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Exercise: adherence (FS-09)
Jean Hay-Smith (New Zealand)
Sarah Dean (United Kingdom)
Helena Frawley (Australia)
Doreen McClurg (United Kingdom)
C Dumoulin (Canada)
This material is provided with the permission of the presenters and is not endorsed by WCPT
Exercise adherence: integrating
theory, evidence and behaviour
change techniques
Jean Hay-Smith PhD, Sarah Dean PhD, Helena Frawley PhD, Doreen McClurg PhD
Learning objectives
We will cover:
Why (long-term) exercise adherence is difficult
How theory helps us understand adherence
Why applying theory needs context-specific knowledge
You will be able to
Identify one or more behaviour change techniques that might support patients’ exercise adherence in your practice
Sarah Dean
Why (long-term) exercise adherence is difficult
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.
Definitions
Activity is any bodily movement produced by
skeletal muscles that results in energy expenditure and is usually measured in kilocalories per unit of time (Caspersen et al., 1985)
Exercise is a sub-set of physical activity and is
planned, structured, repetitive bodily movements that someone engages in for the purpose of improving or maintaining physical fitness or health
Physical Activity and Exercise
Physical activity
Exercise
Cardio
respiratory
Strengthening PFMT
ActivityWork, play,
travel, recreation
Definitions (see Sabatâe, 2003; Myers & Midence, 1998)
Compliance – being told what to do
Adherence – agreeing what to do
Concordance – therapeutic alliance and shared decision making
Intentional versus Unintentional
Phases of Exercise Adherence
Initial uptake
Adoption of main routine
Maintenance routine
Relapse management
Long term adherence to exercise based rehabilitation interventions for the management of chronic conditions is typically very poor:
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)
Why is (longer term) exercise adherence such a problem? (see Myers & Midence 1998)
People often ‘know’ what to do – but there is a large ‘knowledge-behaviour’ gap
Initial take up (often in a supported treatment setting) does not translate into daily routine
People relapse and don’t resume their exercises
Common myths
There is no ‘adherent’ personality
Adherence is not ‘all or nothing’
Non-adherers do not ‘just need more education’
Core concepts
Treatment adherence typically requires health behaviour change
Adherence is an outcome as well as a process –the ‘healthy adherer’ effect (see Simpson et al, 2006)
Core concepts
Measuring adherence is difficult – there is no gold standard (see Bollen et al, 2014)
Most people are willing to report being partially adherent, some are over-adherent
Difficult to be clear about what level of adherence is required to obtain therapeutic benefit
Explaining Adherence
Many theories or models exist to help us explain (non) adherence
No one theory explains the whole story....
We have selected several to focus on today…..
Doreen McClurg
How theory helps us understand adherence
Determinants
Glasgow Caledonian University, Glasgow, UK G4 0BA
A Theory?“He who loves practice without theory is like the sailor who boards ship without a rudder and compass and never knows where he may cast.” (Leonardo Da Vinci, 1452-1519)
a coherent description of a process that is arrived at by a process of inference, provides an explanation for observed phenomena and generates predictions (West & Brown, 2013).
It is strongly recommended that interventions to change health behaviours, including those that promote treatment adherence, are based on a theoretical model which provides an explanation of that behaviour. (Campbell 2001, Ommundsen 2001)
In the UK, the Medical Research Council recommends beginning the development of any complex intervention by identifying relevant theories to advance an understanding of the likely process of change before conducting any exploratory piloting and formal testing (Campbell et al., 2000)
Good practice to take a clinical history but this is meaningless unless we also appreciate the impact of the history on the symptoms the patient presents
with.
