Adherence to lifestyle changes such as starting an exercise program or changing diet is vital to the prevention and treatment of cardiovascular and other chronic diseases. The World Health Organization defines adherence as the extent to which behavior, taking medication, following a diet, and/or executing lifestyle changes, corresponds with agreed recommendations from a health care provider.1 Medication-taking as a behavior has been defined as an ability to initiate a regimen, execute the treatment regimen appropriately, and persist in continuing to be engaged with the prescribed dosing regimen.2
Adherence is also defined as a complex interplay among the patient, provider, and health care system: a behavioral process strongly influenced by the environment in which patients live, health care providers practice, and health systems deliver care.3 The majority of research has focused on identifying and minimizing barriers to adherence encountered by patients. However, health care professionals involved in primary and secondary prevention of cardiovascular disease play a role in enhancing adherence through their interpretation of recommendations, by educating and motivating patients, monitoring responses to recommended therapies, and offering feedback. Health care organizations such as hospitals, health maintenance organizations, physician offices, and cardiac rehabilitation programs also influence the degree to which preventive services are offered.
The issues surrounding adherence are not new. For almost 4 decades, researchers have been attempting to understand the behavioral barriers to adherence to health, promoting medications, and interventions designed to reduce cardiovascular risk. Some researchers have continued to research their own areas of interest for almost 2 to 3 decades, often coming up with the same strategies that were highlighted in the 1970s.4,5 Numerous research papers and meta-analyses have been generated to address the complexities of adherence.6–8 Adherence is actually quite complex, involving not only the individual or patient but also health care professionals, and diverse systems including the home and outpatient clinic.3 Moreover, the food industry, tobacco companies, and advertising agencies often confuse the public with enticing messages that thwart the efforts of individuals to implement health-promoting strategies. As King and Sallis9 have noted in an article about how to improve physical activity, if 95% of individuals who had quit smoking started again, the American public would be outraged. Yet, a recent analysis of physiologic data from the National Health and Nutrition Examination surveys found that only 5% of adult Americans met the 2008 physical activity recommendation of moderate intensity exercise for 30 minutes on most days of the week.10 Physical inactivity is now the fourth leading cause of preventable death behind smoking, hypertension, and obesity, yet little has been accomplished to mobilize/activate the general public to become more physically active.11
Is human behavior so complex that little can be done to change adherence? Have we failed as clinicians to help individuals, due to lack of time, skills, or our focus on disease rather than prevention? Or, is it the system that fails to reimburse us, provide training, or the methods to ensure that individuals succeed with long-term changes? As time goes on, one bad behavior seems to be replaced with another; the significant decline in smoking has been surpassed by the enormous rate of overweight and obesity in the United States today.
The adoption and maintenance of health-promoting behaviors is a daunting task that taxes the efforts of all health care professionals. However, renewed efforts are needed to assist the American public and patients to adopt and maintain health-promoting habits both before and after the onset of cardiovascular events. This article will review the barriers to adherence to lifestyle behaviors and medications and describe techniques for improving adherence in clinical practice and cardiac rehabilitation settings. The scientific review for the article includes a Medline search of key systematic reviews over 3 decades of health-related behaviors, behavioral science and health services research, and other clinical trials associated with health behavior change and adherence. It is not meant to be an exhaustive systematic analysis of all articles published over the past 3 to 4 decades associated with changes in health behaviors.
BARRIERS TO ADHERENCE
Barriers to adherence to healthy behaviors and medications have been identified in numerous studies and in national surveys conducted of health care professionals.12–15 Barriers exist at the patient, provider, and system level of care delivery.3 The complexity of adherence is found in the difficulty of determining who will, or will not, adhere. As many as 200 variables affect the capacity of individuals to change behaviors.16 Moreover, rates of adherence for most behaviors hover at 50% at 1 year, making 1 in 2 individuals at risk for a failed experience to adopt or maintain healthy behaviors.16 The difficulty of changing a single behavior is also compounded when changes in multiple health behaviors are required. The problem is best highlighted by the need for diabetic patients to manage dietary changes, begin an exercise program, record daily blood glucose measures, respond to symptoms of hyper- or hypoglycemia, and take medications to manage not only diabetes, but both cholesterol and hypertension as well.
