Patient Adherence and Behavior Change (Pt. 2)

This post is a continuation on our discussion about psychosocial aspects related to health behavior changes. Again, by equipping ourselves with a general understanding of components that play into motivation, change, and adherence, we can better address our patients’ individual needs. We began with introducing the Transtheoretical Model and will continue with the Health Belief Model.

The Health Belief Model (HBM) is a psychological model that attempts to predict health behaviors. Major concepts that indicate people are likely to comply with an HEP include: perceived susceptibility, perceived severity, perceived threat, perceived benefits, perceived barriers, cues to action, and self-efficacy[1]. Below are definitions of each of these concepts:

Perceived susceptibility: a person’s belief about their likelihood of getting a disease or condition. For example, during one of my earlier clinical experiences, I recall a patient who was very engaged in her rehab plan. She had experienced multiple ankle sprains before, but wanted to avoid surgery at all costs. Her belief (and the fact) that a history of ankle sprains is an indicator for recurrent sprains motivated her in and outside of the clinic. PTs can use this concept by educating patients on the risk of noncompliance and the likelihood of a further decline in health or function if attention isn’t given to their deficits.

Perceived severity: the belief about the seriousness of contracting a condition and/or leaving it untreated. In the example described above, the patient admitted poor compliance after her first ankle sprain because she chalked it up as a ‘freak accident’ and that it would heal on its own. After experiencing her third lateral ankle sprain and her doctor discussing a potential need for surgery, the patient realized the severity of her injury, particularly as it became more painful to ambulate and affected her participation in her activities.

Perceived threat: formed by the combination of susceptibility and severity; thus, if there is no perceived susceptibility or severity, then the perceived threat would be zero.

Perceived benefits: the belief in the benefits of continuing a healthy behavior to reduce threat. In the same patient case above, she was able to tolerate manual therapy to mobilize the scar tissue in her ankle because she understood its benefits in helping her regain full dorsiflexion. Though uncomfortable, the patient was educated on the need for reorienting the scar tissue fibers to prevent adhesion.

Perceived barriers: the possible obstacles to taking action, including negative consequences resulting from an action. All of our patients have different personal factors that can interfere with their plan of care. It’s important to listen to our patients’ individual circumstances to better identify, understand, and address these barriers[2].

Cues to action: internal or external factors that instigate action. These vary by the individual and are required to make perceived threat or perceived benefits relevant.

Self-efficacy: belief that one can perform the recommended health behavior. PTs can improve this in patients by providing training and guidance in the recommended action, using reasonable and progressive goal setting, and giving reinforcement to support patient confidence.

Ultimately, by keeping these concepts in mind, PTs can gear their educational ‘talk’ with patients on the risks and benefits of physical therapy. Anecdotally, I have had success in my clinical experiences by explaining to patients that if they commit to their HEP, our visits can be much more effective, which leads to a faster recovery and return to their desired activity level.

In addition to education on the patient’s condition and risks/advantages of compliance or noncompliance with a HEP, a PT can recruit social support to empower patients. Encouraging the patient to engage their family/friends in their rehabilitative process, stress may be alleviated[3]. Not only does social support attenuate the burden of a present condition, protective aspects of social support have also been shown, such as in mitigating the risk for coronary heart disease and mortality[4]. Having social support can also elicit positive outcomes in patients with chronic conditions, such as cystic fibrosis[5].

 

 

References:
1. Champion VL. The health belief model. 2015.
2. Emmy M Siuijs, Gerjo J Kok J van der Z. Correlates of Exercise Compliance in Physical Therapy.; 1993.
3. Holt-lunstad J, Uchino BN. Social support and health. 2010.
4. Larin HM, Benson G, Martin L, Wessel J, Williams R, Ploeg J. Examining change in emotional-social intelligence, caring, and leadership in health professions students. J Allied Health. 2011;40(2):96-102.
5. Pop-Jordanova N, Demerdzieva A. Emotional health in children and adolescents with cystic fibrosis. Pril (Makedon Akad Nauk Umet Odd Med Nauki). 2016; 37(1): 65-74.doi: 10.1515/prilozi-2016-0005

Patient Adherence and Behavior Change (Pt. 1)

When we ask our clients to adhere to a home exercise program, we’re asking them to make a health behavior change. Often times, clients are given their HEP’s and sent on their way while we hope they’ve absorbed enough of the information that we gave them in a treatment session to self-manage their dysfunction outside of the clinic. However, in order to maximize the potential for compliance, a general understanding of theories behind behavior change is needed to help guide a clinician in education tactics to best meet individual needs. A multitude of studies discuss various theoretical concepts that can be used to identify the most pragmatic strategies for working with clients. The Transtheoretical Model (TTM) and the Health Belief Model (HBM) are two major constructs that we can consider when working with clients. In this two-part series, we’ll start with the TTM.

