Why don’t they do what we tell them?!!! Behaviour change & the CHD population Dr Gail Bohin...

Why don’t they Why don’t they do what we tell do what we tell

them?!!!them?!!!Behaviour change & the Behaviour change & the

CHD populationCHD populationDr Gail BohinDr Gail Bohin

Clinical PsychologistClinical Psychologist

Gloucestershire Cardiac Rehabilitation Gloucestershire Cardiac Rehabilitation ServiceService

[email protected]@hpsygrh.demon.co.uk

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….The reality….

Have you ever struggled to stick to a Have you ever struggled to stick to a diet or exercise plan? diet or exercise plan?

Stopped taking medication before the Stopped taking medication before the end of the prescription?end of the prescription?

Exercised against advice when you Exercised against advice when you had an injury?had an injury?

Everyone is non-adherent sometimes. Everyone is non-adherent sometimes. So is not complying a “normal” So is not complying a “normal” behaviour?behaviour?


The medical modelThe medical model The prevailing model in medicine.The prevailing model in medicine. Health care providers are the “expert” Health care providers are the “expert”

patients are passive recipients of that patients are passive recipients of that expertise.expertise.

Patients are given advice based on the best Patients are given advice based on the best evidence available.evidence available.

Not following advice is viewed as a Not following advice is viewed as a problem, failure or disobedience.problem, failure or disobedience.

Health professionals can disengage with Health professionals can disengage with patients who do not follow advice.patients who do not follow advice.


Non adherence in CHD - Non adherence in CHD - the scale of the problem:the scale of the problem:

1 in 81 in 8 patients patients stop taking medicationstop taking medication within a month of having an MI within a month of having an MI (Ho et al 2006)(Ho et al 2006)

50%50% of those smoking pre-MI continue to of those smoking pre-MI continue to smoke post MI smoke post MI (Scholte op Reimer et al 2006)(Scholte op Reimer et al 2006)

People with CHDPeople with CHD are are lessless likely to likely to exercise exercise (Zhao et al 2008) (Zhao et al 2008)

Research suggests that we should expect Research suggests that we should expect around around 50%50% of patients to follow of patients to follow instructions but that figure can drop to instructions but that figure can drop to around around 10%10% (Ley;1988,1997)(Ley;1988,1997)


Psychological distressPsychological distress

Patients with CHD have higher Patients with CHD have higher prevalence rates of anxiety and prevalence rates of anxiety and depression than the general population.depression than the general population.

Patients with moderate to severe Patients with moderate to severe depression at 69% greater risk for cardiac depression at 69% greater risk for cardiac death & 78% greater risk of all-cause death & 78% greater risk of all-cause death. death. (Barefoot et al 200??)(Barefoot et al 200??)

Often these patients get “missed”. We Often these patients get “missed”. We need to identify these patients early on need to identify these patients early on and consider their additional needs.and consider their additional needs.


Depression and non-Depression and non-adherenceadherence

Depressed patients report lower Depressed patients report lower adherence to :adherence to :

quitting smokingquitting smoking taking all cardiac medicationstaking all cardiac medications exerciseexercise attending cardiac rehabilitationattending cardiac rehabilitation

(Kronish et al 2006)(Kronish et al 2006)


Depression & AnxietyDepression & Anxiety Major depression is associated with Major depression is associated with

poor adherence to aspirin regimen poor adherence to aspirin regimen post diagnosis of CHD. post diagnosis of CHD. Carney et al (1995)Carney et al (1995)

Non adherence rates:Non adherence rates: 15% non depressed patients15% non depressed patients 29% mildly depressed patients 29% mildly depressed patients 37% moderately depressed patients37% moderately depressed patients

took aspirin less than took aspirin less than 80%80% of the time of the time (Rieckmann et al 2006)(Rieckmann et al 2006)


The challenges for our The challenges for our patients….patients….

