Rural Health Webinar “Lifestyle Medicine in Rural Practice – Small changes, big impact
Dimitri:
Dr Hung is there I can see you. I do not know what is going on with Zoom, [distortion] very very unusual. This is probably the 10th webinar [distortion] and it has just gone completely haywire.
Dr Hung:
Okay. Okay. Well, I can see you Dimitri.
Dimitri:
Okay. Hi Amelia, can you hear me? Yes, Hi Amelia.
Amelia:
Yes, I can. Hi
Dimitri:
Apologies for this confusion. I am not 100% sure what has actually happened with Zoom, but we are all here and I think I have come down to the crux of the issue. So, we have everyone attending, can everyone just include in their comments that they can hear us and that they can see us as well. Okay. Thanks. Wee Ong. I can see and hear you. Can everyone else just quickly in the comments section... Okay, so for the time being if you can just put everything in the Q&A function and I will open the chat a little bit later as well.
Okay. So, what I am going to do is I am going to share the presentation with everyone, so if you could just bear with me.
Dr Hung:
Do you want me to share my [distorted as overlap of talking]
Dimitri:
[Distorted as overlap of talking] Oh I think that would be a great idea actually. I am going to...
Dr Hung:
Yeah, because I just saw the share button there, so ...
Dimitri:
Fantastic.
Dr Hung:
What can I do…[trails off]
Dimitri:
Can you see the green share screen button?
Dr Hung:
Yeah. Yeah. Yeah.
Dimitri:
At the, yeah.
Dr Hung:
I can see it. I can see it and I will see if you can.
Dimitri:
Fantastic and if you are able to sort of maybe, expand that.
Dr Hung:
What can you see?
Dimitri:
So, I can see the presenter’s view.
Dr Hung:
Ahh. Okay.
Dimitri:
Yeah.
Dr Hung:
I see. Okay.
Dimitri:
So, the third one. Yep. Presenter. So, you have got play from start, just click the first one there. Fantastic. Look. Yep, you had it just then. Okay. Everyone my sincere apologies for this mix up. I am really not sure what has happened this evening, but we will get started. I am not too sure if anyone has sort of heard of my introductions. But my name is Dimitri. I will be hosting tonight’s webinar. We have Dr Hung and Amelia.
Dr Hung will be co-presenting tonight’s webinar. He is a GP at the Bunurong Health Service in Dandenong Victoria and Medical Educator at the Rural Workforce Agency of Victoria. Dr Hung is also President of the Australasian Society of Lifestyle Medicine. Amelia is a psychologist, executive coach and team dynamics consultant who works with CEOs and senior leaders. Her experience spans the private and public sectors including mining, oil & gas, professional services, tertiary education, health and logistics.
So I would like to begin tonight’s webinar by acknowledging the traditional owners of the lands in which we are coming from and the land on which this event is being broadcast, so I would like to pay our respects to their elders past and present and acknowledge any Aboriginal and Torres Strait Islander people who have joined us this evening and we will also go through the learning outcomes for tonight’s webinar.
So, the first one is to describe the lifestyle medicine approach, translate some of the ways the lifestyle medicine approach is used in rural practice using Aboriginal Health and remote workplaces as examples and apply the foundations of health coaching, but for now I am going to hand it over to Dr Hung. Thank you.
Dr Hung:
Technology. Don’t you love it. Good to see you, Amelia as well. I didn’t get the chance to see you before. So, this is the session plan. So, we will spend probably about 10-15 minutes with each one of those points and I will try to make sure we have time for questions as well. So, back to the beginning.
So, lifestyle measure and this is defined by Garry Egger, a lot of you have already said that you’re lifestyle medicine practitioners, so you would have heard the name Garry Egger. He is the powerhouse behind Lifestyle Medicine in Australia. Introducing the concept about eight years ago. He defined that lifestyle medicine is the application of and when low mental behavioural medical and motivational principles to the management of lifestyle-related health problems in a clinical setting, including self-care and self-management. So, a lot of these things are not new because these are principles that we all know but we apply to them in the management of lifestyle related health problems and so lifestyle medicine is of often seen as lifestyle as medicine and these are clinical context as well, so it is really important to note that lifestyle medicine is practice in the clinical context and it is not elsewhere. This line and next line is about trying to state what lifestyle medicine is, so we sort of understand what it is and what it isn’t, because there is a lot of misconception there.
