04/10/2023

WEEK 8 LECTUREHIWA K. SAAED PHD

2012-1013SCHOOL OF PHARMACY FACULTY OF

MEDICAL SCIENCESUNIVERSITY OF SULAIMANI

Helping Patients Manage Therapeutic Regimens

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Objectives 2

IntroductionFalse Assumptions about Patient Understanding

and Medication AdherenceTechniques to Improve Patient UnderstandingTechniques to Establish New BehaviorsTechniques to Facilitate Behavior ChangeTheoretical Foundations Supporting Behavior

ChangeApplying Motivational Interviewing Principles and

StrategiesSummary

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Introduction3

“Keep watch also on the fault of patients which often makes them lie about taking of things prescribed.” Hippocrates

Hippocrates made this remark over 2,000 years ago!

Unfortunately, concern about how patients actually use their prescribed medications continues to this day.

Compliance

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Compliance: the extent to which a person’s behavior

coincides with the medical advice given. i.e., The extent to which the patient’s follow doctors’ prescriptions about medicine taking.

traditional patient–provider relationship in which providers told patients what to do and patients presumably did it (complied).

Adherence:

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Adherence: the extent to which the patients behavior

matches agreed recommendations from the prescriber. The term “adherence” (emphasizing the need for agreement) has largely replaced “compliance” and was intended to move away from the paternalistic view of patients as individuals who simply did as they were told.

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Concordance: “an agreement reached after negotiation between a patient and health care professional that respects the beliefs and wishes of the patient in determining whether, when and how medicines are to be taken.”

Concordance obligates providers and patients to reach mutual decisions.

This joint decision making requires a meaningful dialogue between patients and providers on medical options and patient preferences.

Concordance

Rate of Adherence

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The exact rate of adherence to medication regimens varies from study to study since researchers in this area define and measure adherence differently.

However, regardless of definition and measurement, adherence rates are well below 100%. The consensus is that adherence rates for long-term therapies tend to be about 50%.

Some researchers use: indirect methods of measuring adherence (interview

patients and family members, have patients keep diaries) direct methods (assessing blood or urine levels of

medication).

Cost of Nonadherence

Most nonadherences have negative effects on patient health which, in turn, can result in

increased :emergency room and physician visits,hospitalizations, disability, premature death.

and decreased productivity in the work place,

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Reasons exist for poor- or nonadherence

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Numerous reasons exist, some reasons are related to Patients, include:

patient perception of medications “the positive outcomes”. Many patients are afraid of taking medications, while some may rely too heavily on medications and take

more than prescribed.Health care providers, Others evolve from the health care delivery system.

lack of insurance coverage, access to medications, and other economic concerns.

Nonadherence can be divided into two broad categories:

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1. Unintentional (inadvertent): forgetting2. Intentional, involves decisions a patient has

made to alter a medication regimen or to discontinue drug therapy (permanently or temporarily).

due to an uncomfortable side effect or skip doses of a medication that should not

be taken with alcohol before going to a party.

False Assumptions about Patient Understanding and Medication Adherence

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Do not assume that:1. Physicians have already discussed the medications.2. Patients understand all information provided. 3. If patients understand what is required, they will be

able to take the medication correctly. 4. When patients do not take their medications correctly

that they: “don’t care”“aren’t motivated”“lack intelligence”or “can’t remember.”

5. Once patients start taking their medications correctly, they will continue to take them correctly in the future.

6. Physicians routinely monitor patient medication use.7. If patients are having problems, they will ask direct

questions or volunteer information.

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1. Emphasize key points. “This is very important” helps them remember what follows.

2. Give reasons for key advice, e.g., with an antibiotic prescription, tell why it is necessary to continue medication use even though symptoms have disappeared.

3. Give definite, concrete, explicit instructions. Any information that patients can mentally picture is more easily remembered. Use visual aids, photographs, or demonstrations.

