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EMPOWERING CHANGEHelp your patients help themselves

Annabelle CitroenPelvic Health

Physiotherapist

OVERVIEW• Patient centered care• Adherence• Theories of Behaviour change• Determinants/Predictors of adherence• Barriers• Monitoring (OMs)• Modifiers• Practical implications

Adherence

Patient Centered

Care

Evidence Based

Medicine Optimal outcomes Patient

Centered Care

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PATIENT CENTERED CARE

Adherence

Patient Centered

Care

Evidence Based

Medicine Optimal outcomes

Adherence

zStress Urinary Incontinence

Urgency Urinary

Incontinence

zFaecal

Incontinence

zProlapse

zConstipationzVoiding

DysfunctionzPelvic Pain

zNocturia

zNocturnal Enuresis

zPELVIC FLOOR DYSFUNCTION

Urgency

THERAPIES FOR PELVIC FLOOR DYSFUNCTION

Pelvic Floor Muscle ExercisesBladder TrainingFluid ModulationFibre modificationWeight LossRoutines/SchedulesMedication

all have one thing in common

Require behavioural

change

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ADHERENCE

“the extent to which a patient’s behavior matches agreed recommendations/instructions from the

prescriber; it is intended to be non-judgmental, a statement of fact, rather than to ascribe blame to the

patient, prescriber, or treatment method”

Haynes et al. (2008)

So……if adherence is preceded by behavioural change…….

HOW DO WE ENHANCE BEHAVIOUR CHANGE?!

BEHAVIOURAL CHANGE TECHNIQUES/THEORIES

• Defined theories to guide delivery of interventions to enhance adherence• Can be useful in:

Reducing a behavior- Consumption of bladder irritants- Just in case voids

BEHAVIOURAL CHANGE TECHNIQUES/THEORIES

• Defined theories to guide delivery of interventions to enhance adherence• Can be useful in:

Adopting a new behavior- Pelvic Floor Muscle Exercises- Bladder training/calming techniques- Increased fluid intake- Evening fluid restriction- Increasing general physical activity- Taking/applying prescribed

medications- Bowel routines

BEHAVIOURAL CHANGE TECHNIQUES/THEORIES

• Defined theories to guide delivery of interventions to enhance adherence• Can be useful in:

Supporting maintenance or relapse management THEORIES OF HEALTH BEHAVIOUR

Information-Motivation-BehaviouralSkill Model

Normalization Process Theory

Motivational Interviewing

Capability, Opportunity

and Motivation Behavior

Information, Satisfaction,

Recall Model

McClurg et al (2015)

Health Belief Model

Theory of Planned

Behaviour

Health Action Process

Approach

Social Cognitive

Theory

Self Regulatory

Model

Transtheoretical Model

Behavioural Change

Techniques Taxonomy

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TRANSTHEORETICAL MODEL5 Phases of change:

• Pre-contemplation, Contemplation = Patient first starts to think they have a problem and then moves to seek help.

• Preparation, Action = provision of specific and concrete plans.

• Maintenance and relapse prevention = crucial to long-term adherence and maintenance of improvement.

Transtheoretical Model

MOTIVATIONAL INTERVIEWING• Used to enhance the patients engagement with treatment• Patient identifies/discovers barriers to change.• Less confronting approach - utilizes patients agenda.

Important components -• Express empathy through reflective listening.• Develop discrepancy between clients' goals or

values and their current behaviour.• Avoid argument and direct confrontation.• Adjust to client resistance rather than opposing it directly.• Support self-efficacy and optimism.

Motivational Interviewing

BEHAVIOUR CHANGE TECHNIQUES TAXONOMY

Behavioural Change

Techniques Taxonomy

• Originally described by Abraham and Michie (2008).

• Described 26 BCTs. Most recent version proposed 93 BCTs, classified into 16 categories. Michie et al. (2013)

• Categories include:• Feedback and Monitoring• Goals and Planning• Social support• Comparison of Behaviour• Self Belief• Comparison of Outcomes• Reward and Threat

HEALTH BELIEF MODEL

• ‘the likelihood of action is increased if the perceived disease threat is high and if the benefits of behaviour are thought to outweigh the barriers.’ McClurg et al. (2015), pp607.