How do you make and maintain multiple How do you make and maintain multiple lifestyle changes, at a time when you may be lifestyle changes, at a time when you may be physically and emotionally depleted, and under physically and emotionally depleted, and under competing pressures?competing pressures?

What information do you need and when is the What information do you need and when is the best time to receive it?best time to receive it?

How does it feel to be confronted with How does it feel to be confronted with information on what you information on what you shouldshould be doing be doing when you don’t feel up to the challenge or when you don’t feel up to the challenge or have other priorities?have other priorities?


Unintentional non-Unintentional non-adherenceadherence

Chronic illnessChronic illness places people under complex places people under complex demands demands

stress/distressstress/distress - interferes with changing our - interferes with changing our behaviour/habits & information processingbehaviour/habits & information processing

unrealistic goal setting/lack of skillsunrealistic goal setting/lack of skills - trying - trying to change too much too quicklyto change too much too quickly

confidenceconfidence - previous experience - have we - previous experience - have we tried to make these changes before and failed?tried to make these changes before and failed?

getting bettergetting better - can de-motivate patients to - can de-motivate patients to change their lifestyles, ongoing symptoms can change their lifestyles, ongoing symptoms can increase motivationincrease motivation


““Deliberate” non-Deliberate” non-adherenceadherence

Denial Denial -- can be a useful coping strategy in the can be a useful coping strategy in the short-term, to stop you being overwhelmed, short-term, to stop you being overwhelmed, but is destructive in the longer term. but is destructive in the longer term.

ReactanceReactance some people feel out of control or some people feel out of control or disempowered by health problems. They regain disempowered by health problems. They regain a sense of control through active defiance and a sense of control through active defiance and react strongly to perceived attempts to “tell react strongly to perceived attempts to “tell them” what to do. them” what to do. (Brehm & Brehm 1981) (Brehm & Brehm 1981)

DissatisfactionDissatisfaction -- adherence can be viewed as adherence can be viewed as an indicator of the quality of the patient - an indicator of the quality of the patient - health care provider relationship health care provider relationship (Salmon 2002)(Salmon 2002)


Patients have different Patients have different views to us….views to us…. Patients now have much greater access to Patients now have much greater access to

information from lay sources. This information from lay sources. This information can be more persuasive than information can be more persuasive than that of your healthcare professionals that of your healthcare professionals (Elliot & (Elliot & Binns 1986)Binns 1986)

If the patient & healthcare professional have If the patient & healthcare professional have different different beliefsbeliefs, the patient is less likely to , the patient is less likely to comply comply (Hunt et al 1989)(Hunt et al 1989)

Generally, adherence relates more to the Generally, adherence relates more to the patient’s viewpatient’s view of the illness, than the of the illness, than the clinician’s clinician’s ((Janz & Becker 1984)Janz & Becker 1984)


BeliefsBeliefs

Beliefs guide all of our behaviour, Beliefs guide all of our behaviour, they shape our understanding of they shape our understanding of ourselves, other people and the ourselves, other people and the world. They are deeply held and can world. They are deeply held and can be resistant to change.be resistant to change.

““Whether you believe you can or Whether you believe you can or believe you can’t, you are right”believe you can’t, you are right”

Henry FordHenry Ford


Patient’s beliefsPatient’s beliefs

Identity- Identity- what is what is this?this?

Cause Cause - how did I - how did I get this? get this?

ControlControl - what can - what can be done to help be done to help me?me? What can I do What can I do to help?to help?

CureCure - is it fixable? - is it fixable? TimelineTimeline -how long -how long

will it be before I’m will it be before I’m better?better?

ConsequencesConsequences - - what does this mean what does this mean for the future?for the future?

(Leventhal (Leventhal et alet al 1980) 1980)

Patients formulate their health beliefs around the following constructs:


Beliefs & non-Beliefs & non-adherence…….adherence…….

IdentityIdentity

“ “ I haven’t got heart disease, I had a heart I haven’t got heart disease, I had a heart attack a while back, but I’m better now”attack a while back, but I’m better now”

CauseCause

“ “ work stress caused my heart problems, work stress caused my heart problems, now I’ve retired early, I should be fine!”now I’ve retired early, I should be fine!”

