Why don’t they do what we tell them?!!!

Behaviour change & the CHD population

Dr Gail Bohin

Clinical Psychologist Gloucestershire Cardiac Rehabilitation Service [email protected]

The benefits of managing risk factors in reducing further cardiac events, strokes and other co-morbidities are abundantly clear.

So why don’t all patients follow the advice of their medical teams and manage their risk factors?

Dr Gail Bohin 4th October 2008

The reality….

 Have you ever struggled to stick to a diet or exercise plan?  Stopped taking medication before the end of the prescription?

 Exercised against advice when you had an injury?

 Everyone is non-adherent sometimes. So is not complying a “normal” behaviour?

Dr Gail Bohin 4th October 2008

The medical model

 The prevailing model in medicine.

 Health care providers are the “expert” patients are passive recipients of that expertise.

 Patients are given advice based on the best evidence available.

 Not following advice is viewed as a problem, failure or disobedience.

 Health professionals can disengage with patients who do not follow advice.

Dr Gail Bohin 4th October 2008

Non adherence in CHD - the scale of the problem:

 1 in 8 patients stop taking medication within a month of having an MI (Ho et al 2006)  50% of those smoking pre-MI continue to smoke post MI (Scholte op Reimer et al 2006)  People with CHD are less et al 2008) likely to exercise (Zhao  Research suggests that we should expect around 50% of patients to follow instructions but that figure can drop to around 10% (Ley;1988,1997) Dr Gail Bohin 4th October 2008

Psychological distress

 Patients with CHD have higher prevalence rates of anxiety and depression than the general population.

 Patients with moderate to severe depression at 69% greater risk for cardiac death & 78% greater risk of all-cause death. (Barefoot et al 200??)  Often these patients get “missed”. We need to identify these patients early on and consider their additional needs.

Dr Gail Bohin 4th October 2008

Depression and non-adherence

Depressed patients report lower adherence to : 

quitting smoking



taking all cardiac medications



exercise



attending cardiac rehabilitation

(Kronish et al 2006) Dr Gail Bohin 4th October 2008

Depression & Anxiety

 Major depression is associated with poor adherence to aspirin regimen post diagnosis of CHD. Carney et al (1995)     Non adherence rates: 15% non depressed patients 29% mildly depressed patients 37% moderately depressed patients took aspirin less than

80%

of the time (Rieckmann et al 2006) Dr Gail Bohin 4th October 2008

The challenges for our patients….

   How do you make and maintain multiple lifestyle changes, at a time when you may be physically and emotionally depleted, and under competing pressures?

What information do you need and when is the best time to receive it?

How does it feel to be confronted with information on what you

should

be doing when you don’t feel up to the challenge or have other priorities?

Dr Gail Bohin 4th October 2008

Unintentional non-adherence

    

Chronic illness

places people under complex demands

stress/distress

- interferes with changing our behaviour/habits & information processing

unrealistic goal setting/lack of skills

change too much too quickly - trying to

confidence

- previous experience - have we tried to make these changes before and failed?

getting better

their lifestyles, ongoing symptoms can increase motivation - can de-motivate patients to change Dr Gail Bohin 4th October 2008

“Deliberate” non-adherence

   Denial can be a useful coping strategy in the short term, to stop you being overwhelmed, but is destructive in the longer term.

Reactance

some people feel out of control or disempowered by health problems. They regain a sense of control through active defiance and react strongly to perceived attempts to “tell them” what to do. (Brehm & Brehm 1981)

Dissatisfaction

- adherence can be viewed as an indicator of the quality of the patient - health care provider relationship (Salmon 2002) Dr Gail Bohin 4th October 2008

Patients have different views to us….

   Patients now have much greater access to information from lay sources. This information can be more persuasive than that of your healthcare professionals (Elliot & Binns 1986) If the patient & healthcare professional have different

beliefs

, the patient is less likely to comply (Hunt et al 1989) Generally, adherence relates more to the

patient’s view

of the illness, than the clinician’s ( Janz & Becker 1984) Dr Gail Bohin 4th October 2008

Beliefs

 Beliefs guide all of our behaviour, they shape our understanding of ourselves, other people and the world. They are deeply held and can be resistant to change.