4. Provide key information at the beginning and end of the interaction.

5. Supplement and reinforce spoken words with written instructions.

6. Assessment of a patient’s ability to read and understand key written instructions is required.

7. End the encounter by taking feedback .

Techniques to Improve Patient Understanding

Techniques to Establish New Behaviors

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1. New behaviors should tied to an existing habits. This strategy is known as “tailoring” of regimens.

2. Provide appropriate adherence aids. -Individualized medication packaging for daily or weekly doses

seems to work for some patients. -Alarms on cell phones and other devices can be programmed

to signal when medication doses are to be taken.

3. Suggest ways to self-monitor. -use a medication diary or calendar on which to record their

medication use. -Other monitoring can involve treatment effects: blood

pressure or testing their blood glucose levels

Techniques to Establish New Behaviors

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4. Monitor medication use.5. Make proper referrals; refer patients to

appropriate social service agencies, such as government programs for low-income patients.

-Barriers to proper adherence can obviously include patients’ inability to obtain needed medications.

Techniques to Facilitate Behavior Change

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Establish a new habit (beginning a medication regimen)

Change old habits (overeating). Stop existing habits (smoking). For chronic diseases such as diabetes, the

changes involve -establishing new behaviors (drug therapy and daily

blood glucose monitoring), -changing old habits (diet and exercise), -ceasing other behaviors (drinking alcohol).

Theoretical Foundations Supporting Behavior Change

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Three components of motivation to change: a. Willingness, which is indicated by the amount

of discrepancy patients perceive between current health status and goals they have for themselves,

b. Perceived ability or the amount of self-confidence patients feel in their ability to initiate and maintain behavioral change (also known as self-efficacy),

c. Readiness, which is related to how high a priority is given to these behavioral changes.

Theoretical Foundations Supporting Behavior Change

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empathic understanding is a core, it facilitates the patient’s own problem-solving

ability. frees patients from the fear that they are being

judged because of their behavior. Rogers’ theory is said to be client- or patient-

centered because the crucial decision to change is seen to reside in the patient. Providers can only assist a patient in making informed decisions that are consistent with the patient’s own goals.

Motivating patients to change

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Express empathy, Develop discrepancyRoll with resistanceSupport self-efficacy, Elicit and reinforce “change talk”

Stages of Change

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Precontemplation: unwillingness to change, lack recognition of problem, deny seriousness of risks.

Contemplation: acknowledging that there is a problem but no ready or sure of wanting to make a change.

Preparation/determination (getting ready to change)Action/willpower (change is initiated)Maintenance (change is established and

incorporated to lifestyle, focus is on avoiding relapse)

Relapse (returning to older bahavior)

STAGE 1: PRECONTEMPLATION

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persons are not thinking seriously about changing. Defend their current bad habit(s) and don’t feel it

is a problemInterventions must focus on getting them to think

about changing habits, to begin to consider the pros and cons of behavior change. Raise awareness of problem Provide information Convey empathy Encourage thinking about Express willingness to help Avoid arguing

STAGE 2: CONTEMPLATION

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The contemplation stage “thinking about” changing their behavior—not immediately but within the next 6 months or so.

They believe in the benefits of change but also see the personal costs or challenges involved. They feel ambivalent.

People are on a teeter-totter, weighing the pros and cons of quitting or modifying their bad behavior.

Interventions at this stage can best be focused on getting patients to describe the “pros”.

STAGE 3: PREPARATION

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the individual is ready to implement a change program or initiate a new regimen almost immediately(< 1 month). These individuals have reached a decision in favor of change.

STAGE 4: ACTION/ Willpower

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The action stage is the initial period in changing a behavior.

During this initial period of change, the desire to go back to old habits makes the potential to relapse of concern.

STAGE 5: MAINTENANCE

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In the maintenance stage, relapse can continue to be of concern but persons can often continue with the new habits without constant vigilance against relapse.

The new behaviors have become more integrated into lifestyles and routines. Patients gain more confidence in their abilities to maintain changes.

However, for certain changes, such as abstinence from addictive substances, dangers of relapse continue indefinitely.