So, the first thing is that lifestyle medicine nonmutually exclusive from therapeutics and other modalities in health and medical practice. It just means that we are not here to say “Oh no we shouldn’t use medication, it is not important” when in actual fact we say the opposite, medication has its place, but we want to elevate the role of lifestyle as a way of treatment for certain chronic diseases. It is an integral and foundational part of practice in medicine, and it is necessary for holistic care without which holistic care is empty word and incomplete practice and I think lifestyle practitioners will appreciate that and appreciate how lifestyle medicine caters for the social aspect of care as well as the cultural aspect of care in some ways the political aspect of care as well and I spend a lot of times under those headings with my GP registrar, in our Aboriginal Health Service. Certainly, lifestyle medicine is not just preventative medicine and as you know preventative medicine goes from primary prevention all the way to tertiary prevention. Therefore, lifestyle medicine has a role to play in treating diseases when they appear treating risk factors when they appear not just before risk factors and diseases. So, it is not just about primary prevention and lastly, and this is where we are going to spend most of our talk is. It relies on a framework for practice and evidence-based tools. Some of these tools are evolving and I will mention some of those as we go along, and they are changing to meet the needs of the communities and the healthcare system. Wherever that may be because different countries have different health systems. It is probably could say here the lifestyle medicine is a global movement, almost, a lot of countries in Europe, Asia, America and Americas have a college or society of lifestyle medicine and it is a movement across the world.
So much so, that this year we have formed the World Lifestyle Medicine Organisation as well. So, let’s look at this scope of lifestyle medicine and so we know what public health is, we know what health emotion is. Public health is an intervention that I think some populations, so it is not a personal approach to manage chronic things in the population.
Health promotion is a combination of educational and environmental support for actions and conditions of living conducive for health. Again, this is in a group of people and may not be personalised, but lifestyle medicine is described as a bridge between the two. They’re a series of interventions that focus on individuals, so very personalised, typically in a person primary care, but more and more we find that tertiary care are embracing some of the tools of lifestyle medicine. I had an endocrinologist in my practice who is very keen to learn more about said medical appointment for example, how he can introduce it to outpatient care, so there is a lot of interest in tertiary care as well. But primarily it is in primary care.
Now I often think that to do lifestyle medicine you have got to have some foundational attitudes to the way you practice medicine. Traditionally or conventionally in medicine what we do is that we treat individual risk factors. The patient is more passive in the process. The patient is not required to make big changes. The treatment is often short term, medication often the end treatment. So, we rely heavily on the medication side of things and the medical technology side of things. We emphasise diagnosis and prescription, the goal is to manage the disease. There is much less consideration for social or environmental issues, and this is obvious when I receive registrar in my practice. We spend a lot of time assessing our patients social and environmental issues and they do not have the skills to do that. It involves other medical specialities and the GP generally act independently on a one-to-one basis.
So that is a conventional approach and I dare say most of you here most of the time do not behave or practice conventionally and this is maybe much more familiar to you. As a foundation attitude to lifestyle medicine practice, we treat lifestyle and environmental causes, so we don’t look at risk factor, we go what actually caused those risk factors. The patient is an active partner, that is really important and that will come out as we talk about tools. Patients are often required to make big changes and we recognise that. We actually say to ourselves “Oh my god, I am going to expect you to make big changes and so I will need to support you”. Just the act of changing how much physical activity you do a week is a big change that we recognise, how big a change that is for some patients.
Treatment is obviously a long-term focus. Medication is necessary but the emphasis is on lifestyle and environmental change. We emphasise facilitation, motivation and adherence rather than just [unsure 26:15] diagnosing prescription. The goal is prevention in all its colours and also remission as I mentioned before, lifestyle as medicine. We don’t have much more conservation for social and environmental factors, and we involve allied health professional health coaches as well as other medical specialists as well. So, the GPs really need to be a part of the multidisciplinary team, regardless of whether they lead the team or not, so other team members may be able to lead lifestyle medicine practice as well, but the GP is a necessary part of that.
This line is just to remind ourselves that chronic disease is on the increase, it is not decreasing and even though the burden of different diseases is changing in terms of ranking and so on. The burden of chronic disease is increasing or is the main issues in terms of morbidity in our country. We are definitely on average living longer and spending more years in full health which means no disease no injury. But we also notice that we are also seeing an increase in number of years in ill health, such that from 2003-2022 Australians are living longer but little change in the portion of life spent in full health and this I think is an issue that we are grappling with and most of the conditions you can see that are related to lifestyle or amenable to lifestyle to lifestyle changes.
So, let’s just say how lifestyle medicine is important but lifestyle medicine also say across the world agree that there are six pillars to lifestyle medicine. So those are physical activity, avoiding substances, social connection, managing stress, sleep and nutritious food. But we also focus on the determinants of health as well, so the social and environmental determinants. We know that social and environment determinants affect behaviours, affect how people can do or address some of the lifestyle measures that are listed as the pillars of lifestyle medicine, so housing and I can get you to think about how does housing affect physical activity, so the location of the housing, the number of people in the house, the sanitation, all those things how does that affect the physical activity, how does that affect social connection and so on. How does racism/disclination affect avoidance of substances, how does it affect sleep, geographic inequality we in the rural health we are very conscious of that, how does that impact on stress and nutritious food and so on. Social inequality, work, schooling, gender. How does all that impact or determine a person’s behaviours in terms of the six pillars of lifestyle medicine. So, in lifestyle medicine practice we do consider all those social conditions that’s why the social history is important in assessing a person’s state of wellbeing.
