Kemenade T, Maes S, van den Broek Y. 
Effects of a health education programme with telephone follow-up during 
cardiac rehabilitation. Br J Clin Psychol 1994;33:367-378.
	58. Ahring KK, Ahring JP, Joyce C, et al. Telephone modem 
access improves diabetes control in those with insulin-requiring diabetes. 
Diabetes Care 1992;15:971-975.
	59. Lerman C, Hanjani P, Caputo C, et al. Telephone counseling 
improves adherence to colposcopy among lower-income minority women. 
J Clin Oncol 1992;10:330-333.
	60. Department of Health and Human Services, Public Health 
Service, Office of Disease Prevention and Health Promotion. ÒPut 
Prevention into PracticeÓ education and action kit. Washington, DC: 
Government Printing Office, 1994.
	61. Woolf SH, Jonas S, Lawrence RS, eds. Health promotion and 
disease prevention in clinical practice. Baltimore: Williams & Wilkins, 
1995.