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Behaviour change is the mainstay in the delivery of lifestyle medicine interventions. It is important that clinicians are familiar with behaviour change techniques that foster self‐efficacy and cultivate a therapeutic relationship to empower the change process. Knowledge of different theories is essential. Practising the different techniques with patients will enable clinicians to become proficient in them. The emphasis is on listening rather than informing the patient, motivating rather than convincing the patient, and collaborating with the patient rather than directing the patient.

This chapter tests the candidate’s knowledge of health behaviour, change theories, and how they can be applied in practice to help patients maintain healthy behaviour. It tests the candidate’s ability to apply motivational interviewing, cognitive behaviour therapy, and positive psychology techniques to the behaviour change process.

1 Which of the following best describes the ‘action’ stage of the Transtheoretical Model of health behaviour?The patient has been making changes within the last six monthsThe doctor assists with plans on specific changesThe patient intends to make changes within six monthsThe patient intends to make some changes within one month

2 Which of the following options best describes the Health Belief Model (HBM) of behaviour change theory?Different interventions should be used at different stages of behaviour changeGovernmental policies lead to health behaviour changeSelf‐efficacy and perceived susceptibility to health threat leads to behavior changeSocial reinforcement leads to a patient maintaining a healthy behaviour

3 Which of the following most appropriately describes the levels of influence on health behavior change?Community factors and social networkIntrapersonal, interpersonal, and institutional factorsIntrospective factors, beliefs, and personalityPublic rules, regulations, and policies

4 A 48‐year‐old woman attends for a review of her asthma and when you mention her BMI of 40 kg/m2, she informs you that she has been thinking of buying an exercise bike for her birthday in two months’ time and becoming more active. What stage of health behaviour change does this best describe?Action stageContemplation stagePrecontemplation stagePreparation stage

5 Which of the following management options will be most appropriate for a person on the precontemplation stage?Discuss health risks and benefits of a healthy lifestyleDiscuss mindfulness‐based stress reductionPersonalize their health risk based on medical historyReferral to a dietician for meal planning

6 The action stage of health behaviour change is best characterized by which of the following?The doctor gives a personalized analysis of risk based on the patient’s historyThe doctor maps out an action plan for the patient to endorseThe patient has been making specific health modifications within the past six monthsThe patient is encouraged to list out all the possible barriers to making progress

7 Which of the following would be the best practice in facilitating health behaviour changes?Aim to document a behaviour change plan in every patient’s health records every yearEnsure that every patient leaves with a clear relapse plan Making available a readiness assessment for patients to complete in advance in the waiting roomReview the patient’s completed readiness assessment form to prioritize lifestyle areas you want the patient to change

8 A health behaviour change theory that best explains the reciprocal influence of personal factors, environmental factors, and the health behaviour on the individual is:Health Review ModelSocial Learning (Cognitive) TheoryTheory of Reasonable BehaviourTheory of Socially Accepted Behaviour

9 Key behaviour theories have several similarities. Which of these options best describes the common features?Environmental influence, e.g. socially accepted norms guarantee behavioursMotivation and beliefs about risk and benefits of the health behaviour underpin changeOne’s confidence in ability to complete the behaviour change is keyRegular self‐criticism and reflection aids in behaviour

10 Which of these options is the most appropriate skill in facilitating sustainable behaviour changes at the early stages?Cognitive behaviour techniquesMotivational interviewingPositive psychologyReframing non‐productive thinking

11 Which of these options best represents the precontemplation stage of behaviour change?I am not thinking about making a change at allI have started a change within the last six monthsI am thinking of making a change within the next six monthsI have been making a change for more than six months

12 Which of the following is the most appropriate management in stage‐matched interventions?Offer an intervention that is acceptable to majority of patientsOffer an intervention that is tailored to the patient’s readiness for a specific actionOffer an intervention that is used by all patientsOffer an intervention that the patient has failed before so he can perfect it

13 Which of these options best represents the process in Stage‐Matched Interventions?Family support should not be solicited as this encourages dependenceIt is important that the patient completes every item at each stageThe degree of readiness is not an important factorThe doctor aims to help the patient move from one stage of readiness to the next

