Session 3 Flashcards
(28 cards)
1
Q
Explain about behaviour and the aim of Motivational Interviewing (MI)
A
Behaviour is the result of the interaction between what we believe and how we feel. If we want to change behaviour, it is necessary to change the underlying beliefs and feelings related to that behaviour
Motivation is a state of readiness or eagerness to change. Motivational interviewing is a relatively new cognitive-behavioural technique that aims to help patients identify and change behaviours that may be placing them at risk of developing health problems or may be preventing optimal management of a chronic condition. It is a relatively simple, transparent and supportive talk therapy based on the principles of cognitive-behaviour therapy. These principles are to help the patient:
- To understand his or her thought processes related to the problem
- To identify and measure the emotional reactions to the problem
- To identify how thoughts and feelings interact to produce the patterns in behaviour
- To challenge his or her thought patterns and implement alternative behaviours
2
Q
From which model does MI takes its theoretical basis from?
A
MI takes its theoretical bases from the Stages of Change model:
- -Pre-contemplation: when the individual is not considering change
- Contemplation: when they are favourably disposed to change but have not made concrete plans or adopted any action
- Planning: when strategies have been selected but not yet used
- Action: when attempts have been made to, for example, stop smoking, lose weight or adhere to some other health advice
- Maintenance phase: when people make deliberate attempts to continue with the change programme.
The model also differentiates between a lapse (a temporary return to the previous behaviour) and a relapse (a permanent return to the behaviour being changes)
3
Q
What are the 8 components of motivational strategies?
A
Motivational strategies include 8 components that are designed to increase the level of motivation the person has towards changing a specific behaviour. These behaviours are not generalizable, that is, if a person is highly motivated to quit smoking it does not necessarily follow that they are highly motivated to take exercise or eat less fat. These components include:
- Giving advice (about specific behaviours to be changed)
- Removing barriers (often about access to particular help)
- Providing choice (making it clear that if they choose not to change that is their right and it is their choice; the therapist is there to encourage change but not insist on change)
- Decreasing desirability (of the ambivalence towards change or the status quo)
- Practicing empathy
- Providing feedback (from a variety of perspectives- family, friends health professionals – in order to give the patient a full picture of their current situation)
- Clarifying goals (feedback should be compared with a standard – an ideal – and clarification of the ideal can provide the pathway to the goal)
- Active helping: such as expressing caring or facilitating a referral, all of which convey a real interest in helping the person to change.
4
Q
What are MI’s 5 basic principles?
A
- Express empathy: conveying a real, i.e. informed, understanding of the person’s predicament and what maintains the ambivalence. It demands active listening and reflection so that the therapist can provide concise statements that encapsulate what the patient has tried to convey. Convey understanding, acceptance (without judgement) and an interest in the person. The situation may not be acceptable but every person is. Only when the patient perceives this acceptance can they experiment with alternative ways of behaving
- Avoiding argument: arguments are counterproductive. The goal of MI is to encourage the patient to hear themselves say why they want to change. If the therapist is not listening to the reasons why it is difficult to stick to a very rigid diet then the patient will work harder to convince the therapist that the reasons are legitimate and that he or she, the patient, is not simply being neglectful or difficult. These arguments are consolidated in the patient’s mind and resistance to change is increased.
- Supporting self-efficacy: belief in one’s ability to make a change and stick to it is fundamental to that change. Encouraging the patient to make overt positive statements that reflect a sense of self-efficacy will help to reframe his or her thinking.
- Rolling with resistance: the aim is not to argue with the statement but delicately challenge the thought processes that underlie the behaviour one wants to change. When done skilfully it can shift the patient’s perspective of the situation. Humour can lighten the mood, and if used skilfully, the patient can feel as though the session had given them a less serious perspective on a problem that was wearing them down.
- Developing discrepancy: Goals should be generated by the patient and not imposed on them. When appropriate goals are established then the therapist can start to identify the difference between the current and ideal situation; this generates some dissonance or conflict in the patient’s mind. Discrepancy is amplified between where the patient is currently and where they want to be. Once the patient has accepted the arguments for change are based on incompatible beliefs of ‘X is where I want to be but Y is where I am’, then with appropriate support he or she can start to move along the cycle of change.