PATIENT-RELATED BARRIERS TO HEALTH BEHAVIOR CHANGE
Many reviews have highlighted the patient factors associated with lack of adherence to health-promoting behaviors including taking medications and adopting lifestyle changes.3 For patients with established cardiovascular disease, the need for change is often heightened because of a cardiovascular event. Yet, all too often as the event fades, so do the lifestyle changes that are critical to outcomes. Even in this situation, commitment to change wanes over time. Barriers to changing lifestyles and taking medications include important factors such as lack of knowledge of the benefits of change, previous failures associated with changing behaviors that raise doubt about the prospects for future success, self-efficacy or confidence in the ability to make changes, the degree of social support, and the complexity of health promotion regimens.3,14
Commonly cited barriers to adhering to medications include forgetting to take a medication, drug side effects, financial costs, confusion about the regimen, and interference with the daily schedule.7 Older individuals often face challenges posed by cognitive deficits, lack of social support, and the need to manage multiple chronic conditions.12,14 Such individuals must also deal with issues of pain and emotional conditions such as depression that further complicate the adoption and maintenance of health-promoting behaviors. One of the most significant patient barriers is lack of motivation due to lack of time, interest, skills, or skepticism about the benefits to be achieved.17 Factors that are weakly associated with adherence include personality, sociodemographic characteristics, marital status, and gender.17 Finally, trust in the provider is critically important to overall communication and implementation of a change in behavior.18 Factors known to improve adherence to health-promoting behaviors include cognitive and behavioral strategies, patient education, the promotion of self-management, and patient reminders.19
HEALTH CARE PROVIDER BARRIERS TO CHANGE
Health care providers play a key role in communicating the need for health behavior change and adherence to medication. However, because of the need to focus on acute illness, health care professionals often lack the time to provide education and counseling. Cardiac rehabilitation personnel including nurses, exercise physiologists, nutritionists, and other allied health professionals have the unique capability to address the barriers that limit successful change; yet, they may lack the skills needed to manage risk factors such as overweight and obesity and smoking cessation.3 They may also perceive that it is the role of the primary care provider or cardiologist who has the primary responsibility for helping individuals with secondary prevention changes.20 Another barrier related to implementing health-related changes is the perceived lack of time during exercise sessions to focus on such health-related changes when a primary focus of many programs is improving overall exercise performance.3 In addition, other health care professional barriers include lack of reimbursement for education and counseling, failure to follow treatment guidelines, and clinical inertia associated with failure to initiate or titrate medications.21 Finally, for effective change to occur, health care providers including rehabilitation specialists, must use effective communication techniques such as motivational interviewing. Health care professionals who lack training in communication and/or motivational interviewing, which includes skills in coaching, may experience a lack of confidence or self-efficacy in their capability to help individuals.22
SYSTEM BARRIERS TO CHANGE
Hospitals, cardiac rehabilitation centers, and health care organizations also play a role in influencing preventive changes. Cardiac rehabilitation programs are well-positioned as organizations to offer risk factor counseling which promotes attainment of treatment goals. However, if the management of risk factors is not central to the mission of cardiac rehabilitation, with distinct roles and responsibilities for the team established, it will not succeed. Ongoing skill-building for health care professionals involved in health behavior change and the use of electronic systems to track outcomes are prerequisite as health care system changes to optimize patient adherence.3 Lack of transportation and the inconvenience and cost of programs for lifestyle management also limit patient participation in health-promoting programs.17 Moreover, one of the seminal system factors associated with lack of long-term change for individuals is the short duration of individual participation in cardiac rehabilitation programs.20 Patients often lack social support once the group program disbands. Appropriate planning is needed to manage the transition following completion of formal cardiac rehabilitation. Similar obstacles are faced by patients attempting to manage weight loss through community-based programs.
