conceptual models and behavioral frameworks in … uab conceptual models... · assessment,...

Conceptual models and behavioral frameworks in adherence: Needs

assessment, interventions and quality improvement

K RIVET AMICO UNIVERSITY OF MICHIGAN

UNDERSTANDING AND IMPROVING TREATMENT ADHERENCE: AN

INTERDISCIPLINARY APPROACH FEBRUARY 26TH 2016

UNIVERSITY OF ALABAMA BIRMINGHAM

DISCLOSURES

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Unrestricted educational grant from Gilead Sciences through the University of Michigan to create PrEP education material Participation in community and stakeholder advisory meetings for PrEP with Gilead Sciences. I have no conflict of interest with any material presented here.

Overview

•  Why we need to use social/behavioral models

•  Some examples

•  Figuring out which model to use

•  Using models productively

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Why we need social/behavioral models…

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Intervention Strategy

Health Outcome Indicator

Need to use social/behavioral models to unpack that black box…

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Social/Behavioral models identify what factors influence the behaviors needed for outcomes to be achieved/sustained

If outcomes are ideal and optimal, less concerned about unpacking factors leading to the outcome

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If outcomes are NOT ideal and NOT optimal, we are very concerned about unpacking factors leading to the outcome

8 Mhaskar et al 2013 IJMC

ART Adherence is NOT optimal for a sizable minority

9 Mhaskar et al 2013 IJMC

ART Adherence is NOT optimal for a sizable minority

For HIV infection, this translates to both individual and public health consequences

Adherence across conditions can be sub-optimal

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Cochrane Review, Oct, 2005; Transplantation (2007;83:858-873) Blood (2007;109:58-60) Disease Rates of non- adherence

ART adherence- Viral Suppression depends on adherence

11 Schaecher K. Am J Manag Care. 2013;19(12 suppl):S231-S237

To improve an outcome, you need to impact the behavior… To impact the behavior, you need to impact the factors that drive the behavior

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Models seek to identify what factors influence those behaviors

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Viral Suppression

INDICATOR

CAUSES

INDICATOR

FACTORS INFLUENCING

BEHAVIOR

ART Adherence

Engagement in Care

Social-behavioral models elucidate the core pathways to the health behavior- parsimony– directing you to what to try to modify

In the absence of models, we have correlates

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And reasons

MODELS SYNTHESIZE COMPLEX CAUSES OF OUTCOMES, BEHAVIORS, AND INFLUENTIAL FACTORS

We all have working models for why things do and do not happen.

• Humans are cause seeking (cause probing)

•  Error prone (short cuts)

• Huge benefit in articulating our causal models

• Better yet- drawing from the evidence base to mobilize vetted and tested models

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Some examples

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HBM

20 http://www.med.upenn.edu/hbhe4/part2-ch3-main-constructs.shtml

Adherence Motivation

Adherence Behavioral Skills

Adherence Information

Adherence Behavior

Health Outcomes

Moderating Factors Affecting Adherence

Fisher, Fisher, Amico, & Harman (2006)

The Information-Motivation-Behavioral Skills Model of Adherence

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Information

Motivation

Care TaskBehavioral Skills Health Outcomes

Feedback Loop

The kinds of information, motivation and skills are those that are most relevant to the target populations- they are SITUATED to the context and change in line with demands of care task

AmicoK.Asituated-Informa3onMo3va3onBehavioralSkillsModelofCareIni3a3onandMaintenance(sIMB-CIM):anIMBmodelbasedapproachtounderstandingandinterveninginengagementincareforchronicmedicalcondi3ons.JHealthPsychol2011,16:1071-1081.

23 Comparison of a one-time educational intervention to a teach-to-goal educational intervention for self-management of heart failure: design of a randomized controlled trial.

DeWalt DA, Broucksou KA, Hawk V, Baker DW, Schillinger D, Ruo B, Bibbins-Domingo K, Holmes M, Weinberger M, Macabasco-O'Connell A, Pignone M - BMC Health Serv Res (2009)

From factors to strategies

24 http://www.slideshare.net/UDDent/theories-of-behaviour-change

From factors to strategies

25 http://www.slideshare.net/UDDent/theories-of-behaviour-change

Motivational Interviewing Patient-centered discourse Problem Solving mHealth Theater/arts Community mobilization Couples counseling Family counseling Navigation

WHAT MODEL TO USE FOR IDENTIFYING CORE FACTORS TO CHANGE? WHAT MODEL TO USE FOR HOW TO CHANGE THEM?

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•  Lack of guidance for what theory is best. • Needs assessment through continuous

quality improvement and intervention mapping approaches can be used to help narrow the field of options

Continuous Quality Improvement Approach

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Model of behaviors

Intervention model Did factors change

Revisit models


29 http://customerthink.com/the-transfer-of-knowledge-in-pdca/

Intervention Mapping

Step 1: Needs AssessmentStep 2: Define Suitable program objectivesStep 3: Select theory-based intervention methods and practical strategiesStep 4: Produce programme components and materialsStep 5: Design an implementation planStep 6: Design an evaluation plan

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Intervention Mapping


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Program Evaluation

Logic Model/Program Evaluation

•  Outcome

•  Gaps and resources

•  Model of what creates gaps and optimizes resources

•  Evidence-informed strategies to change factors influencing outcomes

•  Ways to check if changes in factors are happening

•  Check for change in outcome

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All approaches suggest

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•  Once you have the outcome you want to address

•  Search for evidence on behaviors/factors influencing outcomes

•  Identify evidence-informed strategies to change them

EVIDENCE?

•  Literature

•  Consultation

•  Discussion with stake holders

•  Interviews and groups

•  Listening sessions

•  Experience

How to use models in grants, proposals and presentations •  Know your audience and goal

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Social Cognitive Determinants of Nutrition and Physical Activity Among Web-Health Users Enrolling in an Online Intervention: The Influence of Social Support, Self-Efficacy, Outcome Expectations, and Self-Regulation Eileen Smith Anderson-Bill1, EdD; Richard A Winett1, PhD; Janet R Wojcik2, PhD

Systems Network Model

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Complex is OK But need to focus in on your targets

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If a core factor is identified, you need some strategy to address it and measurement to monitor it


•  Check the literature

•  Outcome

•  Models

•  Intervention strategies

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•  Make an “evidence informed” logic model/argument •  Do not assume (rule out) something that did not work somewhere else if you

can make a solid argument for why it may work in your context

•  Do not assume that something that was effective in one population or outcome will work the same for your population

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•  Make an “evidence informed” logic model/argument

•  Propose metrics for monitoring “proximal determinants” and strategies for “unpacking” intervention effects

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Bottom line: Know what leads to change in your outcome, and how your strategies will influence those causal pathways that lead to change– unpack the black box

WHAT

(Epi, outcome patterns)

WHY

(Correlates, models)

HOW

(delivery/intervention models)

MONITOR DELIVERY

CHECK OUTCOMES

REVISE

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Questions?

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