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Background: The high prevalence of behavioral risk factors for cardiovascular diseases demands innovative approaches to achieving behavior change. Primary care physicians are in an ideal position for offering such interventions. Purpose: To evaluate whether training of primary care physicians in counseling skills based on the Transtheoretical Model (TTM) leads to motivational and behavioral changes in their patients. Method: Seventy-four primary care physicians in Germany were randomly assigned to either an intervention condition (one day of training in TTM-based counseling plus brochures matched to their patients' "stages of change") or a control condition (usual care). Baseline and 12-month follow-up data were collected from 305 of their patients who signed up for a health check-up. Outcome measure: Patients' movements across the stages of change for smoking, diet, exercise and stress management. Results: After 12 months, patients of physicians in the intervention group did not show more movement through the stages of change for any of the behaviors than did patients of control physicians. Additionally, there were no differences between groups in counseling frequency, counseling intensity, or patient satisfaction with counseling. Conclusions: A high dropout rate at follow-up and resulting "power" problems limit the possible conclusions. The high numbers of patients in early stages of change and the minimal improvement over time underline the need for improving motivational counseling skills of primary care physicians in Germany. In our study the dissemination of these strategies failed. We offer lessons we feel can be learned from this outcome. Further studies should focus on ways to enhance the process of educating physicians for implementing counseling strategies in primary care settings.

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Background: Behavior change counseling is one of the most difficult and constant challenges faced by health providers. It has a significant impact on clinical outcomes as well as patient and provider satisfaction. By encouraging patients to participate in a partnership with health care professionals, Brief Negotiation offers techniques to motivate behavior change successfully. We review the key components of Brief Negotiation and describe how one large group model health maintenance organization was able to identify key staff members, develop educational opportunities and implement Brief Negotiation system-wide into standard care practices. Objectives: To expose a maximum number of health care professionals to a recommended model of behavior change counseling; to increase the satisfaction and confidence of health care professionals in counseling for behavior change; and to increase the likelihood of improved patient health outcomes. Method: Two departments created one-day, two-day, six-hour and one-to-two-hour skill-based programs targeted to physicians, nurse practitioners, care managers, clinical health educators, behavioral medicine specialists, physical therapists, pharmacists and medical assistants. Practice protocols, strategic departmental alliances and intranet sites complemented the educational interventions. Results: Over 1000 health care professionals have been exposed to the Brief Negotiation model in over two years. A mailed survey to graduates of the one- and two-day programs indicated that 67% of physicians and 79% of other health professionals felt more confident about working with patients on behavior change after having attended the Brief Negotiation program. Conclusions: System-wide professional development requires multiple exposures to the Brief Negotiation model, considerable resources for curriculum development, training time and follow-up, and credible clinical trainers. Questions remain about the amount of training needed for long-term clinician behavior change and for improved health outcomes in patients.

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Medical education has historically relied on the rational choice model as a vehicle for promoting health behavior change, and has largely overlooked the powerful relationships between social class and health behaviors. The rational choice model, which assumes that people can choose to pursue behaviors that are needed for their health, has some clinical utility, especially in some circumstances, but it runs the risk of missing key sources of in uence and of blaming the victim. The biopsychosocial model provides an alternative basis for teaching about health behavior change. Health behavior needs to be understood in a broad social context, in which social class is recognized as playing a large part in shaping many people's health behaviors through multiple pathways, including limited opportunities for self-fulfillment, financial constraints, health beliefs, self-efficacy, stress, and social support. In addition to highlighting the limitations of the rational choice model, we illustrate how to integrate the socio-cultural context into teaching about behavior change. Specific curricular suggestions include exercises for: (1) increasing students' awareness of their own biases regarding unhealthy behaviors and individual responsibility for change; (2) enhancing knowledge of social factors that impact health; (3) building advocacy skills; (4) learning from patients; and (5) practicing counseling skills through role-plays.

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Context: The Partners in Health Education (PHE) program is an elective that pairs . rst and second year medical students with local classroom teachers to promote health messages to students in kindergarten through grade eight. Designed with the primary goal of helping medical students improve their communication skills through the process of teaching children about health, the PHE program has secondary goals of supporting community teachers in their efforts to promote health and of teaching children about health and the prevention of disease and injury. This report contains the results of the assessment of program impact on the school children. Methods: A total of 327 elementary grade students in 14 experimental classrooms and 13 comparison classrooms comprised the participants for the study. Students were individually interviewed twice over an eight-week period using a structured interview form designed to capture self-report information about health and healthy living. Repeated measures analysis of variance was conducted. The effect of interest in each case was the treatment × time interaction. Results: There were signi. cant treatment × time interactions for several measures of children's reported knowledge and attitudes about health. Discussion: Although designed primarily to help medical students improve their communication skills, the PHE program produced a secondary gain such that elementary students in participating classrooms reported learning more about health than did students in comparison classrooms. Programs such as PHE can provide ways to meet the goal of helping children become empowered to take charge of their own health and to make healthy choices.