“Whether you believe you can or believe you can’t, you are right” Henry Ford Dr Gail Bohin 4th October 2008

Patient’s beliefs

Patients formulate their health beliefs around the following constructs:  Identity what is this?

 Cure - is it fixable?

  Cause this? - how did I get Control - what can be done to help me?

What can I do to help?

  Timeline will it be before I’m better?

-how long Consequences the future?

- what does this mean for (Leventhal et al 1980) Dr Gail Bohin 4th October 2008

Beliefs & non-adherence…….

 Identity

“ I haven’t got heart disease, I had a heart attack a while back, but I’m better now”

 Cause

“ work stress caused my heart problems, now I’ve retired early, I should be fine!”

 Cure/control

“ Heart disease is in the family, there’s nothing I can do about it”

Dr Gail Bohin 4th October 2008

Beliefs and non-adherence…..

 Timeline 

“Once I’ve had my bypass, my consultant says my arteries will be better than his!”

Consequences

“I don’t like taking tablets, don’t they all have side effects? I haven’t been taking mine”

We need to understand our patients better, their views may not make sense to us, but they do to them!

Dr Gail Bohin 4th October 2008

Patient beliefs & Adherence

   These beliefs are central to their motivation to change their behaviour, they drive their disease management.

Often the patient’s beliefs are conflicting with the medical evidence. Despite this, beliefs can be firmly held and resistant to change. They will not be changed by us simply telling them differently.

Not understanding the patient’s view could increase non-adherence

Dr Gail Bohin 4th October 2008

Dissatisfaction

   Patient satisfaction increases when the patient feels that their concerns have been heard and understood (Ley 1988) Patients disengage if they receive conflicting advice from different sources, they are de-motivated by mixed messages (Salmon 2002) CHD is so common, our patients get mixed messages all of the time! (how many newspaper clippings get brought in…?!!) Dr Gail Bohin 4th October 2008

Delivering information

People absorb information in different ways and have different learning styles - this is a minefield of individual differences. Our challenge is to get the information across in the most accessible way for the patient.

  When is the best time to receive information?

How much information should we give?

   How should we deliver it?

Who should give it?

How often should we say it?

Dr Gail Bohin 4th October 2008

Information giving

   Anxiety or stress changes our focus - we attend more to information that is frightening (Williams et al 1997).

Our patients are often stressed.

For some getting information helps to reduce anxiety, for others it increases anxiety. Patients use information to make sense of what is happening to them. We need to ask them how much information they would like.

Dr Gail Bohin 4th October 2008

Information giving……..

Monitors

cope by getting as much information as they can from as many sources as possible (medics, TV internet, friends, other patients etc). They may be reassured by detailed discussions & packages of information

Blunters

cope by avoiding information as much as possible and putting the health event out of their mind.They find being presented with too much information anxiety provoking & unwelcome, often attending to alarming details.

(Miller et al 1988) Dr Gail Bohin 4th October 2008

Making information memorable

   Present the important information first Provide clear, specific information, not general principles Restrict the information into chunks - don’t overwhelm the patient’s processing abilities    Consider the language & terminology used, make it clear & accessible (Flesch Formula readability score) Use different mediums, verbal, written, diagrams , video, websites etc involve peers & expert patients Dr Gail Bohin 4th October 2008

Patient-centred consulting

Sometimes it can be hard for our patient to establish their priorities, or what the most important information is. They need time to reflect, to process what is happening. Motivation to change will also fluctuate throughout the recovery period. We are complicated creatures. There are times when we are receptive to information and do want to be “told” and times when we don’t.

How do we balance their needs, with our needs to do our job, when we are often time limited/resource limited?

Dr Gail Bohin 4th October 2008

Remember…...

