Adherence is a very complex issue. Numerous theories have been developed and they must be integrated into any approach to solve our healthcare problems. Only Intelligent Engagement can incorporate a variety of these theories into a plecosystem of adherence technologies.
Second in a Series: Understanding Health Behavior Theories
Engagement to improve adherence requires an understanding of complex behaviors. Despite the number of "reminder" solutions being offered by text messenging services, only a small portion of non-adherence is due to forgetfulness. There are literally thousands of reasons that people do not remain adherent to their total treatment regimen.
Barriers to adherence include:
Ability to engage in illness-management behavior
Ability to follow instructions
Acceptance of disease
Comorbidities (eg depression, substance abuse)
Complexity of regimen
Degree of family dysfunction
Disease management support
Education and literacy
Immediacy of beneficial effects
Knowledge and skills (injection or inhaler technique)
Perceptions, attitudes, and expectations
Quality of patient-provider relationship
Rate of progression of disease
Restrictions on diet, meals, timing of medication in relation to food intake, etc
Side effects/adverse events
Understanding of disease
The list goes on and on.
Is it any wonder that solving this problem is so difficult?
Collectively, the major theories of health behavior take into account all of these barriers.
As mentioned in the first part in this series, the main theories of behavior change include: Social Cognitive Theory, the Trans-Theoretical/Stages of Change Model (Prochasta), Health Belief Model, the Social Support Model and Social Networks Model.
A Brief Review
The Social Cognitive Theory brings into play the social dynamics of health. A group can bring about a concerted action to change outcome. This model also incorporates incentives as a means to create an environment that leads to motivation. It also takes into account the concept of self-regulation; for instance, self monitoring, goal setting, feedback and self instruction.
The Transtheoretical Model (TTM) and Stages of Change by Prochaska, Redding, and Evers is perhaps the most used and recognized theories in healthcare. This model states that people go through 6 stages in their change process: Precontemplation, Contemplation, Preparation, Action, Maintenance, and Termination. Studies have demonstrated that a variety of interventions can assist in the transition from one stage to the next.
Health Belief Model is based on the theory that healthy behavior is a cognitive function. It proposes that our minds perform a calculation that involves perceived susceptibility, severity, threat, benefits, barriers, and self efficacy. This theory also proposes that “cuing behavior” is important. Many of the apps in the marketplace use parts of this theory to help with forgetfulness. This theory also takes into consideration perceived barriers; numerous studies have demonstrated perceived barriers as one of the strongest predictors of behavior.
The Social Networks and Social Support theories focus on the 4 types of support that social networks provide: emotional support, instrumental support (basically help from the group), information support (and advice), and appraisal support (words of affirmation, encouragement and feedback).
They also consider structural aspects of social networks that come to bear on adherence:
Reciprocity: extent to which resources and support are both given and received within the network
Intensity: extent to which social relationships offer emotional support
Density: extent to which network members know and interact with each other
Homogeneity: extent to which network members are demographically similar
Geographic Dispersion: extent to which network members live close to each other albeit, this is perhaps much less important in the Internet age.
But, no one theory actually addresses, much less, solves all issues with adherence. How can a single tactical approach possibly deal with all of the barriers to adherence, let alone incorporate all of the theories in their design and operation? Keep in mind that the theories were developed through short-term clinical trials. Adherence is a lifelong proposition.
So, how can an organization design an adherence strategy that takes into account the various theories that have been proven over decades of research, and remain flexible over years of need?
Perhaps the answer lies in technology, or more precisely, a plecosystem of technology combined with intelligent engagement. The amount of technology and the scope is actually amazing, and it promises to dramatically change our approach to treatment of disease as well as wellness.
The next article in this series will outline, in general terms, the various technologies used to promote adherence.