Improving Patient Adherence Through Health Behavior Change

1
Improving Patient Adherence Through Health
Behavior Change

• Kent Hunter, PharmD, BS
• Medical Outcomes Specialist
• Pfizer Inc

2
Health Behavior Change Learning Objectives

• 1. Understand and describe the steps necessary
  to negotiating behavior change with your patients
• 2. Define Resistance, Dissonance and
  Ambivalence as they relate to health behavior
  change
• 3. Describe the four categories of resistant
  behavior, causes of resistance, and strategies
  for reducing patient resistance during
  consultation
• 4. Describe the five general principles of
  health behavior change (READS)
• 5. Demonstrate how to evaluate a patients
  readiness to change health behavior.

3
Agenda

• Medication Adherence Overview
• Current Perspectives on Adherence
• Patients Health Behavior Change Model
• Health Behavior Change Application

4
Medication Adherence Overview
5
Compliance, Adherence, Persistence

• Compliance and adherence are frequently used
  interchangeably
• Adherence is the extent to which a patients
  behavior coincides with medical or health advice
• The term compliance suggests a passive approach
  to healthcare on the patients part
• Persistence is defined as staying on a treatment
  or medication as prescribed

Peterson A, et al. Am J Health-Syst Pharm.
200360657-665.
6
Incidence of Medication Nonadherence

• Of the 2 billion prescriptions filled each
  year, approximately half are taken improperly

Daniel Gerner, Chairman, Healthcare Compliance
Packaging Council. As reported in Business and
Health. 19981627-33.
7
Patients in US do not take medications as
prescribed
American Heart Association. Statistics you need
to know. Available at http//www.americanheart.or
g/presenter.jhtml?identifier107. Accessed
November 4, 2004.
8
Economic Toll of Nonadherence

• 10 of all hospital admissions are the result of
  patients failing to take prescription medication
  correctly
• 23 of all nursing home admissions are due to
  patients failing to take prescription medications
  correctly
• The average length of stay in hospitals due to
  medication nonadherence is 4.2 days

American Heart Association. Statistics you need
to know. Available at http//www.americanheart.or
g/presenter.jhtml?identifier107. Accessed
November 4, 2004.
9
Adherence in Perspective
Cause of Death in the US
Cancer
Stroke
Heart Disease
Chronic lower respiratory disease
Cardiac Medication Adherence
1National Center for Health Statistics of CDC.
Available at http//www.cdc.gov/nchs/fastats/deat
hs.htm. Accessed September 18, 2003. 2 McCarthy
R. Business and Health. 199816(10)27-33
10
Current Perspectives on Adherence
11
Five Dimensions Affecting Adherence

• Social and economic factors
• Healthcare team and system-related factors
• Condition-related factors
• Therapy-related factors
• Patient-related factors

WHO. Adherence to Long-Term Therapies Evidence
for Action. WHO 200327-38.
12
Patient-Related FactorsBehavioral Theories
Sources Leventhal H, Cameron L. Patient
Education and Counseling., 1987, 10117138.
Horne R, Weinman J. In Myers LB ,Midence K, eds.
Adherence to treatment in medical conditions.
1998. Skinner BF. The behavior of organisms.
1938. Skinner BF. Science and human behavior.
195323-42 cited by WHO. Adherence to Long-Term
Therapies Evidence for Action. WHO
2003139-140. Gibson CH. J Adv Nurs
199116354-61.
13
Biomedical model of health and illness

• Assumes the patient is or should be sufficiently
  motivated by illness to obey instructions
• Treatments are offered to patients who are not
  ready to follow them
• Reflects bias toward treating the disease and
  fails to address the behavioral requirements of
  the treatment
• Interventions following this model are unlikely
  to cause sustained changes in compliance

WHO. Adherence to Long-Term Therapies Evidence
for Action. WHO 2003139.
14
Key elements of a behavioral approach

• Treats noncompliance as a multivariate problem
• Paradigm shift to independence, or
  self-regulatory activity, of the patient
• Emphasizes positive and negative reinforcement as
  a mechanism for influencing behavior

