Improving Client ‘Adherence’ Improving Client ‘Adherence’ ThroughThrough

Health Behaviour Change Health Behaviour Change

Exercise OneExercise One

The what happens next round…The what happens next round…

The what happens next round…The what happens next round…

• On the next slide there are 12 statements On the next slide there are 12 statements made by clients.made by clients.

• For each statement, write down a typical For each statement, write down a typical response that you might give.response that you might give.

• 6 minutes….go6 minutes….go

1)1) I am overweight but then I have always been overweight and so is I am overweight but then I have always been overweight and so is everyone else in my family.everyone else in my family.

2)2) What can I do to lose weight?What can I do to lose weight?3)3) I don’t smoke as much as other people, only about 10 a day, that’s not I don’t smoke as much as other people, only about 10 a day, that’s not

going to kill me is it?going to kill me is it?4)4) Don’t tell me what to do you’re not me, you’re not fat.Don’t tell me what to do you’re not me, you’re not fat.5)5) I have tried exercising and it hurts, my body aches the next day, that’s my I have tried exercising and it hurts, my body aches the next day, that’s my

body telling me to stop isn’t it?body telling me to stop isn’t it?6)6) It’s not my fault I am fat, my mum used to feed me up, I was a fat kid and It’s not my fault I am fat, my mum used to feed me up, I was a fat kid and

now my wife buys cakes and biscuits every time she goes shopping.now my wife buys cakes and biscuits every time she goes shopping.7)7) I like eating out and eating nice meals, it’s a part of my job and my social I like eating out and eating nice meals, it’s a part of my job and my social

life.life.8)8) Healthy foods taste horrible.Healthy foods taste horrible.9)9) I drank every night last week and I spent £200 on going out, I might have I drank every night last week and I spent £200 on going out, I might have

trouble with paying my rent this week.trouble with paying my rent this week.10)10) I have tried loads of diets but they don’t work, I just put the weight back on I have tried loads of diets but they don’t work, I just put the weight back on

again.again.11)11) I have stopped ‘pigging out’ at night and I have stopped finishing off my I have stopped ‘pigging out’ at night and I have stopped finishing off my

families leftovers after dinner.families leftovers after dinner.12)12) I did start exercising but I hurt my knee and I had to stop, that was four I did start exercising but I hurt my knee and I had to stop, that was four

weeks ago now.weeks ago now.

Learning ObjectivesLearning Objectives

► Critically evaluate interventions aimed at Critically evaluate interventions aimed at increasing physical activity levels. increasing physical activity levels.

► Conduct a motivational interview.Conduct a motivational interview.

Lecture OutlineLecture Outline

• Current Perspectives on AdherenceCurrent Perspectives on Adherence

• Client’s Health Behaviour Change Model Client’s Health Behaviour Change Model

• Health Behaviour Change ApplicationHealth Behaviour Change Application

Compliance, Adherence, PersistenceCompliance, Adherence, Persistence

• Compliance and Adherence are Compliance and Adherence are frequently used interchangeablyfrequently used interchangeably

• Compliance Compliance • Suggests passive approach to healthcare Suggests passive approach to healthcare

on the client’s part.on the client’s part.• Adherence Adherence

• ‘‘the extent to which a client’s behaviour the extent to which a client’s behaviour coincides with medical or health advice’coincides with medical or health advice’

• Persistence is maintaining a given Persistence is maintaining a given behaviour as prescribed behaviour as prescribed

Biomedical model:Biomedical model:Health and illnessHealth and illness

• Assumes client is /Assumes client is /shouldshould be sufficiently be sufficiently motivated by illness to obey instructionsmotivated by illness to obey instructions

• Treatments offered to clients unready to Treatments offered to clients unready to follow themfollow them