5
Q
What are the 8 steps of MI that allow the therapeutic process to work?
A
- Establishing rapport (patient learns to trust the therapist is not there to judge, cajole or bully them into changing). Trust is essential if change is going to be attempted.
- Setting the agenda: the patient should set the agenda for change, but with feedback from the therapist as to what the patient prioritizes, the difficulties they are aware of (or not aware of), and how achievable the goal is given the resources available. Imposed agendas are counter-productive
- Assessing readiness for change: by increasing discrepancy through probing for readiness, willingness and ability to change. It is possible to be willing to change but not ready, able but not willing and so on.
- Sharpening the focus: breaking down the behaviour pattern into its component parts can help the patient to focus on specific behaviours. This not only helps them to see how the patterns are maintained but also makes the task more achievable.
- Identifying ambivalence: ambivalence is being expressed if the patient disagrees, argues, denies or ignores a statement of reflection or requests for elaboration. It is an indication that there are reasons for and against change.
- Eliciting self-motivating statements: take every opportunity to encourage the patient to phase things in a positive way and to highlight successes. Asking what would be the best outcome from a course of action for the patient encourages them to see possibilities and envisage success
- Handling resistance: reflection is a powerful way of handling resistance.
- Shifting the focus: helping people around a barrier can be a way of handling resistance also. The therapist should shift to the beliefs underpinning the behaviour.
6
Q
Define compliance, adherence and concordance
A
- Compliance: the extent to which the patient complies with medical advice
- (Traditionally patient does what they are told, doctor knows best, powerful doctor/ passive patient)
- Adherence: the extent to which patient behaviour coincides with medical advice
- (Nowadays there is an attempt to be more patient-centred, need for agreement, patient’s right to choose)
- Concordance:
Negotiation between patient and doctor over treatment regimes
Patients’ belief and priorities are respected
Patient is active, can make decisions in partnership with doctor
Concordance does not refer to patient’s medicine-taking behaviour, but the nature of the interaction between clinician and patient
7
Q
How can achieving concordance lead to better adherence?
A
- Patient is involved in, and has shared ownership of, decisions about treatment (shared decision making)
- Patients’ beliefs, expectations, lifestyle and priorities can be taken into account
- Barriers to adherence (e.g. practical, informational, perceptual) can be addressed
- It promotes patient trust and satisfaction with care which makes adherence more likely
8
Q
What are the key points in Towards Concordance in Prescribing (Elwyn et al 2003)?
A
- Define problem: clearly specify problem taking in your own and patient’s views
- Convey equipoise: make clear there may not be set opinions about which treatment is best. Describe treatment options and consequences of no treatment
- Provide information in preferred format (e.g. written)
- Check patient understanding of options; elicit patient’s concerns and expectations about condition, possible treatments and outcomes
- Ascertain patient’s preferred role in decision making
- Defer if necessary: review needs and preferences after patient has had time for consideration, with family/friends, if they wish
- Review decisions after specified time period
9
Q
Are there tensions in concordance?
A
- Between evidence-based medicine and patient-choice
- Between individual rights (e.g. patient autonomy) and responsibilities
- Concordance does not address medication-taking
10
Q
What are key points in agreeing treatment plans with patients?
A
- Discuss the patient’s beliefs, concerns and intentions relating to treatment. Where possible, customise the regimen in accordance with the patient’s wishes.
- Simplify the regimen as much as possible
- Provide simple, clear instructions for taking medication
- Elicit the patient’s feelings about his or her ability to follow the regimen and discuss strategies for enhancing adherence.
- Consider the use of medication-taking systems, including electronic reminders
- Emphasise the value of the prescribed regimen and the importance of adherence for producing the best treatment outcomes
- Obtain any necessary help from family members, friends etc
- Combinations of verbal and written information may be more effective than either in isolation. Combined approaches can repeat and reinforce information, as well as emphasise that the doctor is interested in the patient’s understanding of the information and the importance of adherence.