Behavior
Antecedent
Consequence
Source Leventhal H. (1993). Theories of
compliance, and turning necessities into
preferences Application to adolescent health
action. In N.A. Krasnegor, et al (Eds.),
Developmental Aspects of Health Compliance
Behavior (pp.91-124). WHO, 2003
15
Behavioral modelInformation-Motivation-Behavior
Skills Model

• Presence of both information and motivation
  increase the likelihood of adherence
• Interventions based on this model have been
  effective in influencing behavioral change in a
  variety of clinical applications

Information
Behavior Change
Behavior Skills
Motivation
Source Fisher JD, Fisher WA. Psychol Bull, 1992,
111455474 Fisher JD et al. Health Psychol,
1996, 15114123 Carey MP et al. J Consult Clin
Psychol, 1997, 65531541 Mazzuca SA. J Chronic
Dis, 1982, 35521529. as quoted in WHO, 2003.
16
Biomedical Behavioral
17
Patients Health Behavior Change Model
18
Health Behavior Change

• A strategy and collection of methods geared to
  the brief patient-centered consultation, based
  on
• Motivational Interviewing
• Stages of change model
• It is
• Patient-centered
• Directive
• A method of communication
• Used to explore and resolve ambivalence.

Rollnick S, et al. Health Behavior Change A
Guide For Practitioners. Churchill Livingstone
200310,11. Miller WR, et al. Motivational
Interviewing. 2nd ed. Guilford Press 200225.
19
Information-Motivation-Behavior Skills Model
Patient Motivation

• Health Behavior Change fits into the component of
  the IMB model involving patient motivation
• We will see how the Health Behavior Change model
  can be integrated in the patient counseling
  session
• Health Behavior Change and Motivational
  Interviewing terms are frequently used
  interchangeable

Rollnick S, et al. Health Behavior Change A
Guide For Practitioners. Churchill Livingstone
200310,11.
20
Stages of Change (Transtheoretical) Model

• 5 stages of change
• Useful for selecting appropriate interventions
• By identifying a patient's position in the change
  process, physicians can tailor the intervention,
  usually with skills they already possess.
• The focus is not to convince the patient to
  change behavior but to help the patient move
  along the stages of change.

Precontemplation
Contemplation
Maintenance
Preparation
Action
Source Prochaska, Am Psychol 1992 471102-4.
21
Evidence of Effectiveness

• Motivational Interviewing techniques have been
  effective for treating alcohol and drug problems,
  patients with diabetes, hypertension, and bulimia
• The Motivational Interviewing process has been
  found superior to no-treatment control groups
• Readiness to change model was able to predict
  clinical improvement in patients with diabetes

Miller WR, et al. Motivational Interviewing. 2nd
ed. Guilford Press 2002217-250. Peterson KA, et
al. Readiness to change and clinical success in a
diabetes education program. J Am Board Fam Pract.
200215266-271.
22
Evidence of Effectiveness

• The use of a patient counseling intervention
  based on the Transtheoretical Model of Change and
  Motivational Interviewing showed an increase in
  persistency of a medication.
• Drop out rate for study patients was 1.2 vs.
  control group of 10.2 over 3 months

Berger BA, et al. (unpublished data , 2004.)
23
The Spirit of Health Behavior Change

• Collaborate with the patient
• Evoke their readiness to take action
• Develop patients autonomy to take responsibility
  for their own health

Miller WR, et al. Motivational Interviewing. 2nd
ed. Guilford Press 200233-34.
24
Common Issues Among Patients
Ambivalence
Resistance
25
Ambivalence

• Persons desire to do nothing
• Can be a key issue that must be resolved for
  change to occur
• Health Behavior Change process may help people
  get unstuck from their ambivalence

Miller WR, et al. Motivational Interviewing. 2nd
ed. Guilford Press 200213-19.
26
Change and Resistance

