Behavioral approaches to changing adherence

Key Messages

• Commonly used behavioral change techniques may not always be effective in changing behavior
• Utilizing techniques such as motivational interviewing may be useful in changing patient adherence behavior

Commonly used behavior-change strategies

Commonly used behavioral change techniques may not always be the most effective methods  of changing behavior.1 For example, presenting threatening information may not have the desired effect on behavior. In the context of adherence, the evidence that simply telling a patient that they must take their medication (i.e. only providing information and expecting results) will result in weak adherence.2

Asking basic questions such as “Are you still taking your medication?” may result in a patient becoming defensive and not providing truthful answers. In such instances, the clinician might underestimate the extent of non-adherence.3

Patient health behavior and outcomes can be influenced by the use of evidence-based behavioral interventions.2

Techniques used to instigate change in behavior

Behavior-change techniques can be utilized depending on the cause of the adherence issue.4 The COM-B framework is a useful basis for identifying the correct technique for individual patients.2 Screener questionnaires can be used to establish why a patient is not taking their medication correctly (i.e. capability, opportunity or motivation) and thereby how this can be resolved.3 If the lack of adherence is due to negative beliefs about the medication, then a motivational interviewing approach might help to change this.5 If the non-adherence is due to a lack of organization/forgetfulness, then working with them to create an action plan and gain control over their schedule would be appropriate.3

“Nudge” theory

Nudge theory has been demonstrated to enhance adherence. It is based on the idea that people can be helped to optimize their decision making by giving them a “nudge”, i.e. framing their choices in such a way that they are more likely to select the best options. These are often attractive to policymakers as they attempt to steer individuals in a desired direction without removing their freedom of choice.6 Governments have set up dedicated “nudge units” that cover a variety of policy areas, including health and wellbeing, such as encouraging vaccination uptake and organ donation.7–11

Reviews of patients with chronic diseases have demonstrated the effectiveness of nudges in improving disease self-management. A systematic literature review found that the majority of the analyzed studies into the effects of nudge interventions on medication adherence showed significantly positive events. The interventions includes reminders, social support, small financial incentives, feedback and intervention design.6

A study by a group of UK and US researchers (in collaboration with the UK National Health Service) also concluded that nudging is efficient in improving adherence. In this case, patients were reminded of the personal and societal costs of non-adherence.12

The concept of nudge theory was first introduced by Thaler and Sunstein in 2008.6 They outline several cases where nudges can be applicable:13

Health behavior	Definition	Example
Benefits now, costs later	The individual does not seriously consider the future negative impact of their behavior	A patient with chronic pancreatitis who binge drinks alcohol may not react to established safe drinking limits, but may respond to the more tangible concept of seeing their consumption compared to that of their peers
Degree of difficulty	More difficult problems require more help to make the right decision	A patient with chronic pancreatitis who binge drinks alcohol may not react to established safe drinking limits, but may respond to the more tangible concept of seeing their consumption compared to that of their peers
Frequency	A person is confronted with rare and difficult decisions, with significant consequence	A patient that must give their consent for a surgery or treatment with uncertain outcomes that is much more likely to improve the situation than to exacerbate it. A nudge, such as stressing the positive outcome rate (e.g., 90% likelihood of success) could be relevant in such a situation
Feedback	People need feedback on their choices to make further decisions	Consider a person suffering from pancreatic exocrine insufficiency who has stopped taking their PERT without any immediate symptoms. Without any feedback (symptoms or health events), the patient is likely not to adhere to their treatment plan; again, providing information on likely future consequences that are as yet unseen could provoke behavior change
Knowing what you want (and need)	It is particularly hard for people to make choices when they cannot translate them into potential experiences	A patient who is facing a multitude of treatment options that have different cost / benefit outcomes could benefit from the physician breaking this down into simple terms

Increasingly, nudge techniques can be personalized to improve outcomes, utilizing digital technologies.

