Changing Patient Attitudes Towards

Exercise Therapy

Sarah Dean

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.

Acknowledgements

OPAL Hagen, S., McClurg, D., Glazener, C., Abdel-Fattah, M., Wael,

A., Bugge, C., Dean, S., Norrie, J., Hay-Smith, EJC., Kilonzo, M.,

Elders, A., McPherson, G., McDonald A M, Booth, J., Buckley, B.,

Guerrero KL., Wilson, LE.

e-coachER Adrian Taylor, Rod Taylor, John Campbell, Colin Greaves,

Sarah Dean, Kate Jolly, Lucy Yardley, Mary Steele, Paul Little, Nana

Anokye, Nanette Mutrie, Anthony Woolf, Josephine Erwin, Ben Jane,

Jane Vickery & Wendy Ingram, Liz Ford

ReTrain Sarah Dean, Raff Calitri, Anthony Shepherd, Leon Poltawski,

Martin James, Rhoda Allison, Shirley Stevens, Meriel Norris, Anne

Spencer, Rod Taylor, Anne Forster

Free Ben Darlow, Anthony Dowell, G. David Baxter, Fiona Mathieson,

Meredith Perry, and Sarah Dean

Layout of talk

Behaviour Change Techniques (BCTs)

Using a Behaviour Change model

Health Beliefs, Attitudes and Behaviour

Existing research evidence

Current research projects

Common theme of how to promote exercise

Behaviour Change Techniques (BCTs)

The Information Motivation

Behavioural Skill Model

Fisher et al, 2003

NB There are many theories and models for understanding

health behaviours, but no one theory explains it all!

The Information Motivation

Behavioural Skill Model

Fisher et al, 2003

Health Beliefs & Attitudes

• Beliefs - links with information, knowledge &

understanding about health

– Lay theories

– Sense making

– Cognitions, representations or perceptions

• Attitudes - links with mood and motivation

– Positive

– Neutral

– Negative

Patient Beliefs can be very powerful drivers of behaviour

Beliefs about cause and attitudes towards treatment benefits

Beliefs about Myocardial Infarction (MI) and Cardiac Rehabilitation Petrie, K. J., Cameron, L. D., Ellis, C. J. et al 2002.

• Randomised Control Trial with 56 patients with MI to either an

intervention designed to alter their perceptions about their

MI, or to usual care from rehabilitation nurses.

• 3 intervention sessions:

– the pathophysiology of MI,

– patient’s beliefs, misconceptions,

– developing a plan to minimise future events, advice on

exercise, diet and return to work, writing / reviewing plans

for self-management, symptom management, side effects

of drugs, reinforcing need to take medication regularly.

Beliefs about MI and Cardiac Rehabilitation Petrie, K. J., Cameron, L. D., Ellis, C. J. et al 2002; see also Broadbent et al 2009.

• Outcome measures: illness perceptions & return to work.

• At 3 months, significant success in changing patient’s belief to a more positive and controllable view of MI compared to control patients.

• Intervention group had a shorter delay in return to work compared with the control.

Beliefs about MI and Cardiac Rehabilitation

Regular exercise or exercise with education and

psychological support can reduce the likelihood of dying

from heart disease. RR of mortality after 12 months = 0.87

[95% CI 0.75, 0.99]. (Heran et al. Cochrane Review 2011)

Establish people's health beliefs and their specific

illness perceptions before offering appropriate lifestyle

advice and to encourage attendance to a cardiac

rehabilitation programme. [NICE 2013]

Offer cardiac rehabilitation programmes designed to

motivate people to attend and complete the programme.

Explain the benefits of attending. [NICE 2013]

Clinician health beliefs and attitudes –

powerful drivers of patient behaviour

Eur J Pain 16 (2012) 3–17

Do we have risk averse beliefs that we transmit to our

patients with low back pain?

Our concerns about missing a ‘red flag’ (serious spinal

pathology) may inadvertently mean we give messages that

create ‘yellow flags’ (e.g. fear avoidance) in our patients

Clinician beliefs and attitudes – why

so powerful?

Darlow, Dowell, Baxter, Mathieson, Perry & Dean

The Enduring Impact of What Clinicians

Say to People With Low Back Pain 2013

We act as ‘credible sources’ (BCT 74) of information

Patient: “This input improves my quality of life hugely and I’m

very grateful for the chance to do this. It’s like having

somebody walk beside you”

Trust and credibility are a good foundation for facilitating

exercise

Message 1: Check out patient health

beliefs (and our own beliefs)

Fisher et al, 2003

Health Beliefs

about the condition

& expectations of

outcome / treatment

benefit

Information and beliefs are not enough

‘knowing isn’t doing’

Poor adherence to exercise may limit long-

term effectiveness (Jordan et al 2010)

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)

Mild to moderate intensity exercise

150 mins per week

ACSM guidance 2011 (www.acsm.org accessed May 2015)

The Information Motivation Behavioural Skill

Model

Fisher et al, 2003

Can adding internet support help

patients with long-term metabolic,

musculo-skeletal and mental

health conditions to access GP

exercise referral schemes and

remain regularly active?