• Opposite Sides of a Coin

27
Resistance can be bad or good

• Resistance can disrupt and impact the rapport
  between the patient and healthcare provider
• Resistance can be a sign of a patients internal
  conflict between their current behavior and their
  desired behavior

Rollnick S, et al. Health Behavior Change A
Guide For Practitioners. Churchill Livingstone
200323-24.
28
Four Categories ofResistance Behavior

• Negating
• blaming, disagreeing, excusing, minimizing,
  claiming impunity, pessimism, reluctance,
  unwillingness to change
• Arguing
• challenging, discounting, hostility
• Interrupting
• Ignoring
• Inactivity patient does not fill prescription

Miller WR, et al. Motivational Interviewing. 2nd
ed. Guilford Press 200248
29
YES, BUT and PERSUASIVE COMMUNICATION

• Are NOT the solution to resistance!
• Understanding, exploration, and patience are the
  solution

30
Health Behavior Change Application
31
Getting Started
Implementing the Health Behavior Change Process
32
Health Behavior Change Techniques

• Elicit-Provide-Elicit
• Menu of Strategies
• The Five Principles
• READS
• Helpful Tools
• Readiness Rulers
• The Envelope

Rollnick S, et al. Health Behavior Change A
Guide For Practitioners. Churchill Livingstone
2003109. Berger B. Motivational interviewing
helps patients confront change. Available at
http//www.uspharmacist.com/oldformat.asp?urlnewl
ook/files/Phar/nov99relationships.cfmpub_id8art
icle_id450. Accessed January 13, 2004.
33
The Menu of Strategies Elicit

• Opening strategy discussing patients lifestyle,
  how does the patient view it?
• A typical day whats the routine?
• Needed for tailoring
• Identifying dietary needs/problems
• Exercise

Rollnick S, et al. Health Behavior Change A
Guide For Practitioners. Churchill Livingstone
2003112-113. Berger B. Motivational interviewing
helps patients confront change. Available at
http//www.uspharmacist.com/oldformat.asp?urlnewl
ook/files/Phar/nov99relationships.cfmpub_id8art
icle_id450. Accessed January 13, 2004.
34
The Menu of Strategies Elicit

• The good things and bad things
• What do they like and dislike about the proposed
  changes?
• What is their representation of the illness and
  its treatment?
• Do they agree with the MD?
• Do they believe they can do what is asked? What
  will help?
• What are the barriers?

Berger B. Motivational interviewing helps
patients confront change. Available at
http//www.uspharmacist.com/oldformat.asp?urlnewl
ook/files/Phar/nov99relationships.cfmpub_id8art
icle_id450. Accessed January 13, 2004.
35
Readiness Ruler

• Useful tool when you encounter resistance
• Elicits change talk
• Evaluates two concepts
• Importance
• Confidence
• Scale from 1 to 10

Zimmerman GL, et al. A stages of change
approach to helping patients change behavior. Am
Fam Physician. 2000611409-1416.
36
Readiness Ruler
37
Readiness Ruler Questions

• How important is this change for you?
• How confident are you that you can make this
  change if you want to?
• Why did you choose a ____, not a 1?
• What would have to happen for it to be a _____?
  (next highest number from what they stated)

Zimmerman GL, et al. A stages of change
approach to helping patients change behavior. Am
Fam Physician. 2000611409-1416.
38
The Envelope

• Elicits talk of change
• If I handed you an envelope, what would the
  message inside have to say to get you to
  ________?
• Useful when there is ambivalence

39
The Menu of Strategies Provide

• Providing information is the patient ready for
  information?
• Provide patient with all appropriate information
• Dosing how much to take and when to take it
• What the expected onset of action is
• Most common side effects and what to do if any
  occur
• What to do if there are problems
• Ask if patient has any further questions

Rollnick S, et al. Health Behavior Change A
Guide For Practitioners. Churchill Livingstone
2003111-112. Berger B. Motivational interviewing
helps patients confront change. Available at
http//www.uspharmacist.com/oldformat.asp?urlnewl
ook/files/Phar/nov99relationships.cfmpub_id8art
icle_id450. Accessed January 13, 2004.
40
The Menu of Strategies Elicit

