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Conceptual models and behavioral frameworks in adherence: Needs
assessment, interventions and quality improvement
K RIVET AMICO UNIVERSITY OF MICHIGAN
UNDERSTANDING AND IMPROVING TREATMENT ADHERENCE: AN
INTERDISCIPLINARY APPROACH FEBRUARY 26TH 2016
UNIVERSITY OF ALABAMA BIRMINGHAM
Conceptual models and behavioral frameworks in adherence: Needs
assessment, interventions and quality improvement
K RIVET AMICO UNIVERSITY OF MICHIGAN
UNDERSTANDING AND IMPROVING TREATMENT ADHERENCE: AN
INTERDISCIPLINARY APPROACH FEBRUARY 26TH 2016
UNIVERSITY OF ALABAMA BIRMINGHAM
DISCLOSURES
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Unrestricted educational grant from Gilead Sciences through the University of Michigan to create PrEP education material Participation in community and stakeholder advisory meetings for PrEP with Gilead Sciences. I have no conflict of interest with any material presented here.
Overview
• Why we need to use social/behavioral models
• Some examples
• Figuring out which model to use
• Using models productively
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Why we need social/behavioral models…
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Intervention Strategy
Health Outcome Indicator
Need to use social/behavioral models to unpack that black box…
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Social/Behavioral models identify what factors influence the behaviors needed for outcomes to be achieved/sustained
If outcomes are ideal and optimal, less concerned about unpacking factors leading to the outcome
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If outcomes are NOT ideal and NOT optimal, we are very concerned about unpacking factors leading to the outcome
8 Mhaskar et al 2013 IJMC
ART Adherence is NOT optimal for a sizable minority
9 Mhaskar et al 2013 IJMC
ART Adherence is NOT optimal for a sizable minority
For HIV infection, this translates to both individual and public health consequences
Adherence across conditions can be sub-optimal
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Cochrane Review, Oct, 2005; Transplantation (2007;83:858-873) Blood (2007;109:58-60) Disease Rates of non- adherence
ART adherence- Viral Suppression depends on adherence
11 Schaecher K. Am J Manag Care. 2013;19(12 suppl):S231-S237
To improve an outcome, you need to impact the behavior… To impact the behavior, you need to impact the factors that drive the behavior
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Models seek to identify what factors influence those behaviors
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Viral Suppression
INDICATOR
CAUSES
INDICATOR
FACTORS INFLUENCING
BEHAVIOR
ART Adherence
Engagement in Care
Social-behavioral models elucidate the core pathways to the health behavior- parsimony– directing you to what to try to modify
In the absence of models, we have correlates
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And reasons
MODELS SYNTHESIZE COMPLEX CAUSES OF OUTCOMES, BEHAVIORS, AND INFLUENTIAL FACTORS
We all have working models for why things do and do not happen.
• Humans are cause seeking (cause probing)
• Error prone (short cuts)
• Huge benefit in articulating our causal models
• Better yet- drawing from the evidence base to mobilize vetted and tested models
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Some examples
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HBM
20 http://www.med.upenn.edu/hbhe4/part2-ch3-main-constructs.shtml
Adherence Motivation
Adherence Behavioral Skills
Adherence Information
Adherence Behavior
Health Outcomes
Moderating Factors Affecting Adherence
Fisher, Fisher, Amico, & Harman (2006)
The Information-Motivation-Behavioral Skills Model of Adherence
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Information
Motivation
Care TaskBehavioral Skills Health Outcomes
Feedback Loop
The kinds of information, motivation and skills are those that are most relevant to the target populations- they are SITUATED to the context and change in line with demands of care task
AmicoK.Asituated-Informa3onMo3va3onBehavioralSkillsModelofCareIni3a3onandMaintenance(sIMB-CIM):anIMBmodelbasedapproachtounderstandingandinterveninginengagementincareforchronicmedicalcondi3ons.JHealthPsychol2011,16:1071-1081.
23 Comparison of a one-time educational intervention to a teach-to-goal educational intervention for self-management of heart failure: design of a randomized controlled trial.
DeWalt DA, Broucksou KA, Hawk V, Baker DW, Schillinger D, Ruo B, Bibbins-Domingo K, Holmes M, Weinberger M, Macabasco-O'Connell A, Pignone M - BMC Health Serv Res (2009)
From factors to strategies
24 http://www.slideshare.net/UDDent/theories-of-behaviour-change
From factors to strategies
25 http://www.slideshare.net/UDDent/theories-of-behaviour-change
Motivational Interviewing Patient-centered discourse Problem Solving mHealth Theater/arts Community mobilization Couples counseling Family counseling Navigation
WHAT MODEL TO USE FOR IDENTIFYING CORE FACTORS TO CHANGE? WHAT MODEL TO USE FOR HOW TO CHANGE THEM?
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• Lack of guidance for what theory is best. • Needs assessment through continuous
quality improvement and intervention mapping approaches can be used to help narrow the field of options
Continuous Quality Improvement Approach
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Continuous Quality Improvement Approach
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Model of behaviors
Intervention model Did factors change
Revisit models
Continuous Quality Improvement Approach
29 http://customerthink.com/the-transfer-of-knowledge-in-pdca/
Intervention Mapping
Step 1: Needs AssessmentStep 2: Define Suitable program objectivesStep 3: Select theory-based intervention methods and practical strategiesStep 4: Produce programme components and materialsStep 5: Design an implementation planStep 6: Design an evaluation plan
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Continuous Quality Improvement Approach
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Intervention Mapping
Continuous Quality Improvement Approach
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Program Evaluation
Logic Model/Program Evaluation
• Outcome
• Gaps and resources
• Model of what creates gaps and optimizes resources
• Evidence-informed strategies to change factors influencing outcomes
• Ways to check if changes in factors are happening
• Check for change in outcome
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All approaches suggest
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• Once you have the outcome you want to address
• Search for evidence on behaviors/factors influencing outcomes
• Identify evidence-informed strategies to change them
EVIDENCE?
• Literature
• Consultation
• Discussion with stake holders
• Interviews and groups
• Listening sessions
• Experience
How to use models in grants, proposals and presentations • Know your audience and goal
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Social Cognitive Determinants of Nutrition and Physical Activity Among Web-Health Users Enrolling in an Online Intervention: The Influence of Social Support, Self-Efficacy, Outcome Expectations, and Self-Regulation Eileen Smith Anderson-Bill1, EdD; Richard A Winett1, PhD; Janet R Wojcik2, PhD
Systems Network Model
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Complex is OK But need to focus in on your targets
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If a core factor is identified, you need some strategy to address it and measurement to monitor it
How to use models in grants, proposals and presentations • Know your audience and goal
• Check the literature
• Outcome
• Models
• Intervention strategies
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How to use models in grants, proposals and presentations • Know your audience and goal
• Check the literature
• Make an “evidence informed” logic model/argument • Do not assume (rule out) something that did not work somewhere else if you
can make a solid argument for why it may work in your context
• Do not assume that something that was effective in one population or outcome will work the same for your population
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How to use models in grants, proposals and presentations • Know your audience and goal
• Check the literature
• Make an “evidence informed” logic model/argument
• Propose metrics for monitoring “proximal determinants” and strategies for “unpacking” intervention effects
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Bottom line: Know what leads to change in your outcome, and how your strategies will influence those causal pathways that lead to change– unpack the black box
WHAT
(Epi, outcome patterns)
WHY
(Correlates, models)
HOW
(delivery/intervention models)
MONITOR DELIVERY
CHECK OUTCOMES
REVISE
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Questions?
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