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Patient Motivation and Adherence

PTP 581 Module 9

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Upon completion of this module, the student will be able to describe methods to increase patient motivation and adherence.

Objective

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Compliance

Adherence

Motivation

Locus of Control

Terminology

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Compliance indicates goal achievement determined in a health related regimen◦ Are the goals achieved?

Adherence indicates commitment or attachment to a regimen◦ More autonomous,

Nonadherence

Compliance/Adherence

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Biomedical theory-severity of conditon Behavioral/social learning theory-external

factors (cues, reinforcement, encouragement, social support)

Communication models-how well you have explained the program, reasons for adhering

Rational belief theory-explaining the cost and benefits of adherence.

Self-regulatory systems-people can problem solve to regulate their behavior, own cognitive skills. Past experiences.

Theories and Models of Compliance/Adherence

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Outcome Markers Process markers – appointments kept,

medications taken, % sessions completed relative to number prescribed

Patient self-report on following providers’ recommendations

Factors Reflecting Adherence

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Age/Life Stage Socioeconomic status Significant others Severity of disease Nature of regimen (complexity, change) Side effects

Factors Influencing Adherence

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Credibility of source (PT) Physical/logistical barriers Attitude of patient/parent Prior experience with physical activities

Factors Influencing Adherence

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Therapeutic regimens that require significant changes in lifestyle are likely to result in poor adherence.

># of drugs prescribed and more complicated the regimen, the poorer the adherence

Adherence

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Acquisition of behaviors – shaping (successive approximates)

Reinforcement (during/after) Stimulus control (cues) Cognitive strategies (mutual goal setting)

Factors Promoting Adherence

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Support Relevance/Importance Keep simple and within lifestyle Credibility and trust of source Team Approach

Factors Promoting Adherence

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Put in writing

Keep in touch

Check up, often

Consider the costs

Other steps to improve adherence

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Patient/Client Involvement Active in setting goals Active involvement in treatment Confidence in ability to perform exercise Confidence in therapist Demonstrate HEP back to therapist

Encourage Adherence

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Therapist Responsibilities EDUCATE, EDUCATE, EDUCATE Work with other team members Teach how to monitor vital signs Provide written instructions Patient understanding of exercise

program

Encourage Adherence

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Therapist Responsibilities Provide ongoing encouragement/positive

feedback to patients EDUCATE, EDUCATE, EDUCATE Ask patient about particular problems they

are having Review exercise diary/log Follow up phone calls/contact

Encourage Adherence

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1. Anticipate non-adherence2. Consider the regimen from the patient’s

perspective3. Foster a collaborative relationship

based on negotiation4. Be patient –oriented

Patient Adherence Guidelines

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5. Customize treatment 6. Enlist family support7. Provide a system of continuity and

accessibility 8. Make use of community resources & other

health care providers9. Repeat everything10. Do not give up

Patient Adherence Guidelines

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Postsurgical confusion (eg, postsurgical repair of hip fracture)

Emotional lability or irritability (eg. post stroke)

Expressive or receptive aphasia (eg. Post stroke)

Deficits in memory, organization, or planning (eg, secondary to traumatic or acquired brain injury, stroke, delirium following hip fracture surgery)

Common Comorbid ConditionsServing as Barriers to Adherence

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Frailty( eg. secondary to aging, osteoporosis)

Depression ( eg. secondary to chronic pain, spinal cord injury, multiple sclerosis, myocardial infarct)

Attention deficits Poor judgment or impulsivity

Common Comorbid ConditionsServing as Barriers to Adherence

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a. Psychological force that moves a person toward some kind of action

b. Result of both internal and external factorsc. Internal state or condition (sometimes

described as a need, desire, or want) that serves to activate or energize behavior and give it direction (Kleinginna and Kleinginna, 1981)

d. ??

Motivation

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Franken (1994) additional component in definition: persistence of behavior.

Researchers now acknowledge that factors that energize behavior are likely different from factors that provide for persistence of behavior

Motivation

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Premises Integrated wholeness of individual and

hierarchy of goals Not all behavior is motivated Other determinants of behavior other than

motivationPrinciples of hierarchy of needs Physiological, safety, love/belonging, self-

esteem, and self-actualization

Theory of Human Motivation (Maslow 1943)

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How is locus of control associated with compliance/adherence and motivation? -feel like you have control of your environment.-internal: self-contribute to own health outcome-external: what’s going to happen will happen

no matter what I do.

Locus of Control

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Personal Attributes-cognitive, positivity, education

Environmental Influences

Learner Relationship Systems=trust of PT, hold accountable on account of relationship

Motivational Factors

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State of Optimum Anxiety ◦ Moderate anxiety to be suited for learning, reason

to learn, alertness, need to care that you will do well.