So let’s move on to the tools and that is where I want to spend a lot of time is the tools of lifestyle medicine practice when you are working with individuals so there is this framework where we asses the seasonal range for the practice of lifestyle medicine, so in assessment there is heaps of tools that you already know, these could be risk tools. These could be diet scores, these could be anthropometric parameters that we can measure and monitor and more importantly we have tools to assess motivation as well and this is the crux of lifestyle medicine is to move people and we have those tools in terms of assessing a person’s concern, willingness to change and confidence to change.
In terms of that assist, the most important areas that we focus on is the motivational interview and it is something that GPs are good at, but this is a reminder that there is three principles in motivational interviewing. Firstly, it is about collaboration where the GP share power, share information and share options with the client or the patient rather than confront them and not share power, persuades them and not share information or curse them and not give them options to choose. So, it's very important that we collaborate with the patient.
The second principle is one of evocation. In lifestyle medicine practise we believe that patients have their own values, they have an aspiration, their own goals and their own reasons for doing things and their reasons for change as well. Whereby as we it's different to evocate than to educate; where educate is more what needs to happen. It's just to start to tell, tell patients what to do and ignoring or not even asking what their values as personal goals are. So, evocation is about that. The reason why we ask people's values and aspirations is because we honour their autonomy, that we recognise that they have competencies, they do have expertise because it's their own body and their own health. There is expertise in their own social situation and they have certain preferences as well. So, honouring patient autonomy rather than instruct patient to change, which is often the case if one is not, but it's lifestyle medicine. So motivational interviewing is really important.
Lastly, the process includes arranging, which is about goal setting care planning and this idea of chronic disease self-management. Whereby you identify problems, identify goals and support goal attainments, and what we want to achieve is self-efficacy and health literacy and also focus on determinacy which is the social determinants. It's focused on those areas and when we arrange, we use tools like quantities of management and social, prescribing, and so on.
OK, so that's the process that lifestyle medicine goes through when we work with individuals. So, I'm going to introduce a few key tools that the first one we will expand in a little bit, but health coaching is extremely important in milestone medicine. It is it goes beyond the initial motivational. Interview that we do, and we need to acknowledge that the key feature of chronic disease is lifestyle, but knowing what constitute a healthy diet, adequate exercise is not enough. You do need to support people to change and changing. As I said before, is a big thing. It's we're asking the patients to do quite a huge task. So, the prevention treatment of reversible chronic condition requires an evidence-based supportive behaviour change. This is not the mainstay in medical care and health coaching in lifestyle medicine is extremely important. So, one of the benefits of health coaching, it is evidence-based application or questioning conversational and goal setting skills, assist patients to make sustainable health behaviour change consistent with their own values and personal strengths. So, there's a lot of seeking to empower patients to locate their own unique motivating force to respond to the challenges that's ahead in terms of their health and we'll go and a little bit more detail about that, but I'll just move on to other tools that we use and share medical appointments is one of those tools that as I mentioned earlier is still evolving. How that looks in the Australian Healthcare is still evolving at the moment.
There's a lot of uptake In the Aboriginal scene, there's a huge project in the NT at the moment where almost every community that I can think of, and I can think of a lot involved in, looking at your medical appointments and how to run that in their services. Share medical comments are series of consecutive individual medical consultation and in a supportive group setting where all can listen, all patients can listen, interact and learn. OK, so you've got a group of people and you can see the diagram down below. In clinical care, there's one GP, one patient. In group education, which could be a health promotion event. It's 1 educator with 15 to 20 patients, OK and that 1 educator delivers to all those 3. In all those people, we're seeing medical appointments, there's one GP, one facilitator who leads the room and manages the interaction. There could be 6-12 patients and the one GP will consult each one of those patients in turn, while the others can listen and interact and of course also learn. So, these are both an individual consultation and informal group education session. There's a lot of research which is finding around this whereby we notice that there's clinical cost efficiency, the use of peer support for better outcomes. This is extremely important in the Aboriginal space to improve cultural safety where patients are supporting each other and reducing the power of the GP and the consultation and I'll just highlight increased patient and provider satisfaction, both patient and GP and facilitator actually enjoy the process. And it's a very useful, tool in lifestyle medicine practise.
The last tool. There's a lot of tools but I'm just highlighting 3 very important tools. The last 2 I think is really important and that's important to me because as you know, I've worked in Aboriginal health for most of my career, 20 plus years now and community development is part of my practise. Community development is the process where community members are supported by an agent to identify and take collective action on issues which are important to them. OK. So, it's initiated by the community and how's the community members going to create stronger and more connected communities? It's definitely a long-term strategy. This agent needs to be part of the community or live in the community and I guess when you work in rural practice, GPs are part of that community and can use the tool of Community development to affect change in lifestyle medicine. We know that it increased skills and knowledge and there's an increase in empowerment and self-efficacy which is very important in lifestyle medicine and it also has the ability to change social capital within that community as well.