• The future and the presentadditional concerns
• Helping with decision making
• What are your thoughts now about managing
  your...
• Where does this leave you now?
• Do you anticipate having any help?
• ELICIT PROVIDE ELICIT

Rollnick S, et al. Health Behavior Change A
Guide For Practitioners. Churchill Livingstone
2003112. Berger B. Motivational interviewing
helps patients confront change. Available at
http//www.uspharmacist.com/oldformat.asp?urlnewl
ook/files/Phar/nov99relationships.cfmpub_id8art
icle_id450. Accessed January 13, 2004.
41
The Five General Principles of Health Behavior
Change

• R E A D S
• Roll with resistance
• Express empathy
• Avoid arguing
• Develop discrepancy
• Support self-efficacy

Miller WR, et al. Motivational Interviewing. 2nd
ed. Guilford Press 200236. Berger B.
Motivational interviewing helps patients confront
change. Available at http//www.uspharmacist.com/
oldformat.asp?urlnewlook/files/Phar/nov99relation
ships.cfmpub_id8article_id450. Accessed
January 13, 2004.
42
Principles of Health Behavior Change Roll With
Resistance

• Use understanding, empathy
• Get clarification
• New perspectives are invited, not imposed
• Dont give person a reason to resist more
• Resistance is a signal to respond differently
• Repeat your understanding
• The person is a primary resource in finding
  answers and solutions

Miller WR, et al. Motivational Interviewing. 2nd
ed. Guilford Press 200236. Berger B.
Motivational interviewing helps patients confront
change. Available at http//www.uspharmacist.com/
oldformat.asp?urlnewlook/files/Phar/nov99relation
ships.cfmpub_id8article_id450. Accessed
January 13, 2004.
43
Principles of Health Behavior Change Express
Empathy

• An objective identification of another persons
  emotions (not their experience)
• Done throughout the process (menu)
• Identify and understand resistance, reasons for
  unhealthy behaviors without judgment
• Creates a climate for change through trust

Miller WR, et al. Motivational Interviewing. 2nd
ed. Guilford Press 200236. Berger B.
Motivational interviewing helps patients confront
change. Available at http//www.uspharmacist.com/
oldformat.asp?urlnewlook/files/Phar/nov99relation
ships.cfmpub_id8article_id450. Accessed
January 13, 2004.
44
What is NOT Listening

• Ordering, directing, commanding
• Warning or threatening
• Giving advice, suggestions, solutions
• Persuading or lecturing
• Moralizing, preaching (fixing, healing, and
  converting)
• Disagreeing, judging, criticizing, or blaming
• Agreeing, approving, or praising
• Shaming, ridiculing, or labeling
• Reassuring, sympathizing, or consoling
• Questioning or probing

45
Principles of Health Behavior Change Avoid
Arguing

• Dont add to the persons resistance
• Arguing forces people to defend the behavior you
  are trying to change
• Empathy sets you up as being on their side
• Confront, but dont argue
• Feelings arent arguable

Berger B. Motivational interviewing helps
patients confront change. Available at
http//www.uspharmacist.com/oldformat.asp?urlnewl
ook/files/Phar/nov99relationships.cfmpub_id8art
icle_id450. Accessed January 13, 2004.
46
Principles of Health Behavior Change Develop
Discrepancy

• Discrepancy Dissonance
• Good things and bad things about change
• Pros and cons
• Throw system out of kilter
• Restate the discrepancies heard
• Change is motivated by a perceived discrepancy
  between present behavior and important personal
  goals or values

Miller WR, et al. Motivational Interviewing. 2nd
ed. Guilford Press 200236. Berger B.
Motivational interviewing helps patients confront
change. Available at http//www.uspharmacist.com/
oldformat.asp?urlnewlook/files/Phar/nov99relation
ships.cfmpub_id8article_id450. Accessed
January 13, 2004.
47
Principles of Health Behavior Change Support
Self-Efficacy