Behavior change has been studied to illustrate a series of stages occurring often in a nonlinear fashion[1]. To recognize this, the TTM suggests that there are 6 core constructs to behavioral change: pre-contemplation, contemplation, preparation, action, maintenance, and termination. These stages are defined in the table below[1]:

In one example, a study that utilized the TTM in looking at the health behavior change of increasing physical activity to improve metabolic syndrome indicators in women supports the effectiveness of this construct [2]. At 3- and 6-months post-intervention, the researchers found that the group of women that received TTM-based support for behavior change had an increased level of physical activity compared to a control group. According to the results of this study and others similar to it, it appears that a TTM approach may be successful in facilitating health behavior changes.

Just like the individual differences in scar tissue development can impede a post-op recovery, the differences in psychosocial readiness for behavior change can largely impact a patient’s plan of care. What have been your experiences as a clinician working with patients in these various stages of change? What important factors do you consider when prescribing a unique HEP to different patients who might have the same condition? In the next post, we’ll look more closely at the Health Belief Model consider psychological factors behind changing health behaviors.


 

References:
1.     Prochaska JO, Redding CA, Evers KE. The transtheoretical model and stages of change. 2008:97. http://www.josseybass.com/WileyCDA/WileyTitle/productCd-0470432489.html.
2.     Mostafavi F, Ghofranipour F, Feizi A, Pirzadeh A. Improving physical activity and metabolic syndrome indicators in women: A transtheoretical model???based intervention. Int J Prev Med. 2015;2015-April. doi:10.4103/2008-7802.154382.

A PT's Role in Patient Adherence

The level of compliance among patients varies widely. For PTs, it’s easy to chalk it up to individual differences that are largely unaffected by our clinical practice skills.  And in doing so, we can continue to make recommendations on treatment based on the patient’s condition. A lack of adherence in that regard offers some relief to many clinicians, as we can only help those who are motivated and willing to help themselves. But are we doing our patients a disservice by not addressing these psychosocial differences that impact motivation and adherence?

When the patient is a full-time working parent with kids, another family member of their own with declining health, and other life stressors, our 15 minutes, or less, spent discussing a home exercise program likely won’t weigh much on the scale of priorities. Physical therapists have a responsibility to discuss health behaviors with patients, but what is the most effective approach? Although this is emphasized in the Code of Ethics for the Physical Therapist [1] from the American Physical Therapy Association, many PTs still do not routinely discuss healthy behaviors with their patients [2]. However, from the consumer standpoint, most participants (91.3% in a survey of 230 patients) agree that PTs should initiate a conversation about physical activity, maintaining a healthy weight, and smoking cessation [2]. Other topics are included, such as basic nutrition, but this illustrates the role of PTs becoming more predominant in primary care and even extending to the management of chronic conditions [3].

Currently, the economy is pushing for evidence-based medicine and doing what we can to quickly facilitate the healing process measured through validated outcomes to prove our value. After that, the rest lies on the patient to follow their individual home exercise programs, activity modification recommendations, and general health and wellness behaviors. Rather than sending the patient on their way, in order to truly individualize treatment plans, we must educate ourselves on factors that impact patient adherence and treat our patients according to a biopsychosocial framework.By engaging in these conversations, PTs can not only build rapport with their patients, but barriers to plan of care adherence can be identified and addressed. In the following posts, we’ll dig deeper into various psychosocial constructs and discuss the implications in a physical therapy clinic. What have been your experiences as a clinician? What strategies have you found that work or don’t work in various settings?

 

References:
[1] Code of Ethics for the Physical Therapist, APTA
[2] Black B, Ingman M, Janes J. Physical Therapists’ Role in Health Promotion as Perceived by the Patient: A Descriptive Survey. Phys Ther. 2016;96(X):ptj.20140383-. doi:10.2522/ptj.20140383.
[3] Dean E. Physical therapy in the 21st century (Part II): evidence-based practice within the context of evidence-informed practice. Physiother Theory Pract. 2009;25(5-6):354-368. doi:10.1080/09593980902813416.

Welcome to the VK Blog

With a full patient caseload, documentation, and non-clinical obligations, the last thing you want to do is take time away from your personal life and prepare for journal clubs by reviewing complicated articles with questionable procedures and dense statistical analyses. There are other ways to stay up-to-date on current research and events in the profession. Some of it is shared through social media and private groups or summarized in the American Physical Therapy Association’s Year in Review publication.  But it is easy to miss if you don’t actively seek the resources.

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