Helping Patients Manage

Therapeutic Regimens
COMMUNICATION SKILLS IN PHARMACY PRACTICE

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 Objectives
• Introduction
• False Assumptions about Patient Understanding and
Medication Adherence
• Techniques to Improve Patient Understanding
• Techniques to Establish New Behaviors
• Techniques to Facilitate Behavior Change
• Theoretical Foundations Supporting Behavior Change
• Applying Motivational Interviewing Principles and Strategies
• Summary

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 Introduction
“Keep watch also on the fault of patients which often makes
them lie about taking of things prescribed.” Hippocrates

Hippocrates made this remark over 2,000 years ago!

Unfortunately, concern about how patients actually use their
prescribed medications continues to this day.

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 Compliance
Compliance:
The extent to which the patient’s follow doctors’ prescriptions
about medicine taking.

traditional patient–provider relationship in which providers told

patients what to do and patients presumably did it (complied).

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 Adherence:
Adherence:
the extent to which the patients behavior matches agreed
recommendations from the prescriber. The term “adherence”
(emphasizing the need for agreement) has largely replaced
“compliance” and was intended to move away from the
paternalistic view of patients as individuals who simply did as
they were told.

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 Concordance

Concordance: “an agreement reached after negotiation between a

patient and health care professional that respects the beliefs and
wishes of the patient in determining whether, when and how
medicines are to be taken.”

This joint decision making requires a meaningful dialogue between

patients and providers on medical options and patient
preferences.

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 Rate of Adherence
The exact rate of adherence to medication regimens varies from
study to study since researchers in this area define and measure
adherence differently.
However, regardless of definition and measurement, adherence
rates are well below 100%. The consensus is that adherence
rates for long-term therapies tend to be about 50%.

Some researchers use:

• indirect methods of measuring adherence (interview patients
and family members, have patients keep diaries)
• direct methods (assessing blood or urine levels of medication).
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 Cost of Nonadherence
Most nonadherences have negative effects on patient health
which, in turn, can result in
increased :
emergency room and physician visits,
hospitalizations,
disability,
premature death.

and decreased productivity in the work place,

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 Reasons exist for poor- or nonadherence

Numerous reasons exist, some reasons are related to

• Patients, include:
o patient perception of medications
o Many patients are afraid of taking medications,
o while some may rely too heavily on medications and take more than prescribed.

• Health care providers,

• Others evolve from the health care delivery system.
o lack of insurance coverage,
o access to medications,
o and other economic concerns.

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 Nonadherence can be divided into two broad

categories:
1. Unintentional (inadvertent): forgetting
2. Intentional, involves decisions a patient has made to alter a
medication regimen or to discontinue drug therapy
(permanently or temporarily).
due to
o an uncomfortable side effect
o or skip doses of a medication

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 False Assumptions about Patient Understanding and Medication Adherence

Do not assume that:

• Physicians have already discussed the medications.
• Patients understand all information provided and able to take
the medication correctly.
• Once patients start taking their medications correctly, they
will continue to take them correctly in the future.
• If patients are having problems, they will ask direct questions.

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 Techniques to Improve Patient Understanding
1. Emphasize key points. “This is very important” helps them remember what
follows.
2. Give reasons for key advice, e.g., with an antibiotic prescription, tell why it
is necessary to continue medication use even though symptoms have
disappeared.
3. Use visual aids, photographs, or demonstrations.
4. Supplement and reinforce spoken words with written instructions.
5. Assessment of a patient’s ability to read and understand key written
instructions is required.
6. End the encounter by taking feedback .

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 Techniques to Establish New Behaviors

A number of simple suggestions from you when patients are

beginning a new regimen can help get them started on the right
track.
1. Help patients identify ways to integrate new behaviors with
current habits.
2. Provide appropriate adherence aids.
-Individualized medication packaging for daily or weekly doses seems to work for some patients.
-Alarms on cell phones and other devices can be programmed to signal when medication doses
are to be taken.

