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
Cardio
respiratory
Exercise
Strengthening
Physical
activity
Activity
Work, play,
travel,
recreation
PFMT
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?
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)
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.
“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)
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)
()
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 PFMT
Health Belief Model
(Rosenstock & Becker, 1988: 1974)
Theory of Planned Behaviour
(Ajzen, 1991)
Social Cognitive Theory : Self-Efficacy
Beliefs
(Bandura, 1986)
Transtheoretical Model
Chiarelli and Cockburn (1999)
Gillard and Shamley (2010)
Dolman and Chase (1996)
Sacomori et al (2012)
Whitford and Jones (2011)
Chen (2004); Cheng (2010), Lai
(2008), Hallam (2012), Hay-Smith,
Ryan and Dean (2007), Alewijnse et
al. (2003), Messer et al. (2007)
Alewinjse (2002; 2003)
(Prochaska & DiClemente, 1983)
Self-Regulatory Model
Alewinjse (2002; 2003)
(Leventhal, Meyer & Nerenz; 1980)
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
Pre & Post natal
UI
Chiarelli and
Cockburn (2002)
Pelvic Organ
Prolapse
Lower Bowel
Dysfunction
No studies
Reminders on fridge magnets
No studies
Health belief model tailoring PFM
to function and time
No studies
None
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 contextspecific knowledge
Everything, even Evidence-BasedPractice, 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
rating
n=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
Therapy-related
factors
lack of immediacy of beneficial effects,
ineffective feedback of performance
1 (81%)
1 (77%)
poor response to previous treatment
(may have been ineffective treatment)
Social / economic
factors
lack of effective support networks to
reinforce adherence
1 (79%)
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%)
low level of motivation
1 (16%)
perception of minimal benefit /
effectiveness of the exercises
2 (14%)
What is single most
important barrier to
SHORT-TERM
adherence?
lack of understanding or knowledge
about the condition
LONG-TERM
adherence?
forgetting to do exercises
perception of minimal benefit /
effectiveness of the exercises
1 (20%)
2 (12%)
1 (23%)
1 (16%)
our PFMT adherence survey (Frawley et al 2015)
FACILITATORS
Options
Clinician
rating
n=513
Physical /
condition-related
factors
severity of symptoms: mild – moderate
1 (68%)
no / minimal other co-existing health
issues competing for priority
Patient-related
factors
high degree of motivation
1 (71%)
1 (93%)
perception of significant benefit /
effectiveness of the exercises
Therapy-related
factors
patient-therapist relationship: good
rapport, interaction motivates patient
provide immediate beneficial effects
(even if small)
Patient
rating
n=50
1 (90%)
1 (87%)
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%)
perception of significant benefit /
effectiveness of the exercises
1 (19%)
What is single most
important facilitator
to SHORT-TERM
adherence?
high degree of motivation
LONG-TERM
adherence?
perception of significant benefit /
effectiveness of the exercises
1 (20%)
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 2013
See Pathman et al 1996
Attrition in the ‘pipeline’ of
research to practice (Glasziou 2004)
Barriers and Enablers
Barriers & Enablers (Rainbird 2006)
Level
The innovation itself
Individual professional
Patient
Social context
Organisational context
Economic & political
context
Type of barrier
or enabler
Examples
Level
Type of barrier or
enabler
Examples
The innovation itself
-
- 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
Advantages in practice
Feasibility
Credibility
Accessibility
Attractiveness
Level
Type of barrier
or enabler
The innovation itself
Individual professional
Patient
Social context
Organisational context
Economic & political
context
-
Awareness
Knowledge
Attitude
Motivation to change
Behavioural routines
Examples
Orientation:
Phases
in the
process
of
change
(Grol 2013)
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
Orientation
Maintenance
Translating
Research Into
Practice project
(Frawley et al 2014)
Change
Insight
Acceptance
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
Knowledge
Physical skill
Cognition
Feelings
Priority
Services
Fisher et al, 2003
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 performance
Advise 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,
Doreen McClurg
Helena Frawley PhD FACP
Jean Hay-Smith PhD MPNZ
Senior Lecturer in Psychology Applied to
Health, University of Exeter Medical
School, College House, St Luke’s
Campus, Exeter UK
s.dean@exeter.ac.uk
Associate Professor, Allied Health, La
Trobe University
Head, Allied Health Research, Cabrini
Institute
National Health & Medical Research
Council (Australia) Health Professional
Research Fellow
h.frawley@latrobe.edu.au
Reader, Nursing, Midwifery and
Allied Health Professions RU,
Glasgow Caledonian University,
Scotland, UK.
Doreen.McClurg@gcu.ac.uk
Associate Professor, Rehabilitation
Associate Professor, Women’s
Health
University of Otago
New Zealand
jean.hay-smith@otago.ac.nz
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
Sarah Dean
s.dean@exeter.ac.uk
Helena Frawley
h.frawley@latrobe.edu.au
Doreen McClurg
Doreen.McClurg@gcu.ac.uk
Jean Hay-Smith
jean.hay-smith@otago.ac.nz
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