Cure/control Cure/control

““ Heart disease is in the family, there’s Heart disease is in the family, there’s nothing I can do about it”nothing I can do about it”


Beliefs and non-Beliefs and non-adherence…..adherence…..

TimelineTimeline

““Once I’ve had my bypass, my consultant Once I’ve had my bypass, my consultant says my arteries will be better than his!”says my arteries will be better than his!”

ConsequencesConsequences

““I don’t like taking tablets, don’t they all I don’t like taking tablets, don’t they all have side effects? I haven’t been taking have side effects? I haven’t been taking

mine”mine”

We need to understand our patients better, We need to understand our patients better, their views may not make sense to us, but their views may not make sense to us, but they do to them!they do to them!


Patient beliefs & Patient beliefs & AdherenceAdherence

These beliefs are central to their motivation to These beliefs are central to their motivation to change their behaviour, they drive their change their behaviour, they drive their disease management.disease management.

Often the patient’s beliefs are conflicting with Often the patient’s beliefs are conflicting with the medical evidence. Despite this, beliefs can the medical evidence. Despite this, beliefs can be firmly held and resistant to change. be firmly held and resistant to change.

They will not be changed by us simply telling They will not be changed by us simply telling them differently.them differently.

Not understanding the patient’s view Not understanding the patient’s view couldcould increase non-adherence increase non-adherence


DissatisfactionDissatisfaction Patient satisfaction increasesPatient satisfaction increases when the when the

patient feels that their concerns have been patient feels that their concerns have been heard and understoodheard and understood (Ley 1988) (Ley 1988)

Patients disengagePatients disengage if they receive if they receive conflicting advice from different sources, conflicting advice from different sources, they are de-motivated by they are de-motivated by mixed messagesmixed messages (Salmon 2002)(Salmon 2002)

CHD is so common, our patients get mixed CHD is so common, our patients get mixed messages all of the time! (how many messages all of the time! (how many newspaper clippings get brought in…?!!) newspaper clippings get brought in…?!!)


Delivering informationDelivering information

When is the best time When is the best time to receive information?to receive information?

How much information How much information should we give?should we give?

How should we How should we deliver it?deliver it?

Who should give Who should give it?it?

How often should How often should we say it?we say it?

People absorb information in different ways and have different learning styles - this is a minefield of individual differences. Our challenge is to get theinformation across in the most accessible way for the patient.


Information givingInformation giving

Anxiety Anxiety or stress changes our focus - we or stress changes our focus - we attend more to information that is attend more to information that is frightening frightening (Williams et al 1997).(Williams et al 1997). Our patients Our patients are often stressed.are often stressed.

For some getting information helps to For some getting information helps to reduce anxiety, for others it increases reduce anxiety, for others it increases anxiety. anxiety.

Patients use information to make sense of Patients use information to make sense of what is happening to them. We need to what is happening to them. We need to ask themask them how much information they how much information they would like.would like.


Information giving……..Information giving……..

Monitors Monitors cope by getting as cope by getting as much information as much information as they can from as many they can from as many sources as possible sources as possible (medics, TV internet, (medics, TV internet, friends, other patients friends, other patients etc). They may be etc). They may be reassured by detailed reassured by detailed discussions & discussions & packages of packages of informationinformation

BluntersBlunterscope 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)(Miller et al 1988)


Making information Making information memorablememorable

Present the Present the important important information firstinformation first

Provide clear, Provide clear, specific information, specific information, not general principlesnot general principles

Restrict the Restrict the information into information into chunks - don’t chunks - don’t overwhelm the overwhelm the patient’s processing patient’s processing abilitiesabilities

Consider the language Consider the language & terminology used, & terminology used, make it clear & make it clear & accessible (Flesch accessible (Flesch Formula - readability Formula - readability score)score)