It is well-known that systems designed to deliver disease prevention interventions within an organization help individuals to succeed in achieving goals set between them and the health care professional. This is most often accompanied by team changes, the continuous quality improvement (CQI) process, and financial incentives for health care professionals engaged in helping individuals change behavior.19
ANOTHER BARRIER—LACK OF USE OF THEORIES AND MODELS IN DESIGNING INTERVENTIONS
Many theories and models have been scientifically developed and researched around health behavior change. Two widely used theories are clearly linked to individual change: Prochaska and DiClemente's Transtheoretical Model of Readiness to change23 and Bandura's social learning theory,24 specifically self-efficacy. Another model widely adopted by behavioralists to address overweight, smoking, and alcohol abuse is that of relapse prevention developed by Marlatt and Gordon.25 Recognizing the intractability of addictive disorders, these researchers designed a model to help individuals to plan ahead to avoid relapse by identifying high-risk situations, develop coping strategies including self-talk, and practice the strategies to prepare for high-risk situations.25
Yet, how widely have these theories been discussed and applied? In a review of 193 health behavior change articles published from 2000 to 2005, regarding the behaviors associated with tobacco use, physical inactivity, alcohol abuse, nutrition, and disease screening and testing, Painter et al26 found that only 36% of all authors even mentioned a theory. The most commonly cited theories were the transtheoretical model, social cognitive model, and the health belief model. Of the articles in which theories were used to design interventions, 60% were informed by the theory, 22% applied the theory, 7.2% tested the theory, and 12% used the results to build another theory involving health behavior change. The evidence-base related to the application of these theories and models in improving adherence is clearly lacking both in research and clinical practice. Further work is needed to determine whether their application enhances health behavior change and how these theories and models are most effectively implemented.
STRATEGIES TO IMPROVE ADHERENCE TO HEALTH BEHAVIORS
While the literature is replete with barriers that exist at the patient, provider, and system level of change, various interventions have been shown to improve the capacity of individuals to adhere to healthy behaviors and administer medications. Adherence is improved through the use of key behavioral elements shown by psychologists to influence adherence by health care professionals, using communication strategies such as motivational interviewing and coaching, and by instituting system changes such as quality improvement strategies within numerous health care settings which increases adherence at the system level of change.
APPLICATION OF BEHAVIORAL SCIENCE: THE ELEMENTS OF HEALTH BEHAVIOR CHANGE
The elements of health behavior change that are unique to each behavior must be chosen wisely and used when structuring interventions. While there is slight variation in these elements used by behavioral scientists, as shown in Table 1, these cognitive-behavioral strategies are essential components of behavior change interventions. Interventions such as self-monitoring, feedback, and goal-setting are applicable to numerous behaviors such as exercise, weight loss, and diet, in contrast to interventions such as relapse prevention training that are most applicable to the addictive disorders of smoking cessation than to the adoption of more positive behaviors such as exercise.27,28 Finally, because forgetting is the single most common explanation for nonadherence to medications, cueing, or prompting, is the single most important strategy related to the medication-taking behavior.28 Social support, important to many behaviors, is critical in helping individuals undertake and maintain a physical activity program.
In a recent review of interventions to promote physical activity and dietary lifestyle changes for cardiovascular risk reduction in adults, Artinian et al29 documented the “Class A” evidence from randomized controlled trials, expert opinion, and case-controlled studies highlighting the use of many of these cognitive-behavioral elements. See Table 4 in Artinian et al29(p432) for cognitive behavioral strategies commonly used to counsel individuals to promote physical activity and dietary change, and the suggestions for intervention processes and delivery sites.29 One of the most critical considerations in designing behavioral interventions is to incorporate multiple strategies. For example, goal setting is most helpful if accompanied by self-monitoring a behavior using diaries, logs, or calendars. This is especially valuable in the early weeks of adoption. Critical to the maintenance of many behaviors is the use of contracting, relapse prevention training, social support, and ongoing reinforcement.28
In a 1987 review of strategies designed to foster adherence to medications, Haynes et al4,5 identified 4 factors associated with increased adherence, which remained applicable almost 15 years later in 2002. These included simplifying regimens, using reminders for medications and appointments, cueing medications to daily events, and involving family members and significant others. Clinicians need to incorporate multiple elements of intervention including those elements that have been shown to improve long-term adherence.