Theoretical models and PFMT (McClurg et al 2015)
Exercise is a health behaviour
Adherence is crucial to successful PFMT
A literature review of studies that identified
theories of health behaviour and PFMT
13 papers, 6 models applied in PFMT research
Poster RR-PO-99-23-Sat
()
Theories used in PFMTHealth Belief Model(Rosenstock & Becker, 1988: 1974)
Chiarelli and Cockburn (1999)
Gillard and Shamley (2010)
Dolman and Chase (1996)
Sacomori et al (2012)
Theory of Planned Behaviour (Ajzen, 1991)Whitford and Jones (2011)
Social Cognitive Theory : Self-Efficacy
Beliefs(Bandura, 1986)
Chen (2004); Cheng (2010), Lai
(2008), Hallam (2012), Hay-Smith,
Ryan and Dean (2007), Alewijnse et
al. (2003), Messer et al. (2007)
Transtheoretical Model (Prochaska & DiClemente, 1983)
Alewinjse (2002; 2003)
Self-Regulatory Model (Leventhal, Meyer & Nerenz; 1980)
Alewinjse (2002; 2003)
Health Action Process Approach (Schwarzer, 1992)
Hyland (2012)
Health Belief Model (Rosenstock & Becker, 1988:
1974)
Chiarelli and Cockburn 1999
Gillard and Shamley 2010
Dolman and Chase 1996
Sacomori et al 2012
19
Social Cognitive Theory : Self-Efficacy Beliefs (Bandura, 1986)
• Broom (1991, 2001);
Chen (2004); (SE
Scales)
• Cheng (2010); Lai
(2008); Hallam (2012)
• Hay-Smith, Ryan and
Dean (2007);
Alewijnse et al. (2003)
• Messer et al. (2007)
Determinants of adherence (Dumoulin et al 2015)
Population Determinants (Moderators & Mediators) Strategies
Women with
Urinary
Incontinence
(UI)
Alewijnse
Chen
Positive intention to adhere
Amount of urine lost (i.e. symptom level)
Self efficacy expectations
Attitudes towards the exercises
Perceived social pressure to engage
Dyadic cohesion (i.e. feedback)
A structured programme
Enthusiastic physiotherapist
Audio prompts
Use of established theories of
behaviour change
User consultation
Men with UI
Ip 2004
No studies Reminders on fridge magnets
Pre & Post natal
UI
Chiarelli and
Cockburn (2002)
No studies Health belief model tailoring PFM
to function and time
Pelvic Organ
Prolapse
No studies None
Lower Bowel
Dysfunction
No studies None
Motivational interventions to exercise and
traditional physiotherapy (McGrane et al 2015)
14 papers
5 MSK pain
4 obesity
3 cardiac rehabilitation
1 fatigue with cancer
1 sedentary females
6 theories
4 CBT
3 Social cognitive
3 Motivational Interviews
1 Self-determination
1 Transtheoretical
1 Social Learning
Self-efficacy was pooled in 6 studies, (CBT, Mot Int, Soc Cog, Self Deter) sig improvement in self-efficacy
Summary
Motivational interventions/theories to improve exercise adherence have received relatively little research
The same theory can be applied in more than one setting
Specifics of understanding which variables are most influential may be context specific Helena is going to talk more about that……..
Helena Frawley
Why applying theory needs context-specific knowledge
Everything, even Evidence-Based-
Practice, happens in context….
Figure from:Spring & Hitchcock, 2009
Five interacting dimensions
affect adherence (WHO 2003)
Figure from:http://apps.who.int/medicinedocs/en/d/Js4883e/7.2.html#Js4883e.7.2.1
our Pelvic Floor Muscle Training
adherence survey (Frawley et al 2015)
BARRIERS Options Clinician rating n=513
Patient ratingn=50
Physical / condition-related factors
other co-existing health issues which take priority
1 (76%) 1 (68%)
Patient-related factors
low level of motivation 1 (83%)
perception of minimal benefit / effectiveness of the exercises
1 (81%)
Therapy-related factors
lack of immediacy of beneficial effects, ineffective feedback of performance
1 (77%)
poor response to previous treatment (may have been ineffective treatment)
1 (79%)
Social / economic factors
lack of effective support networks to reinforce adherence
1 (68%) 1 (74%)
our PFMT adherence survey (Frawley et al 2015)
BARRIERS Options Clinician rating
Patient rating
Which category is the single most important barrier?
