Behavioral approaches to changing adherence in patients with cardiovascular disease

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Effectiveness of commonly used behavior-change strategies 

Commonly used strategies to influence behavior may work in some settings, but are often the least effective in actually instigating change, such as presenting threatening information.¹ 

In the context of adherence, this might mean simply telling a patient to take a medication and expecting them to do it – the evidence for simply providing information and expecting results is weak.² 

Asking routine questions will influence the answers given – questions like “You are taking your medicines, aren’t you?” or “Are you still taking XXXX?” are unlikely to result in transparent answers, and are likely to create defensiveness on the part of the patient as well as an underestimation of the extent of non-adherence by the clinician.³ 

Using theory driven, evidence-based behavioral interventions can positively influence patient health behavior and outcomes.² 

Behavior change techniques

There are a wide range of behavior-change techniques and their use needs to be matched to the cause of the adherence problem.⁴ The COM-B framework,  as described in article 3 of this series, can be used as a basis for deciding which behavior-change technique is appropriate for helping individual patients to improve their adherence.² Using a screener to identify the cause(s) of a patient’s adherence problem (i.e. capability, opportunity or motivation) can indicate how they can be best helped.³ For example, if a patient forgets or doesn’t have a clear daily plan for taking their medication, then working with them to create a daily action plan will be helpful.³ However , if the patient has negative beliefs about their treatment or their need for it, working with the patient to change these beliefs, using a motivational interviewing approach (as outlined later in this article), is more likely to be helpful.⁵ 

The “nudge” theory 

It is possible to help people and optimize their decision-making by framing their choices so that the best options are more likely to be chosen – to “nudge”, in other words.  

‘Nudge theory’ is a behavioral framework that can be applied to enhance adherence, especially in the era of artificial intelligence (AI) technologies and the increasing number of digital patient-support programs ( see articles 7 and 8). A 2019 study of patients with cardiovascular disease on statins showed that patients receiving personalized nudges designed by AI had increased treatment-adherence rates.⁶ The nudges used were primarily calls, texts and emails, personalized for each patient using the patient’s psychographic profile (e.g., their perspectives, impressions, and opinions about healthcare).⁶ 

A study in patients with chronic disease, conducted by a group of UK and US researchers in collaboration with the NHS, also concluded that nudging is very efficient in improving adherence.⁷ The nudges act as a permanent reminder to the patient of the personal and societal costs of their non-adherence.  

According to Thaler and Sunstein, there are several cases in which nudges are particularly useful. These can be illustrated using desired health behaviors:⁸ 

Health behavior	Definition	Example
Benefits now, costs later	The individual does not seriously consider the future negative impact of their behavior	A patient with hypertension who also happens to be a smoker. Smoking will increase the probability of a cardiac event in the future, although likely not immediately; informing them of the likely consequence could be a useful nudge
Degree of difficulty	More difficult problems require more help to make the right decision	A patient who is about to start a very complex treatment regimen, with which they have no experience, will require more assistance
Frequency	A person is confronted with rare and difficult decisions, with significant consequence	A patient that must give their consent for a surgery or treatment with uncertain outcomes that is much more likely to improve the situation than to exacerbate it. A nudge, such as stressing the positive outcome rate (e.g, 90% likelihood of success) could be relevant in such a situation
Feedback	People need feedback on their choices to make further decisions	Consider a person suffering from hyperlipidemia eating a high-fat diet, without any warning signs until a cardiac event occurs, or the patient who takes treatment for an asymptomatic disease, such as hypertension: without any feedback (symptoms or health events), the patient is likely not to adhere to their treatment plan; again, providing information on likely future consequences that are as yet unseen could provoke behavior change
Knowing what you want (and need)	It is particularly hard for people to make choices when they cannot translate them into potential experiences	A patient who is facing a multitude of treatment options that have different cost / benefit outcomes could benefit from the physician breaking this down into simple terms

With the emergence of digital technologies and machine-learning capabilities, it is increasingly possible to personalize nudge techniques, which can improve outcomes for the patient, their family and society in general.

Motivational interviewing 

Motivational interviewing is a scientifically supported technique for helping people change behavior; it is patient-focused and goal-directed. It is different to ‘nudging’ a patient – it is more geared towards helping the patient reflect on their own motivations, with the physician working in a patient-centric fashion.^5,9 

The basic elements of motivational interviewing include: 

• Asking open-ended questions vs telling patients what to do¹⁰ 

• For example: ‘What are your thoughts about taking XXXXX and how it might affect your heart disease?’ or ‘What benefits do you see from taking XXXX’ 

• Focusing on the patient’s preferences, values and personal situations¹⁰ 
• Directs them towards an outcome in a collaborative fashion¹⁰ 
• Asking for commitment: verbal commitment drives behavioral change¹¹ 
• Helping providers gain insight into how to help patients better adhere, allowing them to give advice that is better received and more likely to be acted on¹²

When implementing motivational interviewing, it is important to prepare the patient with necessary information about the behavior before motivating them to do it, in brief, simple and clear terms. 

Whilst asking strategic, open-ended questions may be a departure from the current approach to non-adherence for physicians, practicing may help healthcare professionals to develop new habits in this area, and ultimately make conversations with non-adherent patients more productive. 

The physician should also follow-up to determine if the advice is followed; if not, asking the same motivational questions again to explore the barriers further, and help the patient find solutions to these. 

Improving patient adherence is a significant opportunity – strategies such as motivational interviewing and applying ‘nudge theory’ appropriately are useful tools in achieving this.

References: 
1. Peters G-JY, et al. Threatening communication: A qualitative study of fear appeal effectiveness beliefs among intervention developers, policymakers, politicians, scientists, and advertising professionals. International Journal of Psychology 2014;2:71–9. 
2. Jackson C, et al. Applying COM-B to medication adherence: a suggested framework for research and interventions. Eur Health Psychol 2014;16(1):7–17. 
3. Weinman J, et al. Pilot Testing Of A Brief Pre-Consultation Screener For Improving The Identification And Discussion Of Medication Adherence In Routine Consultations. Patient Preference and Adherence 2019;13:1895–98. 
4. Michie S and Johnston M. Theories and techniques of behaviour change : developing a cumulative science of behaviour change. Health Psychology Review, 2012; 6 (1), 1-6. 
5. Miller W. Motivational Interviewing with Problem Drinkers. Behavioural Psychotherapy 1983;11(2):147–72. 
6. Intermountain Medical Center. ‘Nudging’ heart patients to take their statins leads to better adherence and better outcomes. Available at: https://www.sciencedaily.com/releases/2019/11/191114075549.htm (Accessed Jan 20, 2021). 
7. Jachimowicz J, et al. Making medication stick: Improving medication adherence by highlighting the personal health costs of non-compliance. Behavioural Public Policy 2019;1–21. 
8. Thaler R and Sunstein C. “Nudge”, Part I “When do we need nudge?”, “Fraught choices”. 2008. 
9. Frost H, et al. Effectiveness of Motivational Interviewing on adult behaviour change in health and social care settings: A systematic review of reviews. PLoS ONE 2018;13(10):e0204890. 
10. Benzo R, et al. Development and Feasibility of a COPD Self-Management Intervention Delivered with Motivational Interviewing Strategies. J Cardiopulm Rehabil Prev 2013;33(2):113–23. 
11. Amrhein PC, et al. Client commitment language during motivational interviewing predicts drug use outcomes. J Consult Clin Psychol 2003;71(5):862–78. 
12. Palacio A, et al. Motivational interviewing improves medication adherence: a systematic review and meta-analysis. J Gen Intern Medicine 2016;31(8):929–40.