• Reflects bias toward trating disease Reflects bias toward trating disease • Fails to address behavioural requirements of Fails to address behavioural requirements of

treatmenttreatment• Interventions unlikely to cause sustained Interventions unlikely to cause sustained

changes in compliancechanges in compliance

Behavioural model:Behavioural model:Information-Motivation-Behaviour Skills ModelInformation-Motivation-Behaviour Skills Model

Information

Motivation

Behaviour Skills Behaviour Change

Behavioural model:Behavioural model:Information-Motivation-Behaviour Skills ModelInformation-Motivation-Behaviour Skills Model

• BBothoth information & motivation information & motivation likelihood likelihood of adherenceof adherence

• Interventions based on this model have Interventions based on this model have been effective in influencing behavioural been effective in influencing behavioural change in a variety of clinical applicationschange in a variety of clinical applications

‘Readiness’ Intention

Perceived Vulnerability

Probable Severity

Benefit Beliefs

Perceived Barriers

Health Belief Model: Rosenstock Health Belief Model: Rosenstock (1974)(1974)

Theory of Planned Behaviour: Theory of Planned Behaviour: Azjen (1985)Azjen (1985)

Normative Beliefs

xCompliance

Behavioural Beliefs

xValues

Attitudes

Intentions Behaviour

Subjective Norms

Perceived Behavioural

Control

Control:Beliefs

xPower

The Spirit of The Spirit of Health Behaviour Change Health Behaviour Change

The Spirit of The Spirit of Health Behaviour Change Health Behaviour Change

• Collaborate with the clientCollaborate with the client• Evoke their readiness to take Evoke their readiness to take

actionaction• Develop client’s autonomy Develop client’s autonomy

• To take responsibility for their own To take responsibility for their own healthhealth

Miller WR, et al. Motivational Interviewing. 2nd ed. Guilford Press; 2002:33-34.

Health Behaviour Change Health Behaviour Change TechniquesTechniques

Health Behaviour Change Health Behaviour Change TechniquesTechniques

• Menu of StrategiesMenu of Strategies• Elicit-Provide-ElicitElicit-Provide-Elicit

• The Five PrinciplesThe Five Principles• R.E.A.D.SR.E.A.D.S

• Helpful ToolsHelpful Tools• Readiness RulersReadiness Rulers• The Envelope The Envelope

The Menu of Strategies:The Menu of Strategies: ElicitElicitThe Menu of Strategies:The Menu of Strategies: ElicitElicit

• Opening strategy:Opening strategy: discussing client’s discussing client’s lifestylelifestyle

• How does the client view it? How does the client view it? • A typical dayA typical day??

• Needed for tailoring, identifying Needed for tailoring, identifying problems, problems, • e.g Exercisee.g Exercise

The Menu of Strategies:The Menu of Strategies: ElicitElicit

• The good things and bad thingsThe good things and bad things• Likes and dislikes about the proposed Likes and dislikes about the proposed

changes? changes? • The representation illness & treatment? The representation illness & treatment? • Agree with Doctor/Practitioner?Agree with Doctor/Practitioner?• Believe they can do what is asked?Believe they can do what is asked?

• What will help? What will help?

• What are the barriers?What are the barriers?

• Providing informationProviding information • is the client ready for information?is the client ready for information?

• Provide client with all appropriate Provide client with all appropriate informationinformation• Dosing – Dosing – • (e.g drugs, how much to take and when to (e.g drugs, how much to take and when to

take it)take it)• (e.g exercise, how much to take and when to (e.g exercise, how much to take and when to

take it)take it)

The Menu of Strategies:The Menu of Strategies: ProvideProvide

The Menu of Strategies:The Menu of Strategies: ProvideProvide

The Menu of Strategies: The Menu of Strategies: ProvideProvide

• What the expected onset of action isWhat the expected onset of action is• Most common ‘side effects’ Most common ‘side effects’

• What to do if any occurWhat to do if any occur

• What to do re: problemsWhat to do re: problems• Any further questions?Any further questions?

