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Exercise: adherence (FS-09)

Jean Hay-Smith (New Zealand)

Sarah Dean (United Kingdom)

Helena Frawley (Australia)

Doreen McClurg (United Kingdom)

C Dumoulin (Canada)

This material is provided with the permission of the presenters and is not endorsed by WCPT

Exercise adherence: integrating

theory, evidence and behaviour

change techniques

Jean Hay-Smith PhD, Sarah Dean PhD, Helena Frawley PhD, Doreen McClurg PhD

Learning objectives

We will cover:

Why (long-term) exercise adherence is difficult

How theory helps us understand adherence

Why applying theory needs context-specific knowledge

You will be able to

Identify one or more behaviour change techniques that might support patients’ exercise adherence in your practice

Sarah Dean

Why (long-term) exercise adherence is difficult

Sarah Dean’s position is supported by the National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care (CLAHRC) for the South West Peninsula. The views expressed in

this presentation are those of the author(s) and not necessarily those of the NHS, the NIHR or the UK Department of Health.

Definitions

Activity is any bodily movement produced by

skeletal muscles that results in energy expenditure and is usually measured in kilocalories per unit of time (Caspersen et al., 1985)

Exercise is a sub-set of physical activity and is

planned, structured, repetitive bodily movements that someone engages in for the purpose of improving or maintaining physical fitness or health

Physical Activity and Exercise

Physical activity

Exercise

Cardio

respiratory

Strengthening PFMT

ActivityWork, play,

travel, recreation

Definitions (see Sabatâe, 2003; Myers & Midence, 1998)

Compliance – being told what to do

Adherence – agreeing what to do

Concordance – therapeutic alliance and shared decision making

Intentional versus Unintentional

Phases of Exercise Adherence

Initial uptake

Adoption of main routine

Maintenance routine

Relapse management

Long term adherence to exercise based rehabilitation interventions for the management of chronic conditions is typically very poor:

Low back pain (e.g. Sluijs et al, 1993)

Cardio vascular rehab (e.g. Jurkiewicz et al, 2011)

Urinary incontinence (e.g. Borello-France et al, 2013)

Why is (longer term) exercise adherence such a problem? (see Myers & Midence 1998)

People often ‘know’ what to do – but there is a large ‘knowledge-behaviour’ gap

Initial take up (often in a supported treatment setting) does not translate into daily routine

People relapse and don’t resume their exercises

Common myths

There is no ‘adherent’ personality

Adherence is not ‘all or nothing’

Non-adherers do not ‘just need more education’

Core concepts

Treatment adherence typically requires health behaviour change

Adherence is an outcome as well as a process –the ‘healthy adherer’ effect (see Simpson et al, 2006)

Core concepts

Measuring adherence is difficult – there is no gold standard (see Bollen et al, 2014)

Most people are willing to report being partially adherent, some are over-adherent

Difficult to be clear about what level of adherence is required to obtain therapeutic benefit

Explaining Adherence

Many theories or models exist to help us explain (non) adherence

No one theory explains the whole story....

We have selected several to focus on today…..

Doreen McClurg


Determinants

Glasgow Caledonian University, Glasgow, UK G4 0BA

A Theory?“He who loves practice without theory is like the sailor who boards ship without a rudder and compass and never knows where he may cast.” (Leonardo Da Vinci, 1452-1519)

a coherent description of a process that is arrived at by a process of inference, provides an explanation for observed phenomena and generates predictions (West & Brown, 2013).

It is strongly recommended that interventions to change health behaviours, including those that promote treatment adherence, are based on a theoretical model which provides an explanation of that behaviour. (Campbell 2001, Ommundsen 2001)

In the UK, the Medical Research Council recommends beginning the development of any complex intervention by identifying relevant theories to advance an understanding of the likely process of change before conducting any exploratory piloting and formal testing (Campbell et al., 2000)

Good practice to take a clinical history but this is meaningless unless we also appreciate the impact of the history on the symptoms the patient presents

with.