I've got a little diagram down there and CD's community development. OK, just to explain what community development is and what it isn’t because you can see a lot of projects that occur in the Community, but they are actually called community-based projects. If you don't involve the community and you're just doing projects within a certain community that doesn't mean it's community development. Community development needs to allow the Community to identify and muscle themselves for collective action. You can have short projects. In community development, it doesn't have to be 1 long one, but they are also led by the community where the community is empowered. So, I think it's hard to grapple community development unless you see an example where you actually experience one.
So, I'm just going to go through an example about how I use lifestyle medicine, including the tool of community development in rural practice and in in Aboriginal health. So, just want to give you an example of a project or we will just call it a project that I did in the community and I've been doing these series of projects over many years. This one I'm going to demonstrate to you is on anaemia, had one on chronic disease self-management we had community talks COVID and also [unclear 40:47], which is dealing with social isolation in an urban context using digital games to involve and teach the community about social isolation, how they can manage that themselves. With the resources and tools within community.
But let me just demonstrate community development from this project. So, this project was actually determined by the community when I asked them, you know, there's money out there that top end division and general practice are giving away. They want us to do a [unclear 40:31] , patient what they want to do and surprisingly, I was hoping to get, you know, diabetes or something like that, but supposing the community says “we are worried about the new rates in our children, despite our diligent efforts in surveillance and treatment of anaemia in children”. Now they're very concerned about children's development at school in this community, and so they're very concerned about new rates and how that affects cognitive development in their children under five. At the time the rate of anaemia under five was 60%. The national average is around 3%, so it's huge, it's very high. So, we went through the process of assessing and assisting and arranging. In terms of assessing, we know the rates. We know that there are worms, we know there's chronic diseases. We know there's chronic infections. All these things are impacting on the rate of anaemia, and we looked at the special situation, the housing overcrowding, sanitation and all those things are contributing to prevalence of worms and nutritional issues. And interestingly, when they say they're diligent in treatment, what they've done is they measure anaemia rates in children 3 times a year and more often in different individuals, and they treat them with iodine.
What’s the time We are going to...
Treat them with iodine they give them albendazole, which isn't helping and they still get 60% and I said to them, have you looked at nutrition? And they said no because, you know, they were very focused on these things. So that was the missing area, and so we did a whole community development approach to all this and I am running out of time. But what we did was we looked at the culture of the community. We need to learn about the leadership. We need to know who holds power? Who cares for the children. So, you know in Aboriginal. communities, it's not the parents necessarily. They care for the people with their aunties and also the grandparents who cares for children. So, we need to target our education. We involve the women at the Women's Centre 1. One of the interesting things, culturally speaking, that the President of this community said to me is, well, you need to go to every sector of the Community and do this session and I said, “why can't they all just come to the health service?” And they said because each service in the community is run by different clan groups, different family groups and so you won't reach all the family groups if you stay in the health service. And that was really a game changer. So we went to the school, we went to the respite. We went to Homeland Services and so on, and it became an extremely successful, because the project actually ran away from the health service, the community just took on board, they put labels in. So, there's huge changes at the store. You see there the fingers pointing at strong blood food. There's huge changes at the stores, things like labelling, things like fruit and vegetable at the front lollies at the back, healthy food or iron rich food at eye level and. And so on. So, lots of changes and that was because the president says, “listen to the health service, to the manager” and he had to make changes.
They had a community garden that started the with the high school kids. They collected seaweed for composting. They when we asked the women what they want to learn in terms of. Cooking nutritious food, they said they want to cook Asian food rather than spaghetti or, you know, you know, colonial food. I. So this is how they learn how to cook Rice as well. So, it's really interesting when you give and the project really did run away so much so that they organise, you know, community events such as volleyball. Here the tug of war so. Battle of the moieties if you understand what moieties is. They created shirts at the school and they have traditional dancing they changed the flour to iron-enriched flour to make damper and so on. So it was extremely successful programme, but the one last thing before I hand over to Amelia that there are some things that are beyond the limits of lifestyle medicine approaches and this is relating to public health, public infrastructure and there's also political advocacy as well, that's beyond lifestyle medicine and that perpetuates poverty, overcrowding and so on. So, at the end of the day, we got the rate of anaemia down to 30% and that persisted for three years without doing anything more than six months, as I said, it ran away from us and the community took it up. But we managed to halve the anaemia rate and it stayed there as well. So that's the power of the community development.
Amelia
Amelia:
Well, I think you've got a question there from Troy. I don't know if you want to answer that now or if you want to wait.
Dr Hung:
Let me just have a look at the question. Troy. OK. How do we start breaking down this kind of system? Medicare?