Motivational interviewing

Motivational interviewing is a patient-focused and goal-directed technique to help patients change their behavior. It differs from nudge theory in that patients are encouraged to reflect on their own motivations, giving insight to the healthcare provider and allowing them to give advice that will be well received and likely to be acted on.5,14,15

The basic elements of this technique would include:

• Asking open-ended questions¹⁶
• Focusing on the patient’s preferences, values and personal situation¹⁶
• Collaborating with the patient to direct them towards the desired outcome¹⁶
• Gaining verbal commitment from the patient¹⁷

The patient should be prepared with the information they need to change their behavior, before motivating them to do it in brief, simple and clear terms. Asking strategic open-ended questions has the potential to make conversations with patients who are not adhering more productive.

It is also important that the physician follows up to assess the success of the intervention. If not, further probing questions can be asked to help the patient find solutions.

References

1. Peters GJY, Ruiter RAC, Kok G. Threatening communication: A qualitative study of fear appeal effectiveness beliefs among intervention developers, policymakers, politicians, scientists, and advertising professionals. Int J Psychol. 2014;49(2):71–79.
2. Jackson C, Eliasson L, Barber N, Weinman J. Applying COM-B to medication adherence – A Suggested framework for research and interventions. Eur Health Psychol. 2014;16(1):7–17.
3. Weinman J, Ali I, Hodgkinson A, Canfield M, Jackson C. Pilot testing of a brief pre-consultation screener for improving the identification and discussion of medication adherence in routine consultations. Patient Prefer Adherence. 2019;13:1895–1898.
4. Michie S, Johnston M. Theories and techniques of behaviour change: Developing a cumulative science of behaviour change. Health Psychol Rev. 2012;6(1):1–6.
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7. Forbes (Marron D). Obama’s Nudge Brigade: White House Embraces Behavioral Sciences To Improve Government. 2015. Available at: https://www.forbes.com/sites/beltway/2015/09/16/obama-nudge-government/?sh=2eb8cad2c996 [Accessed April 2021].
8. The Behavioural Insights Team. About Us. Available at: https://www.bi.team/about-us/ [Accessed April 2021].
9. Apolitical. These 10 governments are leading the world in behavioural science. 2019. Available at: https://apolitical.co/en/solution_article/these-10-governments-are-leading-the-world-in-behavioural-science [Accessed April 2021].
10. The Behavioural Insights Team. Applying Behavioural Insights to Organ Donation. December 2013. Available at: https://www.bi.team/publications/applying-behavioural-insights-to-organ-donation/ [Accessed April 2021].
11. The Behavioural Insights Team. Increasing vaccine uptake in low- and middle-income countries. April 2020. Available at: https://www.bi.team/publications/increasing-vaccine-uptake-in-low-and-middle-income-countries/ [Accessed April 2021].
12. Jachimowicz JM, Gladstone JJ, Berry D, Kirkdale CL, Thornley T, Galinsky AD. Making medications stick: improving medication adherence by highlighting the personal health costs of non-compliance. Behav Public Policy. 2019:1–21.
13. Thaler RH, Sunstein CR. Nudge: Improving Decisions about Health, Wealth, and Happiness. Yale University Press; 2008.
14. Frost H, Campbell P, Maxwell M, et al. Effectiveness of Motivational Interviewing on adult behaviour change in health and social care settings: A systematic review of reviews. PLoS ONE. 2018;13(10):e0204890.
15. Palacio A, Garay D, Langer B, Taylor J, Wood BA, Tamariz L. Motivational Interviewing Improves Medication Adherence: a Systematic Review and Meta-analysis. J Gen Intern Med. 2016;31(8):929–940.
16. Benzo R, Vickers K, Ernst D, Tucker S, McEvoy C, Lorig K. Development and feasibility of a self-management intervention for chronic obstructive pulmonary disease delivered with motivational interviewing strategies. J Cardiopulm Rehabil Prev. 2013;33(2):113–122.
17. Amrhein PC, Miller WR, Yahne CE, Palmer M, Fulcher L. Client commitment language during motivational interviewing predicts drug use outcomes. J Consult Clin Psychol. 2003;71(5):862–878.