Theoretical models and PFMT (McClurg et al 2015)

Exercise is a health behaviour

Adherence is crucial to successful PFMT

A literature review of studies that identified

theories of health behaviour and PFMT

13 papers, 6 models applied in PFMT research

Poster RR-PO-99-23-Sat

()

Theories used in PFMTHealth Belief Model(Rosenstock & Becker, 1988: 1974)

Chiarelli and Cockburn (1999)

Gillard and Shamley (2010)

Dolman and Chase (1996)

Sacomori et al (2012)

Theory of Planned Behaviour (Ajzen, 1991)Whitford and Jones (2011)

Social Cognitive Theory : Self-Efficacy

Beliefs(Bandura, 1986)

Chen (2004); Cheng (2010), Lai

(2008), Hallam (2012), Hay-Smith,

Ryan and Dean (2007), Alewijnse et

al. (2003), Messer et al. (2007)

Transtheoretical Model (Prochaska & DiClemente, 1983)

Alewinjse (2002; 2003)

Self-Regulatory Model (Leventhal, Meyer & Nerenz; 1980)

Alewinjse (2002; 2003)

Health Action Process Approach (Schwarzer, 1992)

Hyland (2012)

Health Belief Model (Rosenstock & Becker, 1988:

1974)

Chiarelli and Cockburn 1999

Gillard and Shamley 2010

Dolman and Chase 1996

Sacomori et al 2012

19

Social Cognitive Theory : Self-Efficacy Beliefs (Bandura, 1986)

• Broom (1991, 2001);

Chen (2004); (SE

Scales)

• Cheng (2010); Lai

(2008); Hallam (2012)

• Hay-Smith, Ryan and

Dean (2007);

Alewijnse et al. (2003)

• Messer et al. (2007)

Determinants of adherence (Dumoulin et al 2015)

Population Determinants (Moderators & Mediators) Strategies

Women with

Urinary

Incontinence

(UI)

Alewijnse

Chen

Positive intention to adhere

Amount of urine lost (i.e. symptom level)

Self efficacy expectations

Attitudes towards the exercises

Perceived social pressure to engage

Dyadic cohesion (i.e. feedback)

A structured programme

Enthusiastic physiotherapist

Audio prompts

Use of established theories of

behaviour change

User consultation

Men with UI

Ip 2004

No studies Reminders on fridge magnets

Pre & Post natal

UI

Chiarelli and

Cockburn (2002)

No studies Health belief model tailoring PFM

to function and time

Pelvic Organ

Prolapse

No studies None

Lower Bowel

Dysfunction

No studies None

Motivational interventions to exercise and

traditional physiotherapy (McGrane et al 2015)

14 papers

5 MSK pain

4 obesity

3 cardiac rehabilitation

1 fatigue with cancer

1 sedentary females

6 theories

4 CBT

3 Social cognitive

3 Motivational Interviews

1 Self-determination

1 Transtheoretical

1 Social Learning

Self-efficacy was pooled in 6 studies, (CBT, Mot Int, Soc Cog, Self Deter) sig improvement in self-efficacy

Summary

Motivational interventions/theories to improve exercise adherence have received relatively little research

The same theory can be applied in more than one setting

Specifics of understanding which variables are most influential may be context specific Helena is going to talk more about that……..

Helena Frawley


Everything, even Evidence-Based-

Practice, happens in context….

Figure from:Spring & Hitchcock, 2009

Five interacting dimensions

affect adherence (WHO 2003)

Figure from:http://apps.who.int/medicinedocs/en/d/Js4883e/7.2.html#Js4883e.7.2.1

our Pelvic Floor Muscle Training

adherence survey (Frawley et al 2015)

BARRIERS Options Clinician rating n=513

Patient ratingn=50

Physical / condition-related factors

other co-existing health issues which take priority

1 (76%) 1 (68%)

Patient-related factors

low level of motivation 1 (83%)

perception of minimal benefit / effectiveness of the exercises

1 (81%)

Therapy-related factors

lack of immediacy of beneficial effects, ineffective feedback of performance

1 (77%)

poor response to previous treatment (may have been ineffective treatment)

1 (79%)

Social / economic factors

lack of effective support networks to reinforce adherence

1 (68%) 1 (74%)

our PFMT adherence survey (Frawley et al 2015)

BARRIERS Options Clinician rating

Patient rating

Which category is the single most important barrier?