We're essentially ending [unclear 48:02] care arrangement. You know. Well, that's politics right there. And I, also think it's a bit of advocacy as well. If so, this is something that you know as well likes to, you know, we're a group of, you know, largely GP's, but are very sizable proportion of allied health professionals trying to have some political clout to change the way. Medicare makes us work. There are some changes in strengthening Medicare. It's happening. It's happening very slowly, but some changes in those are very positive at the moment in terms of putting more emphasis on our health professionals within a primary care setting. But you know, I think for substantial change we need to change some of the Medicare items, recognising shared medical appointments for example, and the role of our allied health professionals in there and that and that you know, practice nurses and all that can also lead. So, there's a bit of politics in there, I'm sure a lot of GPs don't want to relinquish their power either. And so here needs to be a lot of talk between the colleges, different disciplines and see how we can start focusing on chronic disease management in a better way and how the disciplines can work together, so I think it's early days, but there's some positivity I can see with the strength of Medicare's approach.
Amelia:
Right. Thanks, Hung. I'm wondering whether you might stop your screen share and we'll see if I can get my screen share because otherwise, I'll have to ask you to flip my slides all the time. Thanks.
OK.
Alright, so I think everyone should be able to see my slides now. Same slide that was up there before and thanks so much everyone for your patience and for sticking with us tonight. I know it's pretty late where some of you are. Dimitri. Just want to check in about time because I think we're due to finish in 6 minutes.
Dimitri:
We are, yes, but we obviously did start well after 8:30. So yeah, feel free to sort of just go through your presentation as is Amelia. If they have to go at 8:30, then that's fine. The webinar will be made available. On demand in in about 3 weeks’ time and you can visit the RACGP rural page. The web page for that as well, yeah.
Amelia:
OK, great. So, no need to rush basically because this is being recorded.
Dimitri:
No need to rush. That's right.
Amelia:
All right, good. Thanks so much. OK, so hi everyone. It's really great to be here and wonderful to have the opportunity to speak with you tonight. I'm an organisational psychologist, registrar and a coaching psychologist, so I have my own consultancy which has a focus on supporting people, to have fulfilling and sustainable work lives. I'm also a fellow and a board member of the ASLIM. And which probably helps to explain why I'm here tonight, and so some of my rural experience. So, I grew up in Remote WA where our medical service was the Flying Doctor who came in to see us once a fortnight and then in terms of my journey to lifestyle medicine, I think like many others, there was a loved one who has heart disease and we're exploring options to improve their health outcomes and then discover the wonderful world of lifestyle as medicine and never looked back. You might like to know that this person is making an attempt at Australian record for the 21 kilometres running this weekend for their age group, which is above 75 years old and they're also trying to hit the Australian record for the marathon later in the year, so that's a pretty good news story, I think, from lifestyle medicine.
So some of the work that I'm doing at the moment includes travelling to remote areas, as you can see highlighted on this map, most of the time it's in Western Australia, but sometimes over on the East Coast as well and you can see some pictures here from some of my adventures. So, some findings from research by the Centre for Transformative Work Design, which is a collaboration between Curtin University, University of WA and the WA Government. Looking at the impact of FIFO, which is fly in, fly out for those of you who don't know on the mental well-being of. FIFO workers. So, we know that FIFO workers do have lower levels of well-being overall compared to the general population, and there's lots of factors that are contributing to that. You can see here. So, things like loneliness and isolation, the kind of disjointedness that comes from working away, there can be a big impact depending on what sort of a roster you've got and we know that even time rosters have better well-being outcomes.
There's always a sense of job insecurity. So there's kind of boom-bust cycle that has people hang on to their maybe their FIFO roles for longer than they need to and there is different reasons for that kind of the sense of that we call it the golden handcuffs, but also a sense of responsibility to being able to provide the same level of financial resources to the family, and then, of course, living conditions, the quality of the food, which is a really big one, that surprises me every time. Whether or not someone's got a permanent room and then in terms of family, so things like being able to communicate with home. So, when you're working a long day, 12-hour shifts, it's not always easy to find time to have a conversation with your family because they've also got their lives going on, and when you are available, they might not necessarily be. You're also probably pretty tired On some of the sites; some of the oil and gas rigs, they actually have really bad communication, which is a shock, I know, but some of them the Internet doesn't work very well and they might not be able to get phone reception depending how far they are off the coast. So, it can be tricky to communicate with family while you're away, and some of those workers are away for a month at a time.
So just a couple of quotes here to give you a sense of what it's like for some of these FIFO workers. So, the first one is about the quality of food, so I probably I’ll say the quote, “I'd probably say the food that they offer probably doesn't offer enough nutrition to support a healthy diet”. They come to work with lollies. And chocolate. And they drink 5 coffees a day and they struggle so much more than I do, but just instead of a healthy snack, they've got five different desserts to choose from on a regular basis. And that is definitely true. Then in terms of fatigue management, the quote there is, so how do I feel? I feel quite tired and fatigued during my roster getting up at 4:00 in the morning for 14 days in a row. And I also work very hard to turn around and make sure I feel my best because I exercise most nights. I go to the gym, I try to eat reasonably well when I can, and the majority of the time. I'm in bed by 8:00 to try to get the 8 hours of sleep but getting into that second week I'm quite tired.