Patient-related factors 1 (66%) 1 (56%)
Therapy-related factors 2 (17%) 2 (20%)
What is single most important barrier to SHORT-TERM adherence?
low level of motivation 1 (16%)
perception of minimal benefit / effectiveness of the exercises
2 (14%) 1 (20%)
lack of understanding or knowledge about the condition
2 (12%)
LONG-TERM adherence?
forgetting to do exercises 1 (23%)
perception of minimal benefit / effectiveness of the exercises
1 (16%)
our PFMT adherence survey (Frawley et al 2015)
FACILITATORS Options Clinician rating n=513
Patient ratingn=50
Physical / condition-related factors
severity of symptoms: mild – moderate 1 (68%)
no / minimal other co-existing health issues competing for priority
1 (71%)
Patient-related factors
high degree of motivation 1 (93%)
perception of significant benefit / effectiveness of the exercises
1 (90%)
Therapy-related factors
patient-therapist relationship: good rapport, interaction motivates patient
1 (87%)
provide immediate beneficial effects (even if small)
1 (88%)
our PFMT adherence survey (Frawley et al 2015)
FACILITATORS Options Clinician rating
Patient rating
Which category is the single most important facilitator?
Patient-related factors 1 (60%) 2 (37.5%)
Therapy-related factors 2 (34%) 1 (55%)
What is single most important facilitator to SHORT-TERM adherence?
perception of significant benefit / effectiveness of the exercises
1 (19%)
high degree of motivation 1 (20%)
LONG-TERM adherence?
perception of significant benefit / effectiveness of the exercises
1 (21%) 1 (15%)
Clinical Recommendations(1) Patient-related factors may be the most important category of barriers to long-term PFMT adherence these may include the patient’s perception of minimal benefit of the therapy, reduced self-efficacy, poor identification with pelvic anatomy, and understanding of the condition, all of which may lead to low motivation to adhere to PFMT. Health professionals need to identify and address these factors.
(2) Patient- and therapy-related factors may optimally facilitate long-term adherence; health professionals need to provide tangible evidence or feedback to patients on PFMT benefits
(3) Long-term adherence may be best achieved through follow-up appointments and a re-assessment of factors impeding progress; determinants may change over time.
(4) An individualized approach to treatment based on a person’s age, sex, and ethnicity is recommended.
(5) The belief that PFMT adherence determinants differ according to condition is not strongly supported; therefore, individualized patient-centered, as opposed to condition-centered, approaches are recommended.
Remember
Change is difficult!
Figure from:http://www.marketingforchange.com.au/great-behaviour-change-mind-map/
Stages
of
Change(Grol 2013)
Aware
Agree
Adopt
Adhere
Figure from Grol 2013See Pathman et al 1996
Attrition in the ‘pipeline’ of
research to practice (Glasziou 2004)
Barriers and Enablers
Barriers & Enablers (Rainbird 2006)
Level Type of barrier or enabler
Examples
The innovation itself
Individual professional
Patient
Social context
Organisational context
Economic & political context
Level Type of barrier or enabler
Examples
The innovation itself - Advantages in practice- Feasibility- Credibility- Accessibility- Attractiveness
- CPGs may be perceived as difficult to use
- CPGs which recommend discarding may be more difficult than introducing
Individual professional
Patient
Social context
Organisational context
Economic & political context
Level Type of barrier or enabler
Examples
The innovation itself
Individual professional - Awareness- Knowledge- Attitude- Motivation to change- Behavioural routines
Patient
Social context
Organisational context
Economic & political context
Phases
in the
process
of
change (Grol 2013)
Orientation:awareness of innovation
interest and involvement
Insight:understanding
insight into own routine
Acceptance:positive attitude, motivation to change
positive intention or decision to change
Change:actual adoption in practice
confirmation of benefit or value of change
Maintenance:integration of new practice into routines
embedding of new practice in the organisation
Translating
Research Into
Practice project (Frawley et al 2014)
Orientation
Insight
AcceptanceChange
Maintenance
Jean Hay-Smith
Why applying theory needs context-specific knowledge
Identify one or more behaviour change techniques that might support patients’ exercise adherence in your practice
www.opaltrial.co.uk
Planning the OPAL intervention
Information Motivation Behavioural
Skills Model (IMB) (Fisher et al 2003)
Context: the qualitative synthesis(Hay-Smith et al, 2015. Neurourology & Urodynamics, in press)
Knowledge
Feelings about PFMT
Physical skill
Cognitive analysis, planning and attention
Prioritisation
Service provision
IMB Model and synthesis
Fisher et al, 2003
Knowledge
Physical skill
CognitionFeelingsPriorityServices
Behaviour change techniques
(BCTs) (Michie et al 2013)
93 item taxonomy
Naming active ingredients of delivery
Applicable to many health behaviours
Choose for context
Item 74: Credible source
Present verbal or visual communication from a credible source in favour of the behaviour
“your doctor has referred you to me because I am an expert in pelvic floor muscle exercises. I have worked in this area for 20 years and have done extra training to help women with incontinence”
Item 41: Mental rehearsal of
successful performanceAdvise to practice imagining performing the behaviour successfully in relevant contexts.