3. Suggest ways to self-monitor.

-use a medication diary or calendar on which to record their medication use.
-Other monitoring can involve treatment effects: blood pressure or testing their blood glucose
levels

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 Techniques to Establish New Behaviors
4. Monitor medication use.
5. Make proper referrals; refer patients to appropriate social
service agencies, such as government programs for low-
income patients.

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 Techniques to Facilitate Behavior Change
• Establish a new habit (beginning a medication regimen)
• Change old habits (overeating).
• Stop existing habits (smoking).
For chronic diseases such as diabetes, the changes involve
-establishing new behaviors (drug therapy and daily blood glucose monitoring),
-changing old habits (diet and exercise),
-ceasing other behaviors (drinking alcohol).

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 Theoretical Foundations Supporting Behavior Change
• Miller and Rollnick (2002) developed a conceptual foundation
‘motivational interviewing’, to help people make changes in the direction of
better health.

• It builds on the Transtheoretical Model of Change as well as principles of a

number of different theories,

• They identified three components of motivation to change

a. Willingness, which is indicated by the amount of discrepancy patients perceive
between current health status and goals they have for themselves,
b. Perceived ability or the amount of self-confidence patients feel in their ability
to initiate and maintain behavioral change (also known as self-efficacy),
c. Readiness, which is related to how high a priority is given to these behavioral
changes.

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 Theoretical Foundations Supporting Behavior Change
• Motivational Interviewing incorporates many of the relationship-building
principles and techniques of Carl Rogers,
• Rogers emphasized that empathic understanding is a core condition of a
helping relationship because;

 it facilitates the patient’s own problem-solving ability.

 frees patients from the fear that they are being judged because of their
behavior.

• Social cognitive theory of Albert Bandura (1986), behavior change requires

that an individual believe that
(a) “engaging in a particular behavior change will lead to an outcome I desire” ,
and
(b) “I am capable of carrying out the behavior change” .
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 Theoretical Foundations Supporting Behavior Change
• The Trans theoretical Model of Change focus on the stages a
person goes through in making decisions to change their
behavior.

• Behavior change is seen as a process that continues over time

rather than as a defining moment or single event.

• The stages conceptualized by the model are described in the

following sections.

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 Stages of Change
• Precontemplation: unwillingness to change, lack recognition
of problem, deny seriousness of risks.
• Contemplation: acknowledging that there is a problem but no
ready or sure of wanting to make a change.
• Preparation/determination (getting ready to change)
• Action/willpower (change is initiated)
• Maintenance (change is established and incorporated to
lifestyle, focus is on avoiding relapse)
• Relapse (returning to older behavior)

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 STAGE 1:
PRECONTEMPLATION
• persons are not thinking seriously about changing.
• Defend their current bad habit(s) and don’t feel it is a
problem
• Interventions must focus on getting them to think about
changing habits, to begin to consider the pros and cons of
behavior change.
o Raise awareness of problem
o Provide information
o Convey empathy
o Encourage thinking about
o Express willingness to help
o Avoid arguing

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STAGE 2: CONTEMPLATION
• The contemplation stage “thinking about” changing their
behavior—not immediately but within the next 6 months or
so.
• They believe in the benefits of change but also see the
personal costs or challenges involved.
• Interventions at this stage can best be focused on getting
patients to describe the “pros”.

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 STAGE 3: PREPARATION
• the individual is ready to implement a change program or
initiate a new regimen almost immediately(< 1 month). These
individuals have reached a decision in favor of change.

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 STAGE 4: ACTION/
Willpower
• The action stage is the initial period in changing a behavior.
• During this initial period of change, the desire to go back to
old habits makes the potential to relapse of concern.

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 STAGE 5: MAINTENANCE
• In the maintenance stage, relapse can continue to be of
concern but persons can often continue with the new habits
without constant vigilance against relapse.

• The new behaviors have become more integrated into

lifestyles and routines. Patients gain more confidence in their
abilities to maintain changes.

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 Applying Motivational Interviewing Principles and Strategies

• Express empathy
• Develop discrepancy
• Roll with resistance
• Support self-efficacy
• Elicit and reinforce “change talk”

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