COMMUNICATING TO MAKE A DIFFERENCE: THE USE OF MOTIVATIONAL INTERVIEWING AND COACHING
Another strategy that may help us improve adherence to healthy behaviors comes from our ability to communicate well. Because health behaviors are complex and individuals have numerous beliefs about their ability to change, communication skills are required to support them in the process of change. Moreover, more than 90 million Americans suffer from problems of health literacy requiring them to understand information about change in plain language.30 Motivational interviewing, described by Miller and Rollnick in 1982, is a directive, patient-centered counseling method to help individuals explore and resolve their ambivalence about health behavior change.31 The underpinnings of this counseling style are based on Festinger's cognitive dissonance theory,32 Bem's self-perception theory,33 and Bandura's self-efficacy theory,24 as well as the work of Carl Rogers34 on the importance of empathy, congruence, and positive regard. Numerous reviews have highlighted the value of motivational interviewing in helping individuals to change health behaviors including both addictive disorders of drinking and smoking, as well as healthy behaviors associated with adherence to diabetes management, diet, and exercise.35–44
Important insights were gained from a review by Rubak et al,44 who evaluated 72 randomized controlled trials using motivational interviewing to evaluate outcomes including body mass index, hemoglobin A1C, total cholesterol, systolic blood pressure (BP), cigarette smoking, and blood alcohol. A significant effect of motivational interviewing was noted in 74% of studies. Moreover, this type of counseling was found to outperform traditional advice-giving in 75% of studies reviewed. Finally, while the median session for this type of counseling was 60 minutes (range, 10–120 minutes) in noted studies, a single encounter was also effective in 40% of studies with 87% effectiveness noted when 5 sessions were applied. When offered in brief encounters in clinical practice of 15 minutes duration, 64% of studies demonstrated a positive effect.44
Motivational interviewing consists of 2 phases. In the initial phase, intrinsic motivation is enhanced, and in phase 2, commitment to change is strengthened.45 The 4 general principles of motivational interviewing include the following: expressing empathy, developing discrepancy between where individuals presently are and where they would like to be, rolling with resistance that may arise in discussion with a health care professional, and supporting self-efficacy by affirming the individuals when any signs of competence, ability, or resources for change are heard in the course of the conversation.22
While motivational interviewing has been shown to be effective in many research settings and in clinical practice, appropriate training and practice are essential to fully learn and master skills.35 A coding scale has also been developed to determine the integrity of the use of this technique for counseling that may also offer feedback to health care professionals.46 Finally, motivational interviewing cannot be used as a single method to improve adherence but must be accompanied by other strategies. For example, coaching as part of motivational interviewing can be used when an individual is in an advanced stage of readiness to change. One form of coaching involves educating and assessing willingness to change, setting goals and assessing confidence, and ensuring followup by health care professionals whether by phone, mail, or face-to-face contacts. Coaching also involves helping individuals to self-monitor behaviors.22 While coaching is in its infancy, in a review of 15 randomized trials using coaching, significant improvements were seen in the behaviors of nutrition, physical activity, weight management, and medication adherence in 40% of trials. Effective program features included goal setting, motivational interviewing, and collaboration with health care professionals.47
CONTINUOUS QUALITY IMPROVEMENT—CHANGING PATIENT, PROVIDER, AND SYSTEM-RELATED ELEMENTS
More than 10 years ago, Shortell et al48 wrote a seminal article titled “Assessing the Impact of Continuous Quality Improvement (CQI) on Clinical Practice: What Will It Take To Accelerate Progress.” These investigators found fewer than 55 studies met the criteria for the clinical application of continuous quality improvement.48 In the interim, numerous investigators and organizations including the National Committee for Quality Assurance, Joint Commission for the Accreditation of Healthcare Organizations, and Foundation for Accountability have completed numerous CQI projects that strengthen the use of this technique for changing not only the behavior of health care professionals, but optimizing the behavior of patients as well. As shown in Table 2, the CQI process involves a series of steps that enable health care practitioners in a wide variety of health care settings to improve the health of individuals and communities.48 With strong performance measures delineated, cardiac rehabilitation programs have a clear opportunity and mandate to adopt CQI processes known to enhance patient outcomes.49–51
Continuous quality improvement initiatives have recently been shown to increase the capability of health care professionals to influence patient behaviors.19 An evidence-based practice incorporates adherence monitoring at every visit, flagging of the electronic medical records for patients failing to meet goals, and provision of feedback to physicians about their progress in achieving goals. Such CQI initiatives have been shown to improve adherence both in the short-term and long-term.19 The American Heart Association's “Get with the Guidelines (GWTG) project” is a CQI initiative directed at improving secondary prevention in patients with coronary artery disease, heart failure, and/or stroke.52 This hospital-based quality improvement initiative, active since 2000, recently examined 6 performance measures over 3 consecutive 12-month periods in hospitals implementing GWTG (n = 440, 439, 429) and compared these performance measures in non-GWTG hospitals (n = 2438, 2268, 2140) for each 12-month period using the Centers for Medicare and Medicaid Services Hospital database.53 The performance was greater in hospitals using GWTG than in those not using GWTG based on data collected during each 12-month period: GWTG hospitals were independently associated with better adherence performance on 4 of 6 measures. These included aspirin and β-blocker use at hospital entry and discharge. The GWTG hospitals maintained their superior guidelines adherence for the entire 3-year period.53 Cardiac rehabilitation staff play a critical role in ensuring patient adherence to GWTG, not only during hospitalization but also in the early phase of outpatient recovery.