- The benefits of written information can be further enhanced if that information can be customised to each patient (as opposed to generic letters or leaflets)
11
Q
Describe the extent of non-adherence across patient groups
A
Non-adherence to medical advice is the norm
- Chronic illness
50% non-adherent (Horne 1998)
10-25% of all hospital admissions due to non-adherence (Ley 1997)
DiMatteo (2004a) reviewed 733 studies over 50 years and found average rate of non-adherence 24.8%
- Type of treatment regimen – non-adherence to: (DiMatteo 2004a)
Medication 20.6%
Exercise 28%
Health behaviour 31.3%
Diet 41.7%
- Non-adherence is common even in more severe diseases and transplant patients (Wainwright & Gould, 1997)
22% of adult renal transplant are non-adherent to immunosuppressant medications (Greenstein & Seigel 1998)
91% of non-adherent patients experienced organ rejection or death, compared to 18% of adherent patients (Rovelli 1989)
12
Q
What diseases have the highest rates of adherence and non-adherence, and explain the costs and implications of non-adherence?
A
Highest rates of adherence:
- HIV, arthritis, GI disorders, cancer
Highest rates of non-adherence:
- In pulmonary disease, diabetes and sleep disorders (DiMatteo, 2004a)
The impact of non-adherence:
- Impact on patients’ health
- Financial implications e.g. the cost of drugs not used: “increasing the effectiveness of adherence interventions may have a far greater impact on the health of the population than any improvement in specific medical treatments”
- Lots of research has been done but there has been little progress made in reducing rates of non-adherence
13
Q
Why is it difficult to measure adherence?
A
How do you measure adherence? What counts as adherent? Every item of medication exactly as prescribed?
- Not taking enough e.g. too little of recommended exercise
- Taking too much e.g. exceeding prescribed drug dosages
- Not taking at prescribed intervals e.g. exercising too frequently or not as frequently as required.
- Not taking for prescribed duration e.g. ceasing antibiotic medication when one feels better
- Taking medication not prescribed - taking medication without the knowledge of the prescribing medical professional
Treatment not usually a ‘one-off’ event, usually continues over a period of time so do you measure the first week, first month or after a year?
Lack of consistency in measures
Hard to compare studies for different conditions with different medication or treatments
14
Q
Describe techniques for measuring adherence directly, and their strengths and limitations
A
direct measures e.g. Urine or blood test (to detect the presence of a drug or markers or metabolites that result from taking the drug), Observation
- Advantages of Urine or blood test: provides most direct measure of consumption/ adherence
- Disadvantages of Urine or blood test: expensive, limited to use in clinical practice, invasive, affected by metabolism, non-adherence may still be masked (e.g. can take medicine but not as prescribed, just before attending surgery appointment perhaps).
- Observation (e.g. of consumption): similar problems
15
Q
Describe techniques for measuring adherence indirectly, and their strengths and limitations
A
- Pill counts: more objective than self (e.g. patients filling in questionnaire)/other-reports (e.g. number of repeat prescriptions, medical records review) but still subject to inaccuracy (e.g. lost pills)
- Mechanical or electronic measures of dose: e.g. record time at which container is opened: advantages are that it objectively measures whether a dose has been dispensed, more accurate than other indirect measures. Disadvantages: doesn’t measure whether medication has actually been taken
- Patient self-report: advantages are that it’s easy to obtain and inexpensive, give patients an opportunity to explain about lack of adherence and then find solutions. Disadvantages: prone to inaccuracies/bias, tendency to over-report adherence e.g. self-reported non-adherence often 10-20% lower than measured using other methods (Ingersoll 2008)
- Second-hand reports (from doctors, carers etc): similar advantages and disadvantages to patient reports. Also depends on familiarity with patient. Ley (1988) found a correlation of only 0.21 between doctors’ ratings of patient adherence and other measures of compliance
16
Q
What are the factors influencing adherence?
A
Multi-dimensional model of adherence: contributing factors
- Illness factors
- Treatment factors
- Patient factors
- Psychosocial factors
- Healthcare factors
17
Q
Explain about the Illness/Disease factors influencing adherence
A
- Symptoms: adherence tends to be better when patients experience symptoms. Implications for asymptomatic conditions e.g. hypertension, early Type 2 Diametes Mellitus. Some patients may doubt whether they actually have a disease or not which would impact on their willingness to adhere.