• Statistically significant difference in adherence to adequate levels of PFMT with group of patients targeted by strategies to improve intervention based on the HBM, compared to controls Chiarelli and Cockburn (1999)

• The experience of UI or FI, fear of experiencing UI or FI, and perceived level of self efficacy were found to be motivating factors for commencing and adhering to PFMT following perineal tear.

Gillard and Shamley (2010)Health Belief Model

SOCIAL COGNITIVE THEORY

Proposed by Bandura in 1986, previously termed social learning theory.

Behaviour is determined by expectations and incentives.

• Environmental expectation • Outcome expectation • Efficacy expectation - self efficacy.

• Incentives – the value of the outcome (e.g. Lifestyle change).Social

Cognitive Theory

SELF EFFICACY AS A DETERMINANT OF ADHERENCE

• ‘Whether you believe you can or you can’t, you are right’ Henry Ford

• ‘Your beliefs become your thoughts. Your thoughts become your words. Your words become your actions. Your actions become your habits. Your habits become your values. Your values become your destiny’ Gandhi

• Numerous studies have found self efficacy to be significant predictor of adherence.Messer et al. (2007), Chen (2009), Sacomori et al. (2018), Dumolin et al. (2015), Borello-France et al. (2013)

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OTHER DETERMINANTSShort term determinants Long term determinants

Positive intentions to adhere Positive intentions to adhere

Attitude towards therapy UI symptom severity

Perceived benefits of therapy Frequency of wet episodes

High social pressure to engage Short Term adherence

Higher QoL (SF-36)

Baseline PFM strength

Dumoulin et al. (2015), Borello-France et al. (2013), Alewijinse et al.(2003)

BARRIERSCLINICIAN PATIENT

Condition related co-existing health issues which take priority

co-existing health issues which take priority

Patient related lack of patient motivation perception that the exercises had minimal effect

• Difficulty remembering• Hard to find time• No change in symptoms

Borello-France et al. (2010)

• Difficulty attending appointments• Did not which to be referred • Did not think Physiotherapy would benefit them

Lennard, F (2009)

Frawley et al. (2015)

OUTCOME MEASURESTools• Exercise diaries• Self administered questionnaires• Self evaluation scores• Postal questionnaires

Measurements• Clinical visit attendance (individual or classes)• Adherence to home exercises +/or behavioural advice during invention• Adherence post treatment and at follow up.

Dumoulin et al. (2015)

PROMISING ADHERENCE MEASUREMENT TOOL

Borello-France et al. (2013)

In the past week, approximately

how many days did you do your

PFMe?

On a typical day in the past week, how many PFM contractions did

you do?

Did it seem as if the exercises

were not helping your

incontinence?

Were you so much better that you felt you did

not need to continue the

exercises?

Are there any other reasons

why you did not do the exercises?

If yes, explain.

Were you unsure if you were doing

the exercises correctly?

Did the exercises

cause any pain?

Was it hard for you to find

time to do the exercises?

Did you have trouble

remembering to do the exercises?

Now that we have all this background knowledge of behavioural change models, predictors, barriers

and measuring adherence………..

What can we do to enhance adherence?!

• Routine versus Ad hoc approach to home exercise regimes. (Hines et al., 2007)

• Supervision of exercises. (Carrasco and Cantalapiedra, 2012)

• Attending appointments. (Shannon et al., 2018, Borello-France et al., 2013)

FACTORS AND STRATEGIES THAT MAY FACILITATE ADHERENCECLINICIAN PATIENT

Therapy related establishing good rapport with patients motivated PFME

immediate noticeable (even if small) improvement with exercise.

Frawley et al. (2015)

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FACTORS AND STRATEGIES THAT MAY FACILITATE ADHERENCE

• Individualised protocols (Alewijinse et al.,2003)

• Clinicians utilising explicit details of interventions tested in research and reported as effective (Slade et al.,2018)

• Multiprofessional involvement, close patient relationships, continuous monitoring, support with PFMT (Mendes et al., 2016)

• Apps (Araujo et al., 2019, Askland et al., 2019, Kinouchi et al., 2018)

MODIFIERS OF ADHERENCE

Hay-Smith et al. (2015) reviewed13 qualitative studies looking at PFMT for treatment of UI, and discovered six modifiers:

• Knowledge (12)• Physical Skill• Feelings about PFMT• Cognitive Analysis, Planning and Attention (13)• Prioritization (13)• Service Provision

CAPABILITY, OPPORTUNITY AND MOTIVATION BEHAVIOR (COM-B)

influenced by feelings about PFMT/therapy, cognitive analysis,

planning and attention, and prioritisation

influenced by knowledge and physical skill

influenced by external factorsMichie et al. (2011)Haysmith et al. (2015)

CAPABILITYInfluenced by knowledge

If information/education is not sufficient or delivered in an accessible way –individuals may remain confused or unconvinced about the value of the recommended therapy.

and physical skill

Positive affirmation and reassurance regarding mastery of a skill (eg. PFMe) will enhance self efficacy and motivate further adherence.

