1. PTP 581 Module 9 1

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

3.  Compliance  Adherence  Motivation  Locus of Control 3

4.  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

5.  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

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

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

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

9.  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

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

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

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

13.  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

14.  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

15.  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

16. 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

17. 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

18.  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

19.  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

20. 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

21.  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

22.  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

23. 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

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

25.  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

26. 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

27. 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

28. 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

29. 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

30. 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

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

32. 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

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

34.  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

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

36. 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

37. 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

38.  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

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

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

41.  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

42. 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

43.  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

44.  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

45.  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

46.  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 46

47.  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. 47