PTP 581 Module 9 1

Upon completion of this module, the student will be able to describe methods to increase patient motivation and adherence. 2

 Compliance  Adherence  Motivation  Locus of Control 3

 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 4

 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. 5

 Outcome Markers  Process markers – appointments kept, medications taken, % sessions completed relative to number prescribed  Patient self-report on following providers’ recommendations 6

 Age/Life Stage  Socioeconomic status  Significant others  Severity of disease  Nature of regimen (complexity, change)  Side effects 7

 Credibility of source (PT)  Physical/logistical barriers  Attitude of patient/parent  Prior experience with physical activities 8

 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 9

 Acquisition of behaviors – shaping (successive approximates)  Reinforcement (during/after)  Stimulus control (cues)  Cognitive strategies (mutual goal setting) 10

 Support  Relevance/Importance  Keep simple and within lifestyle  Credibility and trust of source  Team Approach 11

 Put in writing  Keep in touch  Check up, often  Consider the costs 12

 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 13

 Therapist Responsibilities  EDUCATE, EDUCATE, EDUCATE  Work with other team members  Teach how to monitor vital signs  Provide written instructions  Patient understanding of exercise program 14

 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 15

1. Anticipate non-adherence 2. Consider the regimen from the patient’s perspective 3. Foster a collaborative relationship based on negotiation 4. Be patient –oriented 16

5. Customize treatment 6. Enlist family support 7. Provide a system of continuity and accessibility 8. Make use of community resources & other health care providers 9. Repeat everything 10. Do not give up 17

 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) 18

 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 19

a. Psychological force that moves a person toward some kind of action b. Result of both internal and external factors c. 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. ?? 20

 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 21

 Premises  Integrated wholeness of individual and hierarchy of goals  Not all behavior is motivated  Other determinants of behavior other than motivation  Principles of hierarchy of needs  Physiological, safety, love/belonging, self- esteem, and self-actualization 22

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. 23

 Personal Attributes-cognitive, positivity, education  Environmental Influences  Learner Relationship Systems=trust of PT, hold accountable on account of relationship 24

 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 25

State of Optimum Anxiety  A state of moderate anxiety is best for learning  Affects the learners’ ability to observe, focus attention, learn and adapt 26

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 27

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 28

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 29

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 30

Motivational Interviewing  Method of staging readiness to change for promoting desired health behaviors  Increase adherence by exploring the person’s motivation for resistance 31

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 32

 Transfer of Learning=take it outside of clinical to functional setting  Continued Reinforcement  Self-control strategies  Relapse/prevention stragegies 33

 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 34

Factors that contribute to relapse (con’t) interpersonal conflict limited social support low motivation high-risk situations stress 35

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) 36

Principles of relapse prevention  Helping people distinguish between o a lapse (e.g. a few days of not participating in their planned activity) and o Can still get back in it. o a relapse (e.g., an extended period of not participating) is thought to improve adherence 37

 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 38

 Inability to slowly progress  Lack of perceived ability  Fear  Lack of professional guidance  Lower education, income 39

 Exercises not adjusted to their situation  Exercises don’t fit in daily routine  Lack motivation  Forget to exercise 40

 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. 41

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 42

 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. 43

 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. 44

 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. 45

 Richards,E., Digger,K. (2011). Compliance, motivation, and health Behaviors of the Learner. In Bastable et al. (Eds.) Health Professional as Educator (pp ). Sudbury: Jones & Bartlett Learning 46

 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