So, I'm providing a case example to illustrate an approach to health coaching using the lifestyle medicine framework, so this example is a 53-year-old male. They're a dump truck operator and they've been doing that for the past 17 years. So that's one of the great big trucks that transport things like iron ore from the mine site to the processing plant or to the rail operation to have it taken off to port. They're doing 12-hour shifts in their truck. They might be doing night shift as well, and it's pretty sedentary and socially isolated role, although they do have a lot of communications across their radios. This person's not doing any physical activity outside of work hours, and they're pretty socially isolated at camp, which is quite typical. People head off to their rooms after they've had something to eat, although some of them might head down to the wet mess or the bar for a couple of beers, which they're still allowed to do. Our example case is married, has been married for 28 years, has two children and one grandchild on the way, they've got limited knowledge about nutrition. They're generally sleeping well apart from some days when they're on night shift. They find it really hard to get to sleep if they have seen the sun come up. They've been a smoker since the age of 16 and so our GP has, of course, advised quitting smoking, starting exercise, improving their nutrition and increasing their social connectedness because of concerns about the person's physical and mental wellbeing and our client is really keen to make changes but is feeling a little bit overwhelmed about where to start.
So when we're using a health coaching approach as Hung has said earlier, we really want to encourage self-efficacy and we're looking at ways to develop intrinsic motivation and we do this by helping the person build their autonomy, their confidence and their sense of connection with others and those of you familiar with self-determination theory will know that these are the three basic needs of self-determination theory.
So, a lot of you are probably using these types of approaches already. So, I won't probably go too much into too much detail around the readiness for change. But essentially, we need to assess the person's readiness for change, as that will help us to tailor our approach and to ensure a more successful outcome. And so, this stages of change model, which you can see there on the left, the readiness precontemplation, contemplation, preparation, action and maintenance was designed to help us understand and explain the process of behaviour change across different health-related behaviours.
Pre contemplation, the person's not yet considering making any changes, so they may not actually even be aware of the negative consequences of their current habits, or they might be feeling quite resistant to change. They might be actually demonstrating denial or have quite low self-efficacy thinking that they're not going to be able to make the change. Contemplation stage with persons becoming more aware of the potential benefits and they understand a little bit more about the positive impacts that having a change might have on their life, but they're still pretty ambivalent about taking action. In the preparation stage the person starting to get ready to take action. So, they're making a commitment and they're starting to investigate a start date or looking for options and gathering information. So maybe you know looking for a gym or local fitness classes.
Then the action stage, we know this is where they're actually implementing the strategies. They're actively modifying their lifestyle, their environment and their habits, and this is the stage that requires the most effort and dedication, and it can sometimes be a little bit of an experimental phase. People trying things and seeing how it works in reality and realising that maybe they've bitten off more than they can chew to start with or they might start really small and realise they can actually do more than they thought.
Then the maintenance phase of course, the person's implemented that behaviour change and they're sustaining it. So, a way that we can assess someone's readiness for change is that we can ask them about how important the change is and how confident they are about making that change. So, we asked them how important it is to make that change on a 1-10 scale and we ask them how confident they are on a 1-10 scale again that they can master whatever the change is in the next three months and we're looking for scores above 7, which indicate that the readiness for change is pretty high. The person is. More likely to achieve their goal. If they're below 7, we can explore what is it going to take to get them to a 7 or an 8 or for them to increase their confidence to be a 7 or an 8. You can also get more insight about where the person is if you ask about, “why did you choose that number and not a lower one?” So, for example, “why did you say 5 and not 4?” and if we go back to our example of the dump truck operator. They've rated the importance of making these changes as a 7 to 8 and their level of confidence as being around 3 or 4. So we can say they've got some motivation, but they're going to need some help.
I'll now talk a little bit about the different health coaching approaches, depending on the person's readiness for change and you can see we have the readiness for change along the left side again and then across the top. The different approaches motivational interviewing which Hung has talked about cognitive behavioural therapy, positive psychology and social support, and then you'll see that motivational interviewing is usually most helpful in the precontemplative and the contemplative stage. CBT we use at preparation, action and maintenance and then positive psychology and social support we'll use across the stage changes. So, Hung has explained, motivational interviewing. So, I won't go into that in more detail, but you can see in in our example here, a way of understanding this, the GP has discussed the health risks associated with smoking, being overweight and a lack of social connection and they've personalised this to their client’s situation. So, you know, highlighting the health risks of FIFO lifestyle and the fact that living the FIFO lifestyle actually has greater negative impacts on people's general health and well-being than the general population, and then also bringing that person's attention to their soon to be born grandchild and how important it is for them to work on their health so that they can be part of the grandchild's life for the future.