Doing a lot of the same thing can make you either really good at your job, or make it more likely that your approach becomes more auto-pilot or “standardised” and less tailored to the individual.

We have a lot to learn about behaviour change So do our patients…...

Dr Gail Bohin 4th October 2008

What skills do we need to help our patients change?

   

Information sharing skills

mediums . How to deliver information as effectively as possible in a variety of

Communication skills

to help improve the quality of our face to face contacts with patients

Behaviour Change Counselling

skills - to help us to empower the patient and move away from teaching or telling, to including them in decisions about their care

Flexible working

- one size doesn’t fit all Dr Gail Bohin 4th October 2008

What skills do our patients need to help them to make changes?

 

Understanding/ comprehension

these changes?

- why do they need to make

Communication -

asserting themselves, stating their needs/priorities, asking questions, being satisfied with their consultations Dr Gail Bohin 4th October 2008     

Goal setting & planning Self monitoring Problem solving Support networks -

both socially & from their health care professionals

decision making /negotiation skills

(Houston Miller et al 1997)

What do services need to be offering?

     More tailored, individualised interventions Better joined up working - risk factor management is not just the job of rehab. Specific behaviour change counselling interventions Follow ups over a longer period & more flexible systems -Use of telephone/e-mail/text follow up?

More resources (that old chestnut…) Dr Gail Bohin 4th October 2008

The reality…..

    How do we implement any of this within our existing, often limited, resources?!!!

We can’t change the world (or the NHS) overnight, but what can we start doing to communicate more effectively & to empower ourselves and our patients? Even small changes can build over time into bigger change what can we do to start identifying patients who may be at risk of non-adherent behaviours early on?

Dr Gail Bohin 4th October 2008

References

Barefoot JC, Helms, MJ, Mark DB, Blumenthal, RM (1996) Depression Predicts Mortality in Coronary Disease, American

Journal of Cardiology

Brehm SS, Brehm JW (1981) Psychological Reactance: A theory of Freedom and Control, New York, Academic Press Carney, M, Freedland K, Rich MW, Jaffe A (1995) Depression as a Risk Factor for Cardiac events in established Coronary Artery Disease: A review of possible mechanisms, Annals of Behavioural Medicine, vol 17, no.2, 142-149 Elliot-Binns CP (1986) An analysis of medicine. Journal of the Royal College of General Practitioners 36, 542-544 Dr Gail Bohin 4th October 2008

References

Houston-Miller N, Hill M, Kottke, T, Ira S, Ockene MD, (1997) The Multi-level Compliance Challenge: recommendations for a call to action, Circulation, 95; 1085-1090 Hunt LM, Jordan B, Irwin S (1989) Views of what’s wrong: diagnosis and patient’ concepts of illness. Social Science and Medicine 28, 945-956 Janz NK, Becker MH (1984) The Health Belief model a decade later, Health Education Quarterly 11, 1-47 Leventhal H, Meyer D, Nerenz, D (1980) The Common Sense Representation of Illness Danger. In S Rachman (Ed), Medical Psychology, Vol 2, pp-7-30. New York: Pergammon. Ley, P (1988) Communicating with Patients. London: Chapman & Hall Dr Gail Bohin 4th October 2008

References

Miller SM, Brody Ds, Summerton J (1988) Styles of coping with threat: implications for health. Journal of Personality and Social Psychology 54 142-148 Rieckmann, N, Kronish, I M, Haas W, Gerin Wf…. (2006) Persistent Depressive Symptoms lower aspirin adherence after Acute Coronary Syndrome, American Heart Journal, vol 152, Issue 5, pages 922-927 Salmon P (2002) Psychology of Medicine and Surgery, Chichester, Wiley Zhao G, Ford E, Li C, Mokdad A (2008), Are United States Adults with Coronary Heart Disease Meeting Physical Activity Recommendations? American Journal of Cardiology 101: 557-61 Dr Gail Bohin 4th October 2008