Use different Use different mediums, verbal, mediums, verbal, written, diagramswritten, diagrams, , video, websites etcvideo, websites etc

involve peers & expert involve peers & expert patientspatients


Patient-centred Patient-centred consultingconsulting

Sometimes it can be hard for our patient to Sometimes it can be hard for our patient to establish their priorities, or what the most establish their priorities, or what the most important information is. They need time to important information is. They need time to reflect, to process what is happening. reflect, to process what is happening. Motivation to change will also fluctuate Motivation to change will also fluctuate throughout the recovery period. We are throughout the recovery period. We are complicated creatures. There are times when complicated creatures. There are times when we we are are receptive to information and do want receptive to information and do want to be to be “told”“told” and times when we don’t. and times when we don’t.

How do we balance their needs, with our How do we balance their needs, with our needs to do our job, whenneeds to do our job, when we are often we are often

time limited/resource limited?time limited/resource limited?


Remember…...Remember…...

Doing a lot of the same thing can make you Doing a lot of the same thing can make you either really good at your job, or make it either really good at your job, or make it more likely that your approach becomes more likely that your approach becomes more auto-pilot or “standardised” and less more auto-pilot or “standardised” and less tailored to the individual.tailored to the individual.

We have a lot to learn about behaviour We have a lot to learn about behaviour changechange

So do our patients…...So do our patients…...


What skills do we need to What skills do we need to help our patients help our patients

change?change? Information sharing skillsInformation sharing skills. How to deliver . How to deliver

information as effectively as possible in a information as effectively as possible in a variety of mediumsvariety of mediums

Communication skillsCommunication skills to help improve the to help improve the quality of our face to face contacts with quality of our face to face contacts with patientspatients

Behaviour Change CounsellingBehaviour Change Counselling skills - to skills - to help us to empower the patient and move away help us to empower the patient and move away from teaching or telling, to including them in from teaching or telling, to including them in decisions about their caredecisions about their care

Flexible working Flexible working - one size doesn’t fit all


What skills do our What skills do our patients need to help patients need to help

them to make changes?them to make changes? Understanding/ Understanding/

comprehensioncomprehension - - why do they need to why do they need to make these changes?make these changes?

Communication - Communication - asserting themselves, stating their needs/priorities, asking questions, being satisfied with their consultations

Goal setting & Goal setting & planningplanning

Self monitoring Self monitoring Problem solving Problem solving Support networks - Support networks -

both socially & from their health care professionals

decision making /negotiation skills

(Houston Miller et al 1997)


What do services need to What do services need to be offering?be offering?

More tailored, individualised More tailored, individualised interventionsinterventions

Better joined up working - risk factor Better joined up working - risk factor management is not just the job of rehab. management is not just the job of rehab.

Specific behaviour change counselling Specific behaviour change counselling interventionsinterventions

Follow ups over a longer period & more Follow ups over a longer period & more flexible systems -Use of flexible systems -Use of telephone/e-mail/text follow up?telephone/e-mail/text follow up?

More resources (that old chestnut…)More resources (that old chestnut…)Dr Gail Bohin 4th October 2008

The reality…..The reality…..

How do we implement any of this within our How do we implement any of this within our existing, often limited, resources?!!!existing, often limited, resources?!!!

We can’t change the world (or the NHS) We can’t change the world (or the NHS) overnight, but what can we start doing to overnight, but what can we start doing to communicate more effectively & to empower communicate more effectively & to empower ourselves and our patients? ourselves and our patients?

Even small changes can build over time into Even small changes can build over time into bigger change bigger change

what can we do to start identifying patients what can we do to start identifying patients who may be at risk of non-adherent behaviours who may be at risk of non-adherent behaviours early on?early on?