“I will pull my muscles up as hard as I can. I will hold as hard as I can. I will keep breathing while I count 1 banana 2 banana 3 banana 4 banana 5 banana and then I will let go. I will rest while I count ….. etc”
Item 71: Behavioural contract
Very familiar with goal setting for the behaviour (Item 66)
Add, item 71. Create a written specification of the behaviour to be performed, agreed by the person, and witnessed by another
We have
Briefly explained:
Why long-term exercise adherence is difficult
How theory helps us understand adherence
Why applying theory needs context-specific knowledge
Referred to a 93 item taxonomy of behaviour change techniques and given 3 specific examples used to support exercise adherence
Questions – Panel – 20 minutes
Sarah Dean PhD, CPsychol, MCSP,
Senior Lecturer in Psychology Applied to Health, University of Exeter Medical School, College House, St Luke’s Campus, Exeter [email protected]
Doreen McClurgReader, Nursing, Midwifery and Allied Health Professions RU,Glasgow Caledonian University,Scotland, UK. [email protected]
Helena Frawley PhD FACP
Associate Professor, Allied Health, La Trobe UniversityHead, Allied Health Research, Cabrini InstituteNational Health & Medical Research Council (Australia) Health Professional Research [email protected]
Jean Hay-Smith PhD MPNZ
Associate Professor, RehabilitationAssociate Professor, Women’s HealthUniversity of OtagoNew [email protected]
Sarah Dean
Good quality information provision is an important platform for promoting adherence but more information alone is not enough to change behaviour, instead:
Use your credibility as a professional / expert in the area (BCT ‘credible source’)
Check and address any information misconceptions (BCT ‘information about health consequences’ )
Promote motivation through
goal setting and action planning
if-then rules
Boost self-efficacy
Work out a relapse strategy
Ensure patient has necessary behavioural skills
correct exercise technique
a regimen to follow that allows progression and relapse management
skills and equipment to self-monitor or review progress
To summarise
Aim for sufficient partial adherence to obtain therapeutic benefit
Help patients establish routines, so that exercises are part of their daily life
Don’t let exercises be a burdensome additional ‘interruption’ to their lives
References - HelenaBehaviour change: http://www.marketingforchange.com.au/great-behaviour-change-mind-map/
Frawley, H., Chiarelli, P., Gunn, J. (2014) Uptake of antepartum continence screening and pelvic floor muscle exercise instruction by maternity care providers: an implementation project. Neurourol Urodynam, 33(6)
Frawley, H., McClurg, D., Mahfooza, A., Hay-Smith, J., Dumoulin, C. (2015) Health Professionals’ and Patients’ Perspectives on Pelvic Floor Muscle Training Adherence – 2011 ICS State-of-the-Science Seminar Research Paper IV of IV. Neurourol Urodynam, accepted.
Grol, R., M. Wensing, et al., Eds. (2013). Improving patient care: the implementation of change in health care. Oxford, Wiley Blackwell.
Rainbird, K et al. (2006) Identifying barriers to evidence uptake http://www.nicsl.com.au/
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WHO 2003: Adherence to Long-Term Therapies - Evidence for Action http://apps.who.int/medicinedocs/en/d/Js4883e/7.2.html#Js4883e.7.2.1
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References - Jean
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