Continuous quality improvement initiatives can be implemented at the patient, provider, and system level of change.3 Walsh et al19 found that in evaluating the implementation of quality improvement strategies for hypertension control, patient-oriented interventions focused on patient education, reminders, and promotion of self-management, while provider interventions were directed at provider education, reminders, audit and feedback, and relaying clinical data.19 Finally system-oriented changes included team restructuring and financial incentives. While most studies included more than 1 intervention (median 3), strategies that had the largest effect on BP outcomes included a team structure change, patient education, facilitated prompt relay of clinical information to providers, and the teaching of self-management skills.19
The Veteran's Affairs has set a performance goal that 75% of veterans with a diagnosis of hypertension meet the criterion of a BP of less than 140/90 mm Hg. Noting that multifaced CQI interventions may have a large effect, the Tennessee Valley Healthcare System initiated a project to improve hypertension care in 2 teaching hospitals, 5 community-based clinics, and 4 contract clinics.54 The goal of the intervention was to promote the proper use of measurement and documentation of BP in the computerized patient record. The elements of intervention included a nursing protocol and checklist for accurate BP measurement, patient education at each primary care visit including the creation of a very simple BP wallet card documenting patient progress toward the BP goal, tracking clinic visit BP and maintaining an updated list of antihypertensive medications and patient-specific special instructions, and important contact information for reaching an MD and pharmacist for questions. Patients record their own BP on the wallet card, and present it for review and updating at each visit. A laminated pocket card with the hypertension guidelines was provided to all physicians, and the final intervention included one-on-one provider educational sessions about national performance measures and goals for hypertension treatment. Each provider was then presented a spreadsheet with the number of patients who had been seen and the percentage achieving goal BP. After interventions were implemented, the investigators found an absolute improvement in BP control of 4.2% (61.5% control prior to intervention versus postintervention 65.7%, P < .0001).54 Results persisted at 1 year after the intervention. The investigators highlighted the factors associated with success. These included identification of local barriers, managing important identifiable tasks with small easy-to-accomplish interventions, and enlisting the support of key providers and buy-in from nurse leaders. Other recent CQI projects have shown great promise in improving BP control in large systems such as Group Health Cooperative.55 What is most compelling is their ability to deliver patient, provider, and system-level interventions on a large scale. These efforts can also be replicated on a smaller scale within cardiac rehabilitation settings.
Barriers to the adoption of healthy behaviors exist at the level of patients, providers, and the health care system as a whole. Patient adoption of health-enhancing behaviors can be fostered in cardiopulmonary rehabilitation programs and other settings by the use of communication techniques such as motivational interviewing and coaching. The elements of health behavior change offered by psychologists and health behavioral scientists can be tailored to specific behaviors. Multicomponent strategies have been shown to enhance long-term adherence. Finally, the CQI process helps to assure that changes at the patient, provider, and system level are sustained over time.
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barriers to adherence; cardiac rehabilitation; prevention of cardiovascular disease
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