14 Thomas is considering becoming more active within the next 30 days to tackle his obesity. Which of these will be the most appropriate action?Check his level of confidence in his ability to carry out his plansDiscuss health risk associated with specific behaviourGive him a lifestyle prescriptionUse CBT to reframe unhealthy thought patterns

15 You are worried that Gabriel still smokes heavily despite his COPD. However, he tells you categorically that he is not willing to give up this habit. Which of these is the most appropriate action for his stage of readiness?You ask the patient to write down his unwillingness to change despite medical adviceYou provide a general healthy lifestyle adviceYou try some CBT techniques to see if you might change his mindYou try to problem‐solve his barriers to stopping smoking

16 Mike tells you that he is already making a change to tackle his unhealthy eating habits. Which of these is the most appropriate next step in his management?Develop a relapse prevention plan if he has been making the change for three monthsDiscuss health risks associated with his unhealthy eating habitGive him an action plan if he is not meeting his goal yetUse CBT to reframe any unhealthy thought patterns

17 Which of the following best describes the stages of readiness?CBT methods work best when started earlyPatients need one month of coaching to complete each stagePositive psychology is counterproductive at the beginning stageThe goal is to move the patient from his current level of readiness to the next stage

18 Which of the following would be most appropriate to include in Health Behaviour Change Readiness tool which a patient could fill while in the waiting room?An assessment of the patient’s confidence that he can improve his nutritionAn assessment of the patient’s marital status and political inclination An assessment of the patient’s perceived importance of lifestyle medicineAn assessment of the patient’s perceived importance of their intellectual abilities

19 Readiness for a change in health behaviour is best determined by which of the following?The doctor’s track record skill of motivational interviewingThe government’s motivations for recommending the changeThe importance the society attaches to the changeThe patient’s confidence level in making the change

20 Which of these is the most appropriate feature of a health behaviour change assessment tool?Patient’s cultural backgroundPatient’s literacy levelPatient’s marital statusPatient’s responses prioritize areas for discussion

21 To facilitate the ‘Coach’ mindset of the Physician, which of the following is the most appropriate recommendation?Be open and compassionateCompel the patient to write his goals downOffer a congratulatory hug to patients for each goal achievedSend a copy of his action plan to his spouse for accountability

22 Which one of these was best demonstrated in the study by Hojat published in the Academic Medicine 2011 on Provider–Patient relationship and illustrated that patients valued empathy from their physician?Improved HbA1c controlImproved literacy levelsImproved social skillsImproved spousal engagement

23 Which statement best summarizes the findings of the study on Provider–Patient relationship Cochrane systematic review (Dwamena et al. 2012)?10‐hour training of providers on attentiveness and empathy did not yield any positive effect on the consultation process10‐hour training on empathy skills achieved the same result as longer trainingLonger training was favoured by most physiciansThe skills had a negligible effect on the consultation process

24 Which of the following best describes key component of good Patient–Provider relationship?Empathetically dwelling on the patient’s negative feelingsIdentifying the patient’s concerns and applying positive psychologyInstructive criticism and goal settingListening carefully and encouraging self‐criticism

25 Which of these approaches is best used in applying the Physician ‘Coach’ Mindset?Discourage family involvement as the patient should not be distractedEncourage patients to take careful note of their weaknessesExplain that obstacles and setbacks on the behaviour change path signals’ poor outcomeShare personal examples where disclosure would support the patient

26 Which of these sets of approaches are most appropriate in the 5 As approach to health behaviour counselling?Advise, agree, approachArrange, amend, acknowledgeAssess, advise, agreeAssist, amend, arrange

27 Which one of these is the most appropriate statement about the 5 As approach to health counselling?Confrontational approach works well in stubborn patientsIt can be used as a brief health behaviour counsellingMotivational speeches are necessary to suppress the patient’s opposition to changePositive psychology should be done by trained psychologists

28 Facilitating behaviour change is best achieved by which of the following?Cognitive behaviour techniques at earlier stages of changeMotivational interviewing at the later stages of changePositive psychology at all stagesWriting down treatment goals

29 It is most appropriate during Motivational Interviewing to do which of the following?Develop discrepancy between where the patient is and what the patient wantsEnsure that the physician sits on the green coaching chair Roll with repentance by remaining non‐judgementalSupport self‐criticism of the patient’s ability to succeed