- Severity: with less serious diseases (e.g. hypertension, arthritis) patients in objectively poorer health are more likely to be adherent than patients in better health. With more serious diseases (e.g. cancer, HIV, heart failure), patients in poorer health are significantly LESS likely to be adherent (DiMatteo 2007) ‘phenomenon of giving up – I’m dying anyway’
- This difference may arise because people with more serious conditions have more physical, practical and psychological barriers to adherence
18
Q
Explain about the Treatment factors influencing adherence
A
- Preparation: treatment setting, waiting time, timing of referral, (in)convenience, poor reputation
- Immediate character: complexity of regimen, duration of regimen, degree of behaviour change, (in)convenience, expense, inadequate labels, container design
- Administration: supervision by healthcare professionals (or parents with children), continuity of care
- Consequences: physical side effects, social side effects, stigma (e.g. in certain communities, it is unacceptable to inject in public)
- It is generally easier for patients to adhere to single daily doses than multiple daily doses and their associated timing schedules. Also easier to adhere to regimens that do not involve multiple medications, specific times or dietary requirements. Adherence rates are lower when patients experience unpleasant medication side effects.
- How well does the treatment fit with the patient’s lifestyle?
- How well is the patient supported?
19
Q
Explain about the understanding and recall re patient factors that influence adherence
A
- Patient understanding of the information and content of the consultation, the illness, the body, treatment regimes (Ley 1988)
- Patient recall: after GP consultation, patients couldn’t recall name of drug (37%); frequency of duration (23%); duration of treatment (25%) (Bain 1977). Patient recall is also influenced by anxiety, knowledge, important, primacy/recency effect, number of statements (Ley 1988)
- From patients’ understanding to patients’ beliefs
20
Q
Explain about the beliefs aspect of Patient factors influencing adherence
A
Health Belief Model: Cognitive model used to explain compliance with medical recommendations – the more a prescribed medication accords with a patient’s belief system, the more likely they are to adhere. Extent of adherence depends on:
- Perceived disease severity (strong positive correlation with adherence, Di Matteo et al 2007)
- Perceived susceptibility to disease
- Benefits of treatment recommended
- Barriers to following treatment
- Beliefs about illness: severity, (lack of) symptoms, understanding of illness as chronic vs. episodic
- Beliefs about medication: necessity, harmful effects (side effects, addiction), stigma, concerns about conflict with activities (e.g. alcohol, exercise), tolerance, masking symptoms, “chemical”
- Patients may reject/actively modify regimen or find alternative resources based on their beliefs and priorities – they may be reluctant to be a pill-popper especially if they do not have any severe symptoms yet
- Barriers to treatment include patients not agreeing with their diagnosis or treatment plan. They may also include concerns about side effects or the long-term effects of medication.
21
Q
Explain about psychosocial factors that influence adherence
A
Psychosocial factors: psychological health
- Limited progress in identifying the “non-compliant personality”
- But cognitive deficits or psychological problems impact on compliance (Christiannse et al 1989) e.g. depressed patients x3 less likely to adhere to medication for chronic illness (DiMatteo, Lepper and Croghan, 2000)
Psychosocial factors: social support and context
- Social support: more socially isolated patients are less likely to adhere. Social support (especially practical support) is associated with higher adherence (DiMatteo, 2004b)
- Family support: cohesive and less conflict-ridden families associated with higher adherence then unstable (DiMatteo, 2004b)
- Social context: homelessness was the only predictor of non-completion of therapy in tuberculosis outpatient clinic (Brainard et al, 1997)
22
Q
Explain about the setting aspect of Healthcare factors in influencing adherence
A
the medical consultation takes place in a social setting, not in isolation
- Organisational setting: primary vs secondary care; initial vs follow-up appointment; links between inpatient and outpatient services; regular follow up
- Appeal and accessibility of venue, waiting times
- The prescriber: their beliefs and attitudes towards treatment (Meichenbaum & Turk 1987), ‘new prescribers’ (pharmacists, nurses) (Horne et al 2005)
23
Q
Explain about the doctor-patient interaction aspect of Healthcare factors that influence adherence
A
- Percieved manner: warm, caring, friendly, interested associated with better adherence (DiMatteo & DiNicola, 1982). Adherence tends to be better if patients have longer consultations and a trusting relationship with a doctor who expresses a genuine interest in their health.