Learner Readiness Realistic Goal Setting Learner Satisfaction/Success Uncertainty-Reducing or Uncertainty –

Maintaining Dialogue

Motivational Axioms “sets the stage”

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State of Optimum Anxiety A state of moderate anxiety is best for

learning Affects the learners’ ability to observe,

focus attention, learn and adapt

Motivational Axioms

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Learner Readiness Desire to move toward a goal Desire can be influenced by external forces

and be promoted Use incentives specific to the individual

learner Present positive perspectives and

encouragement to shape the desired behavior

Motivational Axioms

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Realistic Goals Goals that are achievable set the stage for

motivation Determining what the learner wants to

change is important to ensure goals are realistic

Establish environment for mutual goal setting

Motivational Axioms

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Uncertainty Reduction or Maintenance Common experience for both clients and

health professionals Individual characteristics may determine

one’s response to uncertainty Uncertainty can be reduced or maintained Uncertainty in sufficient concentration

influences choices

Motivational Axioms

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Concept Mapping Enables the learner to integrate previous

learning with newly acquired knowledge through diagrammatic “mapping”

Facilitates acquisition of complex new knowledge through visual links that acknowledge previous learning

Motivational Strategies

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Motivational Interviewing

Method of staging readiness to change for promoting desired health behaviors

Increase adherence by exploring the person’s motivation for resistance

Motivational Strategies

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Motivational Interviewing

Interviewer asks questions that explore reasons for the person’s behavior and what would be needed for the person to modify behaviors

Used as a strategy to explore client motivation for adherence to health regimens

Motivational Strategies

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Transfer of Learning=take it outside of clinical to functional setting

Continued Reinforcement

Self-control strategies

Relapse/prevention stragegies

Factors Promoting Maintenance of Behaviors

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Use concepts of relapse prevention to help new exercisers anticipate problems with adherence

Factors that contribute to relapse • negative emotional or physiologic states• limited coping skills• social pressure

Relapse Prevention Model

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Factors that contribute to relapse (con’t)• interpersonal conflict• limited social support• low motivation• high-risk situations• stress

Relapse Prevention Model

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Principles of relapse prevention Identifying high-risk situations for relapse

(e.g. change in season) and Developing appropriate solutions (e.g.

finding a place to walk inside during the winter)

Relapse Prevention Model

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Principles of relapse prevention Helping people distinguish between o a lapse (e.g. a few days of not participating

in their planned activity) and oCan still get back in it.

o a relapse (e.g., an extended period of not participating) is thought to improve adherence

Relapse Prevention Model

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Lack of time: part of ADL’s, quick Financial Issues Exercise location Injury, health problems Family issues Work issues Lack of support Unrealistic goals/expectations

Reasons to Discontinue or Barriers to Exercise

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Inability to slowly progress Lack of perceived ability Fear Lack of professional guidance Lower education, income

Reasons to Discontinue or Barriers to Exercise

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Exercises not adjusted to their situation Exercises don’t fit in daily routine Lack motivation Forget to exercise

Reasons to Discontinue or Barriers to Exercise

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Extensively researched, but the rates of non-adherence have not changed much in past 3 decades

Health care providers play a unique and important role in assisting patients with health behavior changes.

Problem of Poor Patient Adherence

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Grouped the interventions into categories that can be remembered by the mnemonic “SIMPLE”

Simplifying regimen characteristics Imparting knowledge Modifying patient beliefs Patient communication Leaving the bias Evaluating adherence

SIMPLE

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Methods/strategies to increase patient adherence and motivation were discussed.

Theories/models to explain adherence vary from a biomedical, behavioral, communicative, rational belief, and self regulatory perspectives.

Summary

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Factors influencing and promoting adherence were discussed, which ranged from shaping of behaviors, reinforcement, mutual goal setting, support, relevance, and team approaches.

Motivational factors, axioms, and strategies were covered which contributed to adherence to behavior changes.

Summary

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Factors which promote maintenance of behaviors were covered and include transfer of learning, continued reinforcement, self control and relapse/prevention strategies.

Healthcare professionals have a vital role in assisting patients with behavior changes and various strategies were presented.

Summary

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Richards,E., Digger,K. (2011). Compliance, motivation, and health Behaviors of the Learner. In Bastable et al. (Eds.) Health Professional as Educator (pp 199-225). Sudbury: Jones & Bartlett Learning

References

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Plack M, Driscoll M. Patient education facilitating behavior change. In Plack M, Driscoll M, eds. Teaching and Learning in Physical Therapy: From Classroom to Clinic. Thorofare, NJ: Slack Incorporated; 2011: p 209-212.

References