When physicians talk with patients about adherence issues, attitudes and behaviors should be important topics of discussion. Understanding the best ways to change attitudes and behaviors may be a vital step in improving adherence.
Attitudes, Behaviors, and Adherence Discussions
Discussions about adherence issues are rarely simple and straightforward.
Patients typically have many beliefs and attitudes that influence their adherence behaviors. Some of these may be openly shared. Others may be deeply buried and not so easy to get at.
The way a doctor – or other healthcare professional – feels about a patient may also influence his or her behaviors. For instance, here are possible back-stories to a doctor-patient discussion on adherence:
The patient struggles to come to terms with having a chronic illness. Being “permanently sick” affects their self-image. The patient worries the condition may restrict his lifestyle and fears possible social stigma. Sometimes it’s easier to just avoid the whole issue of being ill – particularly the burden of taking daily medications. The patient isn’t motivated and doesn’t take his medications. With the doctor, he is guarded and evasive.
The doctor isn’t seeing the expected improvement in symptoms and suspects lack of adherence to prescribed medications. The doctor believes it’s the patient’s responsibility to take their medications and has negative feelings towards non-adherence. As a result, the doctor tends to be blunt and prescriptive with the patient.
Of course, this is a constructed scenario. However it illustrates how tricky adherence issues can be, when you factor in the individual attitudes and behaviors involved. In the situation painted above, how easy do you think it would be to get patient engagement? Let alone achieve better adherence?
It’s important to recognize that attitudes and behaviors are forces for both bad and good. The scenario above suggests how they may negatively influence discussion. Now let’s turn it around and look at how addressing patient attitudes and behaviors can help to solve adherence issues.
Non-adherence is a behavioral issue. In fact, more correctly it’s a behavioral change issue; the goal being to get patients to adopt adherent behaviors. Which begs the question: why hasn’t there been greater focus on behavior change approaches to improving adherence?
Effective methodologies are available and effective in increasing adherence.
Earlier this year, for example a meta-analysis of cognitive-based behavior change techniques (CBCTs) was published in the BMJ (see here).
The analysis was based on 26 studies, covering 7 medical conditions, and involving 5216 participants – mainly from the USA. In terms of impact on improving adherence, an effect size of 0.34 was calculated, which was statistically significant (p < 0.001). The authors concluded that:
“Cognitive-based behavior change techniques are effective interventions eliciting improvements in medication adherence that are likely to be greater than the behavioral and educational interventions largely used in current practice.”
Within this meta-analysis, the CBCT technique most commonly used was Motivational Interviewing.
Current interventions produce only limited improvements in adherence and/or are applicable only in specific situations. The bigger aim is to find interventions that provide substantial adherence improvements across multiple patient types and situations. CBCTs offer significant promise in this regard.
- CBCTs change behaviors – a critical step in addressing adherence issues
- CBCTs are effective independent of patient reasons for non-adherence
- CBCTs are therefore broadly applicable to many different patient types
- CBCTs can produce substantial and significant adherence improvements
- Because solutions are drawn from the patient, CBCTs may foster more durable improvements in adherence
Motivational Interviewing is one of the most widely recognized CBCTs. It is designed to facilitate behavior change by resolving patient ambivalence about change. As a relevant footnote, Aetna has some 1800 clinicians and clinical support staff, who use Motivational Interviewing to help patients achieve better health (see here).
Maybe Aetna are setting a trend here. Should others pay heed to it?