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Purpose: Develop and evaluate a course to help . rst-year medical students learn about health-related behavior change by focusing on their personal health goals. Course methods: Students each identi. ed two health-related behavior change goals for themselves. Lectures presented relevant content concerning behavior change. In small group, experiential sessions, students formed . ve-person teams and rotated positions as "patient," "doctor," "manager" and observers. "Doctors" and "patients" had one or two follow-up visits. Students evaluated their goal attainment and the value of their experience as "patient" and as "doctor." Sample: 100 . rst-year medical students. Results: Students chose exercise, nutrition, academic, interpersonal and psychological goals. Rating of the educational values and goal attainments were variable. Mean rating for educational value was 40%, and for goal attainment 55%. Conclusions: Experiential learning is valuable in introducing medical students to behavior change. Students learn from both the role of change agent and the role of "patient." Although the design of the course was cost-effective, with appropriate modi. cations considerably more impact could be gained from such a course. To improve this type of experiential learning we recommend careful attention to goal-setting, and more attention to developing the learners' feedback-giving and facilitation skills.

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Internationally, 20th century medical education concentrated on equipping new graduates with technical skills and pushing the frontiers of technological sciences to extend and enhance life in ways unimaginable in previous decades. In the 21st century, health services are expected to be characterized not by the "fix-up-whenthings-go-wrong" type of care that 20th century physicians have become so good at, but by preventive care that can obviate much of the need for these fix-up services. Enabling doctors to deal with the different health care needs of future patients will require a values shift in medical education. The United States leads the world in per capita health care expenditure yet trails in many important measures of health status. It epitomizes many elements of both the good and the bad in current medical education that may be less obvious in other countries that are less wealthy, less technologically oriented, and less committed to individual freedoms. In this paper we use the US as a case study to argue the need for a fundamental shift in values away from the 20th century emphasis on disease, specialization and treatment, and towards health, generalization and prevention. We draw on data from the National Ambulatory Medical Care Survey to compare roles of primary care physicians and other of. ce-based medical specialties in delivering preventive health care. We also estimate the cost of providing preventive care in terms of physician time. Finally, we contemplate how medical education values must change in the US and other countries if 21st century physicians are to be prepared to meet the health care needs of their communities.

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Intersectoral collaboration has gained acceptance as a strategic approach in promoting health, based on the assumption that the main determinants of health are social, physical and politico-economic factors and not medical care utilization. However, the difficulties of collaborating intersectorally for better health have become apparent over the last two decades. This paper describes an attempt to address these difficulties through an awareness-raising educational initiative devised for undergraduate university students from disciplines other than health. The course aims to raise students' appreciation of the ways in which their future occupations could have an impact on the health of others through intersectoral collaboration and the creation of environments that are supportive of health. The evaluation of the course, which comprised a peer-review process, a questionnaire seeking student feedback, and a task exploring students' ideas on how they could in uence the health of others, demonstrated that students recognized the value of working intersectorally for better health. If intersectoral collaboration is really expected to be the way forward that many public health theorists claim, then this small but effective contribution should best be seen as one of a series of incremental building blocks leading to the desired effects.

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Background: The impact of the social and behavioral sciences on medical education has often been limited due to a variety of organizational , curricular and professional barriers. The new "Medicine, Patient, and Society (MPS)" program in Tel Aviv attempts to rectify this educational shortcoming by exploring new ways to help students acquire the knowledge, attitudes and skills needed for becoming humanistic physicians and for helping patients (and themselves) adopt healthy behaviors. To work toward this goal, this program integrates the biomedical and psychosocial aspects of health care, providing developmentally appropriate learning experiences according to levels of training, together with a variety of educational methods, including learner-centered approaches. Objectives: To implement and evaluate the MPS pilot program. Methods: The MPS program uses a "seamless" model of behavioral science education. This integrated curriculum interweaves several elements: behavioral science topics (presented through multiple approaches), clinical experiences, practical medical skills, and an independent project. During the program's first year there is a strong focus on "health" rather than "disease," with activities designed to encourage healthy behaviors, including smoking cessation, stress management, birth control, AIDS education, life cycle and preventive health services. Assessment of the pilot for first-year students included standardized questionnaires, student focus groups, participant observation of educational activities, and committee feedback. Results: Students' quantitative evaluations indicated high levels of satisfaction with the MPS program, but their qualitative evaluations revealed some concerns. Participant observations and focus groups added unexpected insights. Student concerns included performance fears, difficulties with "learner-centered" education, and incompatibilities between more traditional first-year courses and the MPS program. Long-term follow-up will be needed to determine the impact of this emphasis on health during the first year. We assume it serves as a helpful foundation for students before they focus on disease and its sequelae in their later years.

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Context: In the developing world, drinking water is an important route for transmission of diarrheal disease, a leading cause of morbidity and mortality in children. Objectives: In Field Trial 1 (FT1) and Field Trial 2 (FT2), the effectiveness of the behavior change approach known as motivational interviewing (MI) was compared to the standard practice of health education alone in initiating and sustaining safe water treatment and storage behavior among community residents. In Field Trial 3 (FT3), MI was compared with social marketing. Design: Community surveys were conducted prior to local health promoter training and at follow-up. Setting and Participants: Low socioeconomic status peri-urban communities in Zambia were project sites. Local volunteer health promoters from communities were trained in an adaptation of MI for safe water treatment and storage. Interventions: All health promoters received instruction in the causes and prevention of diarrhea. Health promoters in the experimental (MI) groups received MI training. Main Outcome Measures: FT1 and FT3 measured detectable disinfectant levels in stored household water. FT2 measured disinfectant sales. Findings: No signi. cant differences between the treatment groups were found in FT1. Subsequent MI training incorporated lessons learned from the previous trial and resulted in much higher purchase rates of the disinfectant (FT2) and levels of disinfectant in stored household water (FT3) in the MI group. Conclusion: MI appears promising for public health initiatives in the developing world. Further research to improve and re. ne the method is needed.

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