In CBT, we're addressing negative thought patterns and behaviours that might be hindering someone's progress. So, we're helping clients to identify and reframe limiting beliefs. So, in our example of the operator, the GP has supported that client to reframe. I can't go to the gym after work. I don't have time and I don't know how to use the equipment. To I can ask for some help to use the equipment and I can go to the gym twice per week when I'm on day shift. So positive psychology is about identifying and building strengths and also developing positive emotions, fostering optimism and a constructive outlook outcome, and to help overcome challenges and enhance overall well-being.
So, the GP is going to be highlighting the clients’ strengths along the journey and highlighting their ability to commit to things for the long term, for example their job and their marriage. So, there's a good likelihood that they're going to be able to commit to their health for the long term as well.
Then finally social support. So again, this is important across the whole and readiness for change spectrum, encouraging people to seek support from their friends, their community, their family and as we know how important the sense of belonging and support is to people's general health and well-being.
So, the GP's highlighted the risks of social isolation, especially for FIFO workers. They've personalised this for the individual and encouraged that client to proactively create connections not only at home but also on the work site. So rather than, you know, heading off to his room every night after dinner, and trying to spend some time with his colleagues and getting involved with some of the social activities or the exercise classes that are offered. And the client is also encouraged to enlist the support of his wife and the personal trainer at the camp gym. There's also an option to engage a health coach through the organisations EAP programme.
So, you'll see here a slide highlighting the stages of change and some matched interventions. So, some examples there of the types of language that you might hear which can help you understand where that client might be in terms of change readiness. And then some options in terms of how you can focus your approach depending on what stage of change they're at.
So, I'm going to provide a couple of examples now of action planning, and as Hung has highlighted, we need to start small and create achievable small changes in things that people are doing a lot of. If someone's making a little change in something that they're doing every day, it actually adds up to a lot of change over the course of a week, but just recognising it's really hard to make changes to our routines, to our lifestyles, and so we need to create achievable goals so people can start to feel that sense of. And efficacy and achievement early on that will then encourage them to keep going.
So, we're starting small with our dump truck operator. They haven't been doing any exercise at all, so we don't want to send them into a state of despair because our goals are too high. The lifestyle prescription here is aiming for 60 minutes of exercise per week. You can see here how we spell out the action plan in a lot of detail. So, what is the dump truck operator going to be doing? They're going to be walking on the treadmill. How much of and at what intensity? So, at a pace that they can still speak or converse. For how long? For 15 minutes. So, we're saying 15 minutes because it's probably a little bit of a stretch for this person, they're probably also able to achieve it, and hey, we might see that they do 20 minutes or a little bit more than 15. So how often? Three times a week. With whom? They're going to do it by themselves initially and supported by the personal trainer at the gym of course and then that time is after they finish their work, but before they head off to dinner. Their support system is the PT at the gym who's going to be teaching them how to use the equipment and obviously also providing support in their training program and then their wife, who can help remind the dump truck operator when they're having their daily phone call.
So, the biggest barrier here is feeling tired at the end of the day and just not being bothered to get changed and go to the gym. The solution to that barrier is reminding themselves that walking is going to increase their energy and improve their health. So, he can be around to see his grandkids grow up, and they're also using the supportive approach and the positive psychology here and reminding themselves that they can start small and increase the amount of exercise that they do. So, we can see the confidence level here is a 7 out of 10. So, we're pretty confident that this person is going to be able to implement this program.
Just having a quick look because there is a comment in the chat there. OK. So strong emphasis on collaboration and co-designer goals, yes. As a psychologist, is there a time you've encountered when you have to directly challenge or confront a client or patient to address something they appear to be ignoring or avoiding? That's a very good question and a really difficult one as a psychologist. It depends on the relationship that you have with the client. So we're, trained to be very supportive and to always, I guess be on the side of our client and so if they're ignoring or avoiding, we tend to be, I guess somewhat exploratory and tentative in a way that we might address that or ask questions about that, but of course, if you've got a strong relationship with the client you've been working with for a while, you can be a little bit more upfront. But we're always thinking about the relationship. We don't want to confront someone and damage the relationship and then we don't see them again, and I think it's probably a bit different for psychologists than GP's, as Hung was talking earlier about people expect and you probably didn't exactly say this Hung, but people expect their GP to tell them what to do and psychologists do less of telling what to do. We would probably ask the person about “What's going on? Why is it that they haven't been doing whatever it is that they said they would be doing?”, and the approach would be different if we were in a coaching relationship compared to with therapy relationship as well. So, in therapy, we do have to pay very close attention to that relationship and to looking after the individual and not causing any sort of rupture in coaching, we probably have a bit more commission to push a little bit harder, especially when it's around goals, and if you've got them written down beautifully like this, it's a lot more easy to ask people about what's going on. OK, hopefully that answered that question.