30 Motivational Interviewing techniques are useful when discussing weight and lifestyle interventions with patients. It’s most helpful to do which of the following?Acknowledge the patient’s prior effortsEmphasize that the cause of obesity is simply overeatingEnsure that obese patients all line up to check their weight in the waiting roomRealize that most obese people have never attempted to lose weight

31 Which of these patterns most represents a type of non‐productive thinking harmful to the patient?All or nothing thinkingCatastrophe avoidingMind mappingUndergeneralization

32 Which of these most suitably describes a feature of unproductive thinking useful to identify in Cognitive Behavioural Therapy (CBT)?Catastrophe avoidingHappiness acting‘Should’ and ‘must’ statementsUndergeneralization

33 Which one of these options best explains how Cognitive Behavioural Therapy (CBT) helps patients?Decrease awareness of their upsetting emotionsDiscourage parental inputMask underlying beliefs that can interfere with behaviour changeReframe thoughts to support behaviour change

34 Cognitive Behavioural Therapy (CBT) is best used in what stages of change?Contemplation and precontemplation stagesMaintenance and precontemplation stagesPrecontemplation and action stagesPreparation and action stages

35 Which of these best explains the role of the clinician during the clinic visit?Encourage more realistic interpretations of thoughtsFacilitate the patient in examining evidence for and against his thoughts Insistence on homework assignments for the patient to practise new thinking strategiesMonitor and explore all thoughts that the patient has

36 Which of the following is the most accurate interpretation of the acronym ABCD in the ABCD method of identifying underlying beliefs that can interfere with behaviour change?Assess the patient’s readiness for changeBerate self about what has occurredConsequences of those beliefs should be exploredDeal with those beliefs

37 Which of the following is the best description of a successful relapse prevention plan?Focusing on self‐criticism when you notice a lapseIdentifying people to blame for a lapseKnowing what to do when a lapse occursTaking steps to write down your action plan

38 Which of the following is a key step in Positive Psychology?Building on dreamsDiscouraging thoughtsEncouraging criticismReinforcing self‐efficacy

39 Which of the following is the best description of the important role the patient’s social and environmental factors play in their health behaviour change?Can help support accountabilityCan have a negative influence due to scrutinyShould ideally be faith‐basedShould never be electronic social networks due to distractions

40 Which of the following is the most effective at undermining health behaviour change?Faith‐based groupsFamily and friendsPeer modelling strategiesPoor goal setting

41 Positive relationships can help support the patient’s health journey by encouraging which of the following?Self‐accountingSelf‐autonomy Self‐criticismSelf‐effacing

42 Which of the following is the most appropriate way for care providers to empower patients?Encouraging dependency on familyProviding monetary supportProviding social entertainmentSignposting to environmental and social support

43 Which of the following is a key feature of poor counselling techniques on health behaviour change?Encouraging introspection and focus on areas of weaknessEncouraging the involvement of family members in action plansGuiding the patient to do a social support analysisOffer stage‐matched intervention at every visit

44 52‐year‐old Sue has been found to have high cholesterol of 7.2 mmol/l. She says she hates vegetables and would not ever eat them. She is already considering registering with a gym to increase her physical activity but is concerned her bad knee may not allow her exercise much.On the advice of a friend, she has bought a cookery book to explore healthy meals that do not include vegetables. What is the best course of action to facilitate her health behaviour change journey?Cognitive Behavioural Therapy (CBT) to address her concern that her knee would be a limiting factorCognitive Behavioural Therapy (CBT) to counter her hatred of vegetablesMotivational interviewing to address her plans of registering with a gymMotivational interviewing to address her use of the cookery book

45 Lucy has a blood pressure of 173/92. She is adamant that she will not take medication. She is keen to try lifestyle changes and is already cooking with less salt and adding garlic to her meals. She refuses to go for a walk as she is afraid of the youngsters hanging about the street corners and her husband is always too tired to come walking with her.What is the best course of action to address her concerns?Cognitive Behavioural Therapy (CBT) to explore her mindset about taking medicationMotivational Interviewing to address her fear of youngsters in the streetMotivational Interviewing to address the perceived limiting effect that her husband’s tiredness is having on her healthPositive psychology to affirm what she is already doing with her meals