- Positive behaviours: eye contact, smile, etc associated with better adherence
- Communication: perceived poor communication associated with higher non-adherence (Haskard et al 2009)
- Perceived competence: interpersonal and technical competence associated with better adherence (Hall et al, 1988)
- Adherence is also influenced by the provision of information by the clinician and efficient use of this information. The exchange of information should not just focus on facts about illness and its treatment but also on the emotional concerns of the patient. Good communication skills are required to elicit patients’ beliefs, respond to them sensitively and to include these when developing a treatment plan that will most likely be adhered to.
24
Q
Define intentional and unintentional adherence, and identify potential reasons for each
A
Unintentional non-adherence:
- Arises from capacity and resource limitations that prevent patients from following treatment recommendations
- May be associated with individual constraints (e.g. memory, dexterity) and/or aspects of their environment (e.g. problems of accessing prescriptions, competing demands) e.g. patients may not understand the instructions for treatment or may forget the instructions, may find it difficult to follow their regimen or simply forget to take doses
Intentional non-adherence: arises from the beliefs, attitudes and expectations that influence patients’ motivation to begin with and persist with the treatment regimen
25
Why is the self-regulatory model of illness important?
The self-regulatory model of illness representations highlights the need to pay attention to a patient’s understanding of their illness including its cause and treatment. There are 3 important aspects of self-regulatory processes:
1. Rational planning of responses to illness
2. Emotional responses to illness and treatment
3. Patient’s monitoring and appraisal of their behaviour and of the progress of treatment
This model therefore emphasises the patient’s ability to reflect on his/her actions and their consequences. Also highlights the constant interaction between the 3 components: beliefs, emotions and appraisal
This model helps explain the various reasons for non-adherence including defensive coping or denial of the threat posed by the illness, missing medication doses to avoid unpleasant side effects or stopping treatment early when symptoms subside.
26
When is adherence better, and why do patients need information?
Adherence is better when patients are satisfied with the amount of information given and when they are able to understand and recall this information. Patients need information to:
* Allow them to be adherent
* Counter fears or misconceptions about their treatment
* Counter feelings that they have not received adequate attention
HOWEVER more information is not always a good thing. Too much information can hamper efficient decision making.
* Information about low treatment efficacy or side effects may lead to lower adherence rates.
27
Describe the nature, effectiveness of, and problems with, interventions to improve adherence
Approaches:
* Addressing practical barriers (re capacity and resources)
* Addressing perceptual factors influencing motivation
Effectiveness:
* Broadly effective, but small effects
* Better in comprehensive interventions (combining approaches) than those focusing on a single cause
Problems:
* Many lack theoretical input – difficult to tell why some interventions work but others do not
* Few are truly ‘patient-centred’ – lack of individualising approach to match patients’ needs and preferences
Various methods can be used to help patients follow through on their intentions to take medication. These include: specific action plans or implementation intentions clear written or printed information, and the use of electronic reminders or monitors of medication use.
28
What can be done to improve adherence?
To improve adherence, it may be important to: provide information, reminders, counselling, support, and reinforcement; discuss the severity of the patient’s illness and emphasise the importance of adherence before a treatment begins.
Adherence tends to be better when the doctor and patient are able to talk about it in a non-judgemental way (Noble, 1998). It is preferable that such discussions happen when treatment is being decided on rather than after the patient’s non-adherence has occurred. It is also important to monitor adherence and to give appropriate feedback to patients.
* Monitor adherence: watch for the markers of non-adherence such as missed appointments, missed refills and a lack of response to medication
* Express approval of adherence and encourage continued adherence. When appropriate, include objective measures of improvement due to treatment
* Ask the patient about non-adherence and barriers to adherence in an understanding, non-confrontational way
* If adherence appears unlikely, consider prescribing more ‘forgiving’ medications i.e. medications whose efficacy is less affected by missed doses. Options may include medications with long half-lives, depot (extended-release) medications or transdermal medication.