Patient-related factors 1 (66%) 1 (56%)

Therapy-related factors 2 (17%) 2 (20%)

What is single most important barrier to SHORT-TERM adherence?

low level of motivation 1 (16%)


2 (14%) 1 (20%)

lack of understanding or knowledge about the condition

2 (12%)

LONG-TERM adherence?

forgetting to do exercises 1 (23%)


1 (16%)


FACILITATORS Options Clinician rating n=513

Patient ratingn=50

Physical / condition-related factors

severity of symptoms: mild – moderate 1 (68%)

no / minimal other co-existing health issues competing for priority

1 (71%)

Patient-related factors

high degree of motivation 1 (93%)

perception of significant benefit / effectiveness of the exercises

1 (90%)

Therapy-related factors

patient-therapist relationship: good rapport, interaction motivates patient

1 (87%)

provide immediate beneficial effects (even if small)

1 (88%)


FACILITATORS Options Clinician rating

Patient rating

Which category is the single most important facilitator?

Patient-related factors 1 (60%) 2 (37.5%)

Therapy-related factors 2 (34%) 1 (55%)

What is single most important facilitator to SHORT-TERM adherence?


1 (19%)

high degree of motivation 1 (20%)

LONG-TERM adherence?


1 (21%) 1 (15%)

Clinical Recommendations(1) Patient-related factors may be the most important category of barriers to long-term PFMT adherence these may include the patient’s perception of minimal benefit of the therapy, reduced self-efficacy, poor identification with pelvic anatomy, and understanding of the condition, all of which may lead to low motivation to adhere to PFMT. Health professionals need to identify and address these factors.

(2) Patient- and therapy-related factors may optimally facilitate long-term adherence; health professionals need to provide tangible evidence or feedback to patients on PFMT benefits

(3) Long-term adherence may be best achieved through follow-up appointments and a re-assessment of factors impeding progress; determinants may change over time.

(4) An individualized approach to treatment based on a person’s age, sex, and ethnicity is recommended.

(5) The belief that PFMT adherence determinants differ according to condition is not strongly supported; therefore, individualized patient-centered, as opposed to condition-centered, approaches are recommended.

Remember

Change is difficult!

Figure from:http://www.marketingforchange.com.au/great-behaviour-change-mind-map/

Stages

of

Change(Grol 2013)

Aware

Agree

Adopt

Adhere

Figure from Grol 2013See Pathman et al 1996

Attrition in the ‘pipeline’ of

research to practice (Glasziou 2004)

Barriers and Enablers

Barriers & Enablers (Rainbird 2006)

Level Type of barrier or enabler

Examples

The innovation itself

Individual professional

Patient

Social context

Organisational context

Economic & political context


Examples

The innovation itself - Advantages in practice- Feasibility- Credibility- Accessibility- Attractiveness

- CPGs may be perceived as difficult to use

- CPGs which recommend discarding may be more difficult than introducing

Individual professional

Patient

Social context




Examples

The innovation itself

Individual professional - Awareness- Knowledge- Attitude- Motivation to change- Behavioural routines

Patient

Social context



Phases

in the

process

of

change (Grol 2013)

Orientation:awareness of innovation

interest and involvement

Insight:understanding

insight into own routine

Acceptance:positive attitude, motivation to change

positive intention or decision to change

Change:actual adoption in practice

confirmation of benefit or value of change

Maintenance:integration of new practice into routines

embedding of new practice in the organisation

Translating

Research Into

Practice project (Frawley et al 2014)

Orientation

Insight

AcceptanceChange

Maintenance

Jean Hay-Smith


Identify one or more behaviour change techniques that might support patients’ exercise adherence in your practice

www.opaltrial.co.uk

Planning the OPAL intervention

Information Motivation Behavioural

Skills Model (IMB) (Fisher et al 2003)

Context: the qualitative synthesis(Hay-Smith et al, 2015. Neurourology & Urodynamics, in press)

Knowledge

Feelings about PFMT

Physical skill

Cognitive analysis, planning and attention

Prioritisation

Service provision

IMB Model and synthesis

Fisher et al, 2003

Knowledge

Physical skill

CognitionFeelingsPriorityServices

Behaviour change techniques

(BCTs) (Michie et al 2013)

93 item taxonomy

Naming active ingredients of delivery

Applicable to many health behaviours

Choose for context

Item 74: Credible source

Present verbal or visual communication from a credible source in favour of the behaviour

“your doctor has referred you to me because I am an expert in pelvic floor muscle exercises. I have worked in this area for 20 years and have done extra training to help women with incontinence”

Item 41: Mental rehearsal of

successful performanceAdvise to practice imagining performing the behaviour successfully in relevant contexts.