46 Which of the following is the most appropriate step in effective consultation during Action Planning?Address the patient’s questions about his diagnosisConfront the patient on his lack of progressSummarize the patient’s comments to show how negative he isThe doctor sets goals for patients to facilitate their behaviour change

47 In the precontemplation stage of health behaviour change, it is most appropriate to do which of the following?Ask the patient to identify the major obstacle to completing goal and strategy to overcome itElicit the patient’s level of confidence in achieving a specific goal (1–10 with 10 being extremely confident)Ensure goals are specificGive general advice on benefits of leading a healthy lifestyle

48 Action plans are lifestyle prescriptions tailored to the individual patient. Which of these is most appropriate to consider when drawing up action plans?AbilityFamilyNeighbourhoodSocial connections

49 Lifestyle prescriptions are best based on which of the following?Current level of activityMay be adjusted as the patient’s situation changesThe patient’s readiness for changeScientific evidence

50 Which of the following is best considered in relapse prevention plans?Develop plan at the precontemplation stageFixed to ensure stabilityRechecked with the patient as life situations changeShould not be planned in anticipation of a relapse

51 At which of these points is Cognitive Behavioural Therapy (CBT) most useful?At the precontemplation stage of changeThe patient is experiencing feelings of courageThe patient is feeling out of controlWhen the patient is succeeding with his goals to prevent him from getting too comfortable

52 Which of these most accurately describes relapse?Relapse is a sustained period when an action plan is not followedRelapse is easier to address before it becomes a habitRelapse is more likely to occur if an action plan is written downRelapse needs to be addressed as a continuation of the previous action plan

53 Which of these most accurately describes lapse?Lapse is a short period when an action plan was not followedLapse is more likely to occur if an action plan is written downIt can take less energy to re‐start an action plan if allowed to lapse for a long timeIt is easier to deal with a lapse by allowing some time to pass before revisiting the issue

54 Which of the following is the most appropriate to address in a relapse prevention plan?Disclosing the frequency of lapse occurrence in the populationThe patient identifying when a lapse is likely to occur and what to do thenWhat occupation predisposes the patient to lapsesWhat the patient’s neighbours frequently engage in that can cause a lapse

55 Which of these is the most appropriate self‐management strategies for lapse prevention?Digital and live exploration of triggersFrequent exposure to lapse triggersMaking use of the friends’ recommended social media sitesSupport with digital self‐help apps

56 Danny started smoking again after three months of abstinence. He now wants to quit smoking again. Which of these is the most appropriate advice for him?Create a backup plan at the time of any relapse to enable you stay on track.Encourage a significant other to help remind you of your action plan when they notice a lapseFrequent exposure to your smoking buddies to develop toleranceReach out to your care provider when you find yourself off action plan for more than a few months

57 As a care provider, your most appropriate next step in facilitating your client’s action plan is to:Emphasize the importance of a verbal action planEnsure action plans are completed based on readiness for appropriate behaviour change Keep a copy of the action plan in the medical archivesReview action plans every year

58 Which one of these is best avoided by the coach during follow‐up visits?Confront the patient’s lack of progressCongratulate the patient on the progress madeDiscuss barriers and develop solutionsDiscuss the progress made by the patient

59 Which of the following is best avoided during follow‐up?Failures should be discussed firstHave a patient’s action plan in front of youReflect back what the patient has reported to show an understandingSuccesses should be discussed first

60 Lifestyle prescriptions are best described by which of the following?Evidence‐basedSpecific to the patient’s peculiar health issueTailored to the patient’s abilitiesThe same as action plans

61 What is the next best step using motivational interviewing techniques in a patient who wants his chest to get better but does not want to stop smoking?The interviewer needs to discuss an action plan with the patientThe interviewer should develop discrepancy between where the patient is and what he wantsThe interviewer should withhold empathy to demonstrate the seriousness of the issueThe patient’s resistance is a cue to the interviewer to insist on a quit attempt

62 Which of the following statements most appropriately describes cognitive behavioural techniques?It assists with deeper understanding of underlying challengesIt is the counsellor’s job to generate the solutions as the expertPatient ambivalence is accepted as a natural part of change processPatient resistance is decreased using non‐confrontational methods