• The future and the present:The future and the present:• Additional concerns Additional concerns

• Helping with decision makingHelping with decision making • ““What are your thoughts now about managing What are your thoughts now about managing

your...”your...”• ““Where does this leave you now?”Where does this leave you now?”• ““Do you anticipate having any help?”Do you anticipate having any help?”•

ELICIT PROVIDE ELICITELICIT PROVIDE ELICIT

The Menu of Strategies:The Menu of Strategies: ElicitElicit

The Menu of Strategies:The Menu of Strategies: ElicitElicit

The Five General Principles of The Five General Principles of Health behaviour ChangeHealth behaviour Change

The Five General Principles of The Five General Principles of Health behaviour ChangeHealth behaviour Change

• RRoll with resistanceoll with resistance • EExpress empathy xpress empathy • AAvoid arguingvoid arguing• DDevelop discrepancyevelop discrepancy• SSupport self-efficacyupport self-efficacy

Roll With ResistanceRoll With ResistanceRoll With ResistanceRoll With Resistance

• Use understanding, empathyUse understanding, empathy• Get clarificationGet clarification• New perspectives invited, not imposedNew perspectives invited, not imposed• Don’t give a reason to resist moreDon’t give a reason to resist more• Resistance: a signal to respond differentlyResistance: a signal to respond differently• Repeat your understandingRepeat your understanding• The person is primary resource for The person is primary resource for

answers and solutionsanswers and solutions

Express EmpathyExpress EmpathyExpress EmpathyExpress Empathy

• An objective identification of another An objective identification of another person’s emotions person’s emotions • (not their experience)(not their experience)

• Continuous throughout the processContinuous throughout the process• Identify and understand: Identify and understand:

• resistance, resistance, • reasons for unhealthy behaviours reasons for unhealthy behaviours • without judgmentwithout judgment

• Creates a climate for ‘change through trust’Creates a climate for ‘change through trust’

Principles of Health Behaviour Principles of Health Behaviour Change:Change: Avoid ArguingAvoid Arguing

Principles of Health Behaviour Principles of Health Behaviour Change:Change: Avoid ArguingAvoid Arguing

• Don’t add to the person’s resistanceDon’t add to the person’s resistance• Arguing forces people to defend the Arguing forces people to defend the

behaviour you are trying to changebehaviour you are trying to change• Empathy sets you up as being on “their” Empathy sets you up as being on “their”

sideside• Confront, but don’t argueConfront, but don’t argue• Feelings aren’t arguableFeelings aren’t arguable

Develop DiscrepancyDevelop DiscrepancyDevelop DiscrepancyDevelop Discrepancy

• Discrepancy = DissonanceDiscrepancy = Dissonance• Good things and bad things about changeGood things and bad things about change

• Pros and consPros and cons

• Throw system out of kilterThrow system out of kilter• Restate discrepancies heardRestate discrepancies heard• Change: motivated by perceived Change: motivated by perceived

discrepancy between present behaviour discrepancy between present behaviour and important personal goals or valuesand important personal goals or values

Support Self-EfficacySupport Self-EfficacySupport Self-EfficacySupport Self-Efficacy

• Belief in possibility of change: important Belief in possibility of change: important motivatormotivator

• Notice the positive, including statements, not Notice the positive, including statements, not just behavioursjust behaviours• Let the person know you’ve noticedLet the person know you’ve noticed

• The person, is responsible for choosing and The person, is responsible for choosing and carrying out changecarrying out change

• Let them know how you feelLet them know how you feel• Praise the behaviour, not the personPraise the behaviour, not the person• Support self-efficacy throughout the processSupport self-efficacy throughout the process

Readiness RulerReadiness Ruler

The EnvelopeThe Envelope

• Elicits change talkElicits change talk• ““If I handed you an envelope, what would If I handed you an envelope, what would

the message inside have to say to get you the message inside have to say to get you to ________?”to ________?”

