Overcoming Barriers to Adherence and Resistance to Change

Nonadherence to treatment has a significant impact on diabetes care. Patients who take their medications incorrectly are 2.5 times more likely to be hospitalized.¹ Glycemic control is also affected. Each 10% increase in adherence to a regimen may result in a drop in hemoglobin A_1C (HbA_1C) of 0.16%.¹ The economic impact of poor glucose control is also significant. Average diabetes health care costs are $685 to $950 higher on average per year for patients who do not achieve sustained HbA_1C reductions.² Improving outcomes is directly related to overcoming barriers to adherence and resistance to change.

Barriers to Adherence

Causes of poor adherence, which are numerous, can be divided into medication-related factors, patient-related factors, and provider-related factors. Recognizing these barriers is an important first step in improving outcomes of medication therapy. A medication-related barrier, such as a complex regimen, may be solved simply by the use of combination products. A patient-related barrier, such as lack of money to pay for medications, may be solved by accessing manufacturers'assistance programs. Provider-related barriers may be more difficult to correct because they are usually the result of poor patient-provider relationships and poor communication skills. Good communication establishes the relationship between the patient and provider and provides the exchange of information necessary to provide good pharmaceutical care.

Research has uncovered gaps in communication that may have serious consequences. These gaps in communication include:

• Patients leaving physician offices and pharmacies with questions and concerns they did not express
• Patients leaving physician offices with prescriptions they do not want and do not think they need
• Patients experiencing problems with medications they do not convey to providers
• Patients making their own decisions regarding response to treatment

Providers often inadvertently discourage patient involvement in communication. Encouraging patients to call if questions or problems arise or offering to discuss concerns is not an effective way to elicit questions from patients. Patients are more likely to ask questions if they have first been given information by providers. Then, the use of open-ended questions encourages sharing of information. Patients engage more fully if they are asked to describe their experience of illness and response to therapy rather than being asked "yes/no"questions. Giving reasons for advice that is shared also helps because patients perceive that advice as more important if there is a reason behind it. Pharmacists should take the lead in initiating communication, because patients interpret this effort as a sign of caring.

Motivational Interviewing: Overcoming Resistance to Change

Change is difficult for many reasons, and of the people who need to make a change in behavior, 50% to 70% are not ready to do so. Most interventions that try to push or pull people into change result in temporary changes that do not last.

The Transtheoretical Model of Change (TTM) consists of several stages of readiness for change. The objective is to move the patient to the next stage on the continuum, not directly to action. These stages and their characteristics include precontemplation ("I won't"), contemplation ("I might"), preparation ("I will"), action ("I am"), and maintenance ("I have"). Knowing a patient's stage of readiness can predict behavior and outcomes and also allows the provider to target specific interventions based on where the patient is in the continuum. Communication strategies differ per stage as follows:

• Precontemplation: Offer information; do not use scare tactics or try to persuade the patient. Empathy and nonjudgmental listening are critical.
• Contemplation: Offer information, ask the patient to tell you health goals, and ask the patient for pros and cons and then contrast these.
• Preparation: Focus on pros, help the patient set specific goals, set up a reward system, and identify a support person or group.
• Action/maintenance: Continue to build self-efficacy, avoid relapse, remove temptations and cues that trigger unwanted behavior, and maintain a support system.

Motivational interviewing consists of 5 main communication principles that are used to help overcome resistance to change. These include:

• Express empathy: "You seem upset, afraid, confused, etc." "What concerns you the most?"
• Develop a discrepancy in the patient's mind: Repeat pros and cons of change as listed by the patient Ask questions about behaviors that do not support goals Use the Envelope ("If I were to give you an envelope, what would the message inside have to say for you to think about changing?")
• Avoid arguing
• Roll with resistance
• Support self-efficacy

Efficient use of these skills then allows the pharmacist to use various strategies designed to assess behaviors that need changing, assess the patient's stage of readiness for change, identify barriers to these changes, and then involve the patient in creating a plan for change. Interventions that incorporate these principles have been shown to help patients move toward the action stage of change.^3,4

Management of chronic diseases is often difficult for patients, and pharmacists must convey understanding of these difficulties when they work with people to improve adherence. Diagnosis of a disease such as diabetes means a considerable change in one's life. People are often resistant to change, and an empathic, nonjudgmental communication style facilitates behavior modification. Patients are the ultimate decision makers in their care, and their feelings and attitudes should be respected even if their behavior does not reflect their own goals of improved health. True genuineness, caring, and honesty can help patients with diabetes, or any other chronic illness, move toward these goals.

Dr. Garrett is a clinical pharmacist practitioner at Cornerstone Health Care in High Point, NC.

For a list of references, send a stamped, self-addressed envelope to: References Department, Attn. A. Stahl, Pharmacy Times, 241 Forsgate Drive, Jamesburg, NJ 08831; or send an e-mail request to: astahl@ascendmedia.com.