ReferencesReferencesBarefoot JC, Helms, MJ, Mark DB, Blumenthal, RM (1996) Barefoot JC, Helms, MJ, Mark DB, Blumenthal, RM (1996)

Depression Predicts Mortality in Coronary Disease, Depression Predicts Mortality in Coronary Disease, American Journal of CardiologyAmerican Journal of Cardiology

Brehm SS, Brehm JW (1981) Brehm SS, Brehm JW (1981) Psychological Reactance: A Psychological Reactance: A theory of Freedom and Controltheory of Freedom and Control, New York, Academic , New York, Academic PressPress

Carney, M, Freedland K, Rich MW, Jaffe A (1995) Carney, M, Freedland K, Rich MW, Jaffe A (1995) Depression as a Risk Factor for Cardiac events in Depression as a Risk Factor for Cardiac events in established Coronary Artery Disease: A review of established Coronary Artery Disease: A review of possible mechanisms, possible mechanisms, Annals of Behavioural MedicineAnnals of Behavioural Medicine, , vol 17, no.2, 142-149vol 17, no.2, 142-149

Elliot-Binns CP (1986) An analysis of medicine. Elliot-Binns CP (1986) An analysis of medicine. Journal of Journal of the Royal College of General Practitionersthe Royal College of General Practitioners 36, 542-544 36, 542-544


ReferencesReferencesHouston-Miller N, Hill M, Kottke, T, Ira S, Ockene MD, (1997) Houston-Miller N, Hill M, Kottke, T, Ira S, Ockene MD, (1997)

The Multi-level Compliance Challenge: recommendations for The Multi-level Compliance Challenge: recommendations for a call to action, a call to action, CirculationCirculation, 95; 1085-1090, 95; 1085-1090

Hunt LM, Jordan B, Irwin S (1989) Views of what’s wrong: Hunt LM, Jordan B, Irwin S (1989) Views of what’s wrong: diagnosis and patient’ concepts of illness. diagnosis and patient’ concepts of illness. Social Science and Social Science and MedicineMedicine 28, 945-956 28, 945-956

Janz NK, Becker MH (1984) The Health Belief model a decade Janz NK, Becker MH (1984) The Health Belief model a decade later, later, Health Education QuarterlyHealth Education Quarterly 11, 1-47 11, 1-47

Leventhal H, Meyer D, Nerenz, D (1980) The Common Sense Leventhal H, Meyer D, Nerenz, D (1980) The Common Sense Representation of Illness Danger. In S Rachman (Ed), Representation of Illness Danger. In S Rachman (Ed), Medical Medical PsychologyPsychology, Vol 2, pp-7-30. New York: Pergammon. , Vol 2, pp-7-30. New York: Pergammon.

Ley, P (1988) Ley, P (1988) Communicating with PatientsCommunicating with Patients. London: Chapman . London: Chapman & Hall& Hall


ReferencesReferencesMiller SM, Brody Ds, Summerton J (1988) Styles of Miller SM, Brody Ds, Summerton J (1988) Styles of

coping with threat: implications for health. coping with threat: implications for health. Journal of Journal of Personality and Social PsychologyPersonality and Social Psychology 54 142-148 54 142-148

Rieckmann, N, Kronish, I M, Haas W, Gerin Wf…. Rieckmann, N, Kronish, I M, Haas W, Gerin Wf…. (2006) Persistent Depressive Symptoms lower aspirin (2006) Persistent Depressive Symptoms lower aspirin adherence after Acute Coronary Syndrome, adherence after Acute Coronary Syndrome, American American Heart JournalHeart Journal, vol 152, Issue 5, pages 922-927 , vol 152, Issue 5, pages 922-927

Salmon P (2002) Salmon P (2002) Psychology of Medicine and SurgeryPsychology of Medicine and Surgery, , Chichester, WileyChichester, Wiley

Zhao G, Ford E, Li C, Mokdad A (2008), Are United Zhao G, Ford E, Li C, Mokdad A (2008), Are United States Adults with Coronary Heart Disease Meeting States Adults with Coronary Heart Disease Meeting Physical Activity Recommendations? Physical Activity Recommendations? American American Journal of CardiologyJournal of Cardiology 101: 557-61 101: 557-61


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