• Useful when there is ambivalenceUseful when there is ambivalence

Feedback:Feedback:The what happens next round…The what happens next round…

• For each statement you wrote down a For each statement you wrote down a typical response that you might give.typical response that you might give.

• Check your statements against the following Check your statements against the following lists to see if you, or how many times you lists to see if you, or how many times you ‘roadblocked’ your client.‘roadblocked’ your client.

Roadblocks.Roadblocks.1.1. Ordering, directing or commandingOrdering, directing or commanding

2.2. Warning or threateningWarning or threatening

3.3. Giving advice, making suggestions, providing solutionsGiving advice, making suggestions, providing solutions

4.4. Persuading with logic, arguing, lecturingPersuading with logic, arguing, lecturing

5.5. Moralising, preaching or telling people the ‘should’…Moralising, preaching or telling people the ‘should’…

6.6. Disagreeing, judging, criticising, blamingDisagreeing, judging, criticising, blaming

7.7. Agreeing, approving, praisingAgreeing, approving, praising

8.8. Shaming, ridiculing or labellingShaming, ridiculing or labelling

9.9. Interpreting or analysingInterpreting or analysing

10.10. Reassuring, sympathising or consolingReassuring, sympathising or consoling

11.11. Questioning or probingQuestioning or probing

12.12. Withdrawing, distracting, humouring or changing subjectWithdrawing, distracting, humouring or changing subject

ExercisesExercises

Stages of Change ModelStages of Change ModelUnaware or Unwilling

Pre-contemplation

Contemplation

Relapse

Preparation

Action

Think of Something (not too personal) Think of Something (not too personal) that you would like to change.that you would like to change.

• Identify your stage of change:Identify your stage of change:• Denial / Pre-contemplationDenial / Pre-contemplation• ContemplationContemplation• PreparationPreparation• ActionAction• RelapseRelapse

• Identify some event/behaviour in your own life that Identify some event/behaviour in your own life that shows example of TWO stages of changeshows example of TWO stages of change• With a partner, explain a behaviour and see if they With a partner, explain a behaviour and see if they

agree about your stage of changeagree about your stage of change• Think about a behaviour in your life you HAVE Think about a behaviour in your life you HAVE

changedchanged• What elicited that change?What elicited that change?

• Can you identify events that occurred while you were going Can you identify events that occurred while you were going through any of the above stagesthrough any of the above stages

My Example: Stretch after ExerciseMy Example: Stretch after Exercise

• Good exerciser, but I don’t stretch enoughGood exerciser, but I don’t stretch enough• I know that not stretching I know that not stretching likelihood of likelihood of

injuryinjury• I get back injuries and stiffness all the time I get back injuries and stiffness all the time

nowadaysnowadays• I run out of time to stretch in the gym etc.I run out of time to stretch in the gym etc.• I have bought yoga DVD and a yoga belt in I have bought yoga DVD and a yoga belt in

the summerthe summer• They are still in the packagingThey are still in the packaging

Using one of your identified Using one of your identified behavioursbehaviours

• On you own:On you own:• Identify a behaviour at the:Identify a behaviour at the:• Contemplation or Preparation stageContemplation or Preparation stage

• What would someone have to say to What would someone have to say to encourage you to move to the next stageencourage you to move to the next stage

• What could someone say that would really What could someone say that would really annoy you when you told them about the annoy you when you told them about the behaviour. behaviour.

Scenario 1Scenario 1• First visit:First visit:

• Client: 40 year old male, smoker, 40 units per week Client: 40 year old male, smoker, 40 units per week drinker.drinker.

• Sedentary job (Taxi Driver) has not exercised since he Sedentary job (Taxi Driver) has not exercised since he hurt his back playing football age 21.hurt his back playing football age 21.

• Reason for visit:Reason for visit:• Check up by doctor has shown BMI 30, and that he has Check up by doctor has shown BMI 30, and that he has

high cholesterol and is borderline type 2 diabetic.high cholesterol and is borderline type 2 diabetic.