• A persons belief in the possibility of change is
  an important motivator
• Notice the positive, including statements, not
  just behaviors
• Let the person know youve noticed
• The person, not the counselor, is responsible for
  choosing and carrying out change
• Let them know how you feel
• Praise the behavior, not the person
• Continue to support self-efficacy throughout the
  process

Miller WR, et al. Motivational Interviewing. 2nd
ed. Guilford Press 200236. Berger B.
Motivational interviewing helps patients confront
change. Available at http//www.uspharmacist.com/
oldformat.asp?urlnewlook/files/Phar/nov99relation
ships.cfmpub_id8article_id450. Accessed
January 13, 2004.
48
Health Behavior Change Summary

• Elicit - Provide - Elicit
• Address ambivalence, create dissonance
• Explore resistance
• Ask evocative questions
• Exploring the concerns and the pros and cons of
  change
• Ask the patient to elaborate
• Elicit change talk
• Identify patients Goals and Values

49
Other Adherence Resources

• Ask Me 31 www.askme3.org Patient awareness
  initiative
• CMAG-12 Guidelines from the Case Management
  Society of America for improving patient
  adherence to medication therapies

1. Partnership for Clear Health Communication.
Program funded by Pfizer Inc. Available at
www.askme3.org. Accessed October 30, 2004. 2.
Case Management Society of America. Available at
www.cmsa.org/CMAG. Accessed October 30, 2004.
50
Additional Reading

• Rollnick S, Mason P, Butler C. Health Behavior
  Change A Guide For Practitioners. Edinburgh,
  Scotland Churchill Livingstone2003.
• Miller WR, Rollnick S. Motivational Interviewing.
  2nd ed. New York, NY Guilford Press 2002.
• Vermiere E, Hearnshaw H, Van Royen P, Denekens J.
  J Clin Pharm Ther. 200126331-342.
• Miller NH, Hill M, Kottke T, Ockene I.
  Circulation. 1997951085-1090.
• Berger B. Motivational interviewing helps
  patients confront change. Available at
  http//www.uspharmacist.com/oldformat.asp?urlnewl
  ook/files/Phar/nov99relationships.cfmpub_id8art
  icle_id450. Accessed January 13, 2004

51
Bibliography

• Rollnick S, Mason P, Butler C. Health Behavior
  Change A Guide For Practitioners. Edinburgh,
  Scotland Churchill Livingstone2003.
• Peterson A, Takiya L, Finley R. Meta-analysis of
  trials of interventions to improve medication
  adherence. Am J Health-Syst Pharm.
  200360657-665  
• McCarthy R. The price you pay for the drug not
  taken. Business and Health. 19981627-33.
• American Heart Association. Statistics you need
  to know. Available at http//www.americanheart.or
  g/presenter.jhtml?identifier107. Accessed
  November 4, 2004.
• National Center for Health Statistics of CDC.
  Available at http//www.cdc.gov/nchs/fastats/deat
  hs.htm. Accessed September 18, 2003.
• World Health Organization. Adherence to Long-Term
  Therapies Evidence for Action. Geneva,
  Switzerland World Health Organization 2003.

52
Bibliography (continued)

• Miller WR, Rollnick S. Motivational Interviewing.
  2nd ed. New York, NY Guilford Press 2002.
• Prochaska, Am Psychol 1992 471102-4.
• Peterson KA, Hughes M. Readiness to change and
  clinical success in a diabetes education program.
  J Am Board Fam Pract. 200215266-271.
• Berger B. Motivational interviewing helps
  patients confront change. Available at
  http//www.uspharmacist.com/oldformat.asp?urlnewl
  ook/files/Phar/nov99relationships.cfmpub_id8art
  icle_id450. Accessed January 13, 2004
• Zimmerman GL. Olsen C, Bosworth M. A stages of
  change approach to helping patients change
  behavior. Am Fam Physician. 2000611409-1416.

53
FINAL COMMITMENT

• What is one thing (point/process) from todays
  presentation that you will take back and use to
  try to improve patient care?