Another example here for the dump truck operator. Great. Thanks. Sorry. So, our lifestyle prescription here is around nutrition, so eating 1 cup of leafy greens at dinner every day. Again, this might seem like a pretty small goal from some of your perspectives but trust me if you see the plates of some of these people coming out of the canteen, there's not many green items to be seen, so if we can start off with getting them to think about eating more leafy greens and that's a great start. So, we've got what? Is it eating leafy greens? There's lots of examples there for them. How much we're going for: One cup at dinner. We're going to do this for three weeks, and then we're going to check in. So how often do we want the person to do it: every day, and they're going to do it by themselves at the dry mess, so the dry mess is the canteen. The wet mess is the bar. They'll do that at around 6:30 when they have their dinner. Their support system is their wife and their onsite personal trainer who knows about their health improvement plan. The biggest barrier is there are multiple tasty meal options available that don't include leafy greens, and when I'm tired, I just choose what I feel like eating so they've always got options of things like fried chicken wings or meat curries and things like that. So, it's really tricky and we highlighted earlier the dessert options as well. There's a lot of sugar available easily. So, the solution to the barrier is to remind themselves that small improvements in their nutrition are going to have a positive impact on their energy and improve their health and the way that they're feeling day-to-day and it's going to contribute to their long-term health goals. Confidence level here is a little bit lower, so it's a 5 out of 10 for our dump truck operator. As I said earlier, they don't have a lot of existing knowledge about nutrition. So, you might be looking at all this and thinking “Oh my gosh, I don't have time to coach someone through goal setting like this and where am I going to, be able to get a health coach”. So, the field of health coaching is really growing, which is great. You'll find some psychologists are specialising in in health coaching now. We also see quite a lot of nurses getting trained up in health coaching techniques as well and doing health coaching and what we're trying to do is pull together a directory of people who are health coaches. So, if you're interested in having access to a list of health coaches that you can refer on to, please let us know and we can share that list with you.
Then finally, as an organisational psychology consultant, I'm working with organisations, so not just individuals promoting health and well-being and lifestyle medicine applied at work obviously needs to be part of a systemic approach. So similar to the message that Hung was saying about our systems and how we need them to support our health. So, you can see a model here from the Future of Work Institute, which highlights the pillars of well-being at work and also strategies to support these. So, we need to also acknowledge that work is really key to the well-being of individuals. It provides a source of meaning, purpose and connection, but the workplace can be a source of great stress for people as well. So, the systemic approach to thriving at work includes addressing the risks at the systemic levels and providing education about wellbeing and pathways to support individuals.
So that's the end of my presentation. Just checking in, there's another question quickly before I hand back to Dimetri and Hung.
Dimitri:
Yeah, I think that question was for Hung and I think it was more sort of just a comment from his earlier answer.
Amelia:
OK.
Dimitri:
Fantastic. Sorry, Amelia. Yeah. [overlap of talking[
Amelia:
[Overlap of talking] Hung would you want to? I was going to say Hung do you want to speak to this to the conference?
Hung:
Yeah. So, thank you everyone for sticking at it to the to the very end. Sorry about technical issues, but I just got a couple of slides that that we like to promote for you. The first one is this one and its quite timely cause about this time next month we've got an Australasian Society of Lifestyle Medicine event conference that we have every year. It's an international conference. So mainly Australians and New Zealand, but a lot of people from Europe and the Pacific also come so learning with us. If you're interested in more of that lifestyle medicine, if you're interested in becoming a lifestyle medicine practitioner and not knowing what that actually means, this is the tribe that you need to go and talk to, and they're not necessarily GPs. They're all allied health professionals, nurses and so on and also medical specialists there as well. So, there's an academic program. There's a lifestyle medicine program of course. There are workshop programs and the like. There's a strong focus on Aboriginal or indigenous health, with the Māori population as well as Torres Strait Islanders and Aboriginal people. So, because it's in keeping with the theme, better help for all. So, we deal with disability and LGBTIQA people as well aged care, etcetera. So, please come. It's a great theme and we'd love to meet you there as well and you get to see me and Amelia there of course.
So next slide. I think most people at RACGP would know this, but certainly as we would like you to give it a go, this is healthy habits. It's a program. It works on an app. It's for patients who are at risk or living with chronic disease. They often need extra support as you can see from Amelia's presentation. So, there's a little bit of monitoring and understanding the role of their diet and exercise and sleep as part of a healthy lifestyle. Those data are collected by them and they will be able to share that with their health professionals, including their GP's, of course, and then to map out an action plan, something like that. So, it is used in a different way, but it's available for members and please, please check it out.
Dimitri:
Great, thank you, Hung, and just to add to that as well that the healthy habits program is free and primary care professionals can register it as well with their patients. So, just go to their website for more information.
Well, thank you so much, Amelia and Hung for that very informative webinar. Thank you again for everyone, for their patience. We did make it through, which is good. A reminder to just complete the evaluation at the end of the webinar. It'll only take a couple of minutes to complete and will help us improve the content and format for future webinars.
Certificates of attendance will become available on everyone's CPD statements within the next couple of days. If you are a non RACGP member and would like a certificate of attendance then please email rural@racgp.org.au and of course don't forget to tune into our other free monthly webinars held on the 1st Thursday of every month and on that note, I will end the webinar, for all have a great night and take care. Thank you.