Users learn about setting SMART goals to increase moderate intensity physical activity

and have examples

and stories linked

to travel, leisure

and domestic

activities.

‘Steps to Health’

• Participants are invited to go through 9 ‘steps to health’ which are designed to help them increase their level of physical activity.

Goal setting as a ‘cornerstone of rehab’

• Summary of issues-

see Levack & Dean in Chapter 4

Interprofessional Rehabilitation 2012

• Cochrane review- updating the evidence Levack, Siegert, Dean, McPherson, Hay-Smith & Weatherall. Goal setting

in rehabilitation (Protocol). Cochrane Database of Systematic Reviews

2012, Issue 4.

See also: Siegert, R.J. & Levack, W.M.M. (Eds) (2014) Rehabilitation Goal

Setting: Theory, Practice and Evidence, CRC Press

BCT Group: Goal Setting and Action Planning

BCTs in this group are:

• Problem solving

• Goal setting (behaviour)

• Goal setting (outcome)

• Action planning

• Review behaviour goal(s)

• Review outcome goal(s)

• Behavioural Contract

Source: BCT Taxonomy (v1) Michie et al 2013

Behavioural Contract and Commitment

• Make sure patient is involved in all goal setting and that

they understand and agree in writing to all short term

and long term goals and verbalise their commitment.

1) Clinician: “please will you sign (initial) this sheet where

I have written down the goal we have just agreed”

2) Ask the person to make statements indicating strong

commitment to change the behaviour:

3) Patient: “I will do my exercises ….. x times per week…”

Message 2: Check attitudes towards

exercise; make use of the suite of BCTs to

enhance motivation

Fisher et al, 2003

Goal Setting, Action

Planning and

Behavioural Contracts

On-going exercising - still a problem

Initial take up (often in a supported treatment

setting) does not translate into daily routine

People relapse and don’t resume their

exercises

Need different strategies and skills for the

different phases of exercise

The Information Motivation Behavioural Skill

Model

Fisher et al, 2003

Compares usual (basic) pelvic floor exercises

versus pelvic floor exercises with biofeedback

Aim to intensify the exercise intervention

BCTs to operationalise the use of

Biofeedback to increase intensity of, and

adherence to, pelvic floor exercises http://www.hta.ac.uk/project/2986.asp

BCT 23: Rehearsal & Practice of Skills

• A pelvic floor muscle contraction is a physical

(neuromotor) skill

BCT 14 : Biofeedback

• Women highly value knowing that they can

perform a correct contraction – skill mastery

Rehabilitation Training after Stroke (ReTrain): A Pilot Randomised Control

Trial (RCT) Sarah Dean, Raff Calitri, Anthony Shepherd, Leon Poltawski, Martin James, Rhoda Allison,

Shirley Stevens, Meriel Norris, Anne Spencer, Rod Taylor, Anne Forster

This poster presents independent research funded by the Stroke Association and 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 poster are those

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

ReTrain programme

ReTrain is based on the ARNI programme

(www.arni.uk.com)

Improving functional mobility via personalised

negotiated goals with exercise professionals

ReTrain enhances function via task related

practice, strengthening training and

compensatory strategies

Develops self management skills and instils a

commitment for regular exercise

Funded by

the:

On-going management BCT

• Reinforce by praising progress or

adoption of any self-management.

• Teach the patient self-

assessment skills so they know

when to focus on their own

exercises versus how and when to

seek further help.

• Analyse factors influencing

exercise behaviour to overcome

barriers or increase facilitators

Social reward

Self-monitoring

of behaviour

Social support

(practical)

Problem solving

(includes coping

with relapse)

Message 3: Don’t forget to add the skills

training

Fisher et al, 2003

Skills for doing the

exercises and for self

managing on-going

exercises

What next?

• Explicit use of BCTs in clinical practice

• Cochrane review on goal setting Levack et al

• On-going research

– OPAL

– ecoachER

– ReTrain

– Measuring exercise (adherence) Bollen, Dean et al 2014,

BMJ Open.

Summary of talk

Shown how we can use BCTs to change patient beliefs

and attitudes towards therapeutic exercise and give

them the skills to uptake, adopt and maintain their

exercises

Quality information – check beliefs

Motivational strategies – promote positive attitude

Skill training – for exercises & for self-management

Evidence informed practice combining patient beliefs

with clinician expertise and context specific factors

Thank you

s.dean@exeter.ac.uk

University of Exeter Medical School