“I will pull my muscles up as hard as I can. I will hold as hard as I can. I will keep breathing while I count 1 banana 2 banana 3 banana 4 banana 5 banana and then I will let go. I will rest while I count ….. etc”

Item 71: Behavioural contract

Very familiar with goal setting for the behaviour (Item 66)

Add, item 71. Create a written specification of the behaviour to be performed, agreed by the person, and witnessed by another

We have

Briefly explained:

Why long-term exercise adherence is difficult



Referred to a 93 item taxonomy of behaviour change techniques and given 3 specific examples used to support exercise adherence

Questions – Panel – 20 minutes

Sarah Dean PhD, CPsychol, MCSP,

Senior Lecturer in Psychology Applied to Health, University of Exeter Medical School, College House, St Luke’s Campus, Exeter [email protected]

Doreen McClurgReader, Nursing, Midwifery and Allied Health Professions RU,Glasgow Caledonian University,Scotland, UK. [email protected]

Helena Frawley PhD FACP

Associate Professor, Allied Health, La Trobe UniversityHead, Allied Health Research, Cabrini InstituteNational Health & Medical Research Council (Australia) Health Professional Research [email protected]

Jean Hay-Smith PhD MPNZ

Associate Professor, RehabilitationAssociate Professor, Women’s HealthUniversity of OtagoNew [email protected]

Sarah Dean

Good quality information provision is an important platform for promoting adherence but more information alone is not enough to change behaviour, instead:

Use your credibility as a professional / expert in the area (BCT ‘credible source’)

Check and address any information misconceptions (BCT ‘information about health consequences’ )

Promote motivation through

goal setting and action planning

if-then rules

Boost self-efficacy

Work out a relapse strategy

Ensure patient has necessary behavioural skills

correct exercise technique

a regimen to follow that allows progression and relapse management

skills and equipment to self-monitor or review progress

To summarise

Aim for sufficient partial adherence to obtain therapeutic benefit

Help patients establish routines, so that exercises are part of their daily life

Don’t let exercises be a burdensome additional ‘interruption’ to their lives

Sarah [email protected]

Helena [email protected]

Doreen [email protected]

Jean [email protected]

References - HelenaBehaviour change: http://www.marketingforchange.com.au/great-behaviour-change-mind-map/

Frawley, H., Chiarelli, P., Gunn, J. (2014) Uptake of antepartum continence screening and pelvic floor muscle exercise instruction by maternity care providers: an implementation project. Neurourol Urodynam, 33(6)

Frawley, H., McClurg, D., Mahfooza, A., Hay-Smith, J., Dumoulin, C. (2015) Health Professionals’ and Patients’ Perspectives on Pelvic Floor Muscle Training Adherence – 2011 ICS State-of-the-Science Seminar Research Paper IV of IV. Neurourol Urodynam, accepted.

Grol, R., M. Wensing, et al., Eds. (2013). Improving patient care: the implementation of change in health care. Oxford, Wiley Blackwell.

Rainbird, K et al. (2006) Identifying barriers to evidence uptake http://www.nicsl.com.au/

Spring, B. & Hitchcock, K. (2009) Evidence-based practice in psychology. In I.B. Weiner & W.E. Craighead (Eds.) Corsini’s Encyclopedia of Psychology, 4th edition (pp. 603-607). New York:Wiley

WHO 2003: Adherence to Long-Term Therapies - Evidence for Action http://apps.who.int/medicinedocs/en/d/Js4883e/7.2.html#Js4883e.7.2.1

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References - Jean

Fisher WA, Fisher JD and Harman J (2003) The Information-Motivation-Behavioral Skills model: A general social psychological approach to understanding and promoting health behavior. In: Suls J, Wallston KA (eds) Social Psychological Foundations of Health and Illness. Blackwell Publishing, 82–106.

Hay-Smith J, Dean S, Burgio K, McClurg D, Frawley H, Dumoulin C. Pelvic-Floor-Muscle-Training Adherence ‘‘Modifiers’’: A Review of Primary Qualitative Studies—2011 ICS State-of-the-Science Seminar Research Paper III of IV. Neurourol Urodyn 2015, in press

Michie S, Richardson M, Johnston M, Abraham C, Francis J, HardemanW, Eccles MP, Cane J, Wood CE. The Behavior Change Technique Taxonomy (v1) of 93 Hierarchically Clustered Techniques: Building an International Consensus for the Reporting of Behavior Change Interventions. Ann Behav Med 2103; 46(1): 81-95. DOI 10.1007/s12160-013-9486-6

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