How Can HCPs Improve Patient Motivation to Adhere?

By | February 26, 2014

Lack of patient motivation is a major barrier to adherence; one that may be under-recognized and under-addressed. Yet highly effective ways exist to both assess and improve motivation to adhere. This post explores the available tools to improve patient motivation.

Is Patient Motivation an Adherence Deal Breaker?

My last post explored the importance of patient motivation as an adherence factor. It concluded that lack of motivation to adhere can be a deal breaker; if unrecognized or not addressed by healthcare professionals (HCPs).

Patient motivation to adhere is an under-addressed issue. Use of motivational interviewing and behavioral economics can help HCPs tackle this problem.Why is that? Well consider this analogy.

When faced with non-adherence, HCPs develop plans for how to change a patient’s adherence behaviors. Such plans often have several different components. For example, a plan could comprise counseling, patient education, reminders, and cost reduction measures. Let’s say this plan is like an ‘adherence improvement engine’, where all the parts need to work together smoothly and effectively.

To continue this analogy ‒ engines need fuel, which is where patient motivation comes in. Motivation is the gas or electricity that makes the engine work. It’s tough for patients to change their adherence behaviors; they need to be very motivated. Without patient motivation to adhere, an HCP’s plan may never really get off the ground.

If patient motivation is such a deal breaker for adherence, should it not receive greater attention? Indeed the case can be made that assessing patient motivation should be front-of-mind for HCPs when faced with non-adherent patients. And if motivation is lacking, then HCPs need to address this before tackling other factors contributing to non-adherence.

Patient Motivation to Adhere Can Be Simply Assessed

As the overall goal is to change a patient’s adherence behaviors, a useful surrogate here is to assess ‘readiness to change’. An easy way to evaluate readiness to change can be found here.

The patient is asked to rate his or her willingness to change their adherence-related behaviors using a 0-to-10 scale. Zero on the scale equates to the patient being ‘not ready’. While 10 means the patient is ‘ready to change’.

Once the patient provides a ‘readiness score’, the authors then suggest how a conversation can progress. For example, if the patient score is a 3, a follow-up to emphasize positive progress might be: “Why did you choose 3 and not a 1?” Another question to promote stepwise progress could be: “What would need to happen for you to choose a score of 5?”

This simply approach can provide valuable insights on how to further strengthen a patient’s resolve to change their behaviors.

Just how important a factor is patient motivation? Here are some thoughts on why it's of primary importance to improving adherence.Two Ways to Enhance Patient Motivation to Adhere

So a patient’s willingness to change adherence behaviors can easily be measured. But what do HCPs do if motivation is lacking?  Well, there are at least two approaches that HCPs can use to improve a patient’s motivation to adhere. These approaches are summarized below.

1.      Motivational Interviewing

Motivational interviewing (MI) is a well-known, scientifically tested, counseling style that was first described in 1983. MI uses special techniques to facilitate collaborative conversations that strengthen a person’s own motivation for and commitment to change.

MI is an established approach for treating persons with substance use disorders. It has also been used successfully to address motivation-related adherence issues in several different disease areas.

The effectiveness of MI techniques in improving adherence is summarized in two separate meta-analyses publications (see here and here).

Some key characteristics of MI are:

  • It respects the patient’s autonomy
  • It involves directive and client-centered counseling
  • It identifies and mobilizes the patient’s intrinsic values and goals to foster behavior change
  • Motivation to change behavior is elicited from within the patient, not imposed by others

2.      Behavioral Economics

Behavioral economics (BE) is a newer field; though one that offers strong promise for improving patient motivation to adhere. BE is based on the proposition that while human decision-making is often irrational; people are in fact predictably irrational. For example people will tend to:

  • Be biased towards overestimating small probabilities
  • Favor short-term rewards over longer-term rewards (present bias)
  • Prefer avoiding loss over acquiring gain (loss aversion bias)

For an example of how such ‘predictable irrationalities’ can be used to enhance adherence, I’d strongly recommend you take a look here (see pages 43-44). In this case study, non-adherence of the blood thinner warfarin was reduced dramatically using a combination of the three biases described above.

In addition to the three listed above, many other biases have been described. And from an understanding of these behavioral cues, it’s possible to construct other incentives that enhance patient motivation to adhere.

So the tools to assess and improve motivation are available. What can be done to increase their use? I’ll go into this more in later posts.

What other approaches to improving patient motivation to adhere can you think of?