• Other information:Other information:• Has two young children, wife is very worried about him.Has two young children, wife is very worried about him.

Clients turn around now.Clients turn around now.

• Interviewers:Interviewers:• Ask as many dead end questions as you Ask as many dead end questions as you

can.can.• Questions that can be answered with a number Questions that can be answered with a number

or a yes/no responseor a yes/no response• How much do you weigh, drink etc?How much do you weigh, drink etc?• Do you think you are overweight?Do you think you are overweight?• Do you know exercise can help?Do you know exercise can help?• Do you know you are classified as obese?Do you know you are classified as obese?• You know you have to lose weight don’t you?You know you have to lose weight don’t you?

Asking open ended ‘questions’.Asking open ended ‘questions’.• Open ended ‘questions’:Open ended ‘questions’:

• Tell me why you are here today.Tell me why you are here today.

• Reflective listening statements:Reflective listening statements:• The results of your tests particularly bother you.The results of your tests particularly bother you.• You think that you weigh/smoke/drink more than other You think that you weigh/smoke/drink more than other

people.people.• You would like to do something about your exercise You would like to do something about your exercise

habits.habits.• Describe a typical day’s eating/drinking/smoking or Describe a typical day’s eating/drinking/smoking or

general routinegeneral routine

• Summary and Reflection Summary and Reflection • Summarise one client response and then add ‘what Summarise one client response and then add ‘what

else’ at the end of it.else’ at the end of it.

What can be done in 5 mins?What can be done in 5 mins?

• Elicit informationElicit information• Open ended questionsOpen ended questions

• Not yes / noNot yes / no

• Support self efficacySupport self efficacy• Summarising/repetition of positive behavioursSummarising/repetition of positive behaviours

• Identify stage of changeIdentify stage of change• When will you be ready to provide information?When will you be ready to provide information?

What can be done in 5 mins?What can be done in 5 mins?

►Ask Ask OOpen Questionspen Questions►AAffirmffirm►RRevieweview►SSummariseummarise

Health Behaviour Change Health Behaviour Change SummarySummary

Health Behaviour Change Health Behaviour Change SummarySummary

• Elicit - Provide - ElicitElicit - Provide - Elicit• Address ambivalence, create dissonanceAddress ambivalence, create dissonance• Explore resistanceExplore resistance• Ask evocative questionsAsk evocative questions• Exploring the concerns and the pros and Exploring the concerns and the pros and

cons of changecons of change• Ask the client to elaborateAsk the client to elaborate• Elicit change talkElicit change talk• Identify client’s Goals and ValuesIdentify client’s Goals and Values

FoundationsFoundations• Your style is a powerful determinant of client Your style is a powerful determinant of client

resistance and changeresistance and change• Confrontation is a goal, not a styleConfrontation is a goal, not a style• Argument is a poor method to induce changeArgument is a poor method to induce change• Evoking client resistance stops clients Evoking client resistance stops clients

changingchanging

FoundationsFoundations

• Client motivation can be increased by a Client motivation can be increased by a variety of strategiesvariety of strategies

• Even brief interventions can have Even brief interventions can have substantial impactsubstantial impact

• Motivation emerges from interpersonal Motivation emerges from interpersonal interaction between client and counsellor.interaction between client and counsellor.

• Ambivalence is normal, not pathologicalAmbivalence is normal, not pathological• Helping people resolve ambivalence is the Helping people resolve ambivalence is the

key to change.key to change.

Principles and TrapsPrinciples and Traps

• Stages of ChangeStages of Change• R.E.A.D.SR.E.A.D.S• O.A.R.SO.A.R.S• TrapsTraps

• The Question-Answer trapThe Question-Answer trap• The Confrontation-Denial trapThe Confrontation-Denial trap• The Expert trapThe Expert trap• The Labelling trapThe Labelling trap• The Blaming trapThe Blaming trap