Transcript Slide 1

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….
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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
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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:
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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 likely to exercise (Zhao
et al 2008)
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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
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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
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(Kronish et al 2006)
Dr Gail Bohin 4th October 2008
Depression & Anxiety
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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….
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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
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Chronic illness places people under complex demands
stress/distress - interferes with changing our
behaviour/habits & information processing
unrealistic goal setting/lack of skills - trying to
change too much too quickly
confidence - previous experience - have we tried to
make these changes before and failed?
getting better - can de-motivate patients to change
their lifestyles, ongoing symptoms can increase
motivation
Dr Gail Bohin 4th October 2008
“Deliberate” non-adherence
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Denial - can be a useful coping strategy in the shortterm, 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)
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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….
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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)
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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
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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:
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Identity- what is this?
Cause - how did I get
this?
Control - what can be
done to help me?
What can I do to
help?
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Cure - is it fixable?
Timeline -how long
will it be before I’m
better?
Consequences - what
does this mean for
the future?
(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”
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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”
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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
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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
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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.
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When is the best time to
receive information?
How much information
should we give?
Dr Gail Bohin 4th October 2008
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How should we deliver
it?
Who should give it?
How often should we say
it?
Information giving
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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
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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
Dr Gail Bohin 4th October 2008
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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
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?
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Information sharing skills. How to deliver
information as effectively as possible in a variety of
mediums
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?
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Understanding/
comprehension - why
do they need to make
these changes?
Communication asserting themselves,
stating their
needs/priorities, asking
questions, being satisfied
with their consultations
Dr Gail Bohin 4th October 2008
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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?
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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…..
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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