MOTIVATIONInfluenced by cognitive analysis, planning and attention

Are these exercises worth doing?

How will I keep doing these exercises in

amongst my holidays and work

commitments?

How can I change my

daily habits to include these

exercises?

How will I remember to

keep doing these exercises every

day for the rest of my life?

MOTIVATIONand prioritization

Impacted by internal and external factors.E.g. Time, energy.

and feelings about PFMT*

Positive feelings, e.g. Sense of self control (prescription of meaningful task) versus – negative feelings, e.g. frustration, lack of importance, discomfort. .

* Or alternative behavior change

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OPPORTUNITYInfluenced by external factors

• Stories and opinions of others. • Expectation of disapproval from others (e.g. therapist) for not doing exercises

– leads to self blame.• Competition for resources

• decisions about priority • family and work commitments

• Service provision – timing, location.

BEHAVIOUR CHANGE WHEEL

Michie et al. (2011)

Bringing it all together…..

PRACTICAL IMPLICATIONS

• Adequate information.

• Health literacy.

• Types of resources.

• Limitations of educator.

• Accessible language.

• Confident delivery.

EDUCATOR

TRAINER

• Importance of correct skill • individual examination and instruction, • prescription of individual treatment protocols.

• Positive affirmation and reassurance of correct technique.

• Promote sense of capability• frequency of reviews,• tools to enhance mastery.

PERSUADER

• Nurture positive thoughts.• Avoid imparting guilt or blame for past or current

adherence failures.• Identify reasons for personal change/prioritization.• Understand patient expectations.• Promote realistic expectations of treatment and

outcome.

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ENABLER

• Address barriers –• On initial contact and during intervention. • Assist patients with integrating exercise/change into

daily routines, utilize timer, attaching to routine daily behavior, environmental cues.

• Maximise supervision/clinician availability.

SUMMARY• Target interventions to the specific needs of the individual,

identified by a patient centred assessment.• Identify perceived barriers, health beliefs and self efficacy.• Consider the stage of behavioural change your patient is at when

you first meet them (Transtheoretical Model).• Utilise an outcome measure to determine adherence in addition to

a condition-specific outcome measure and reassess factors impeding progress.

• Utilise knowledge of ‘modifiers’ to enhance adherence.

THANK YOU FOR YOUR ATTENTION!

Questions??

REFERENCESAraujo, C. C., Marques, A. A., & Juliato, C. R. T. (2019). The adherence of home pelvic floor muscles training using a mobile device application for women with urinary incontinence: A randomized controlled trial. Female Pelvic Medicine & Reconstructive Surgery, doi:10.1097/SPV.0000000000000670 Sacomori C PT, ,PhD., Berghmans B PT, MSc,,PhD., de Bie R PT, ,PhD., Mesters, I. P., & Cardoso FL, P. (2018).Predictors for adherence to a home-based pelvic floor muscle exercise program for treating female urinary incontinence in brazil. Physiotherapy Theory and Practice, , 1-10. doi:10.1080/09593985.2018.1482583

Slade, S. C., Hay-Smith, J., Mastwyk, S., Morris, M. E., & Frawley, H. (2018). Strategies to assist uptake of pelvic floor muscle training for people with urinary incontinence: A clinician viewpoint. Neurourology and Urodynamics, 37(8), 2658-2668. doi:10.1002/nau.23716Mori,A., Kakiuchi, M., Matsumoto, E., & Nozaki, S. (2017). Ingenuity for enabling the habituation of pelvic floor muscle training. Journal of Physical Therapy Science, 29(8), 1287-1291.Hay-Smith, E. J., McClurg, D., Frawley, H., & Dean, S. G. (2016). Exercise adherence: Integrating theory, evidence and behaviour change techniques. Physiotherapy, 102(1), 7-9. doi:10.1016/j.physio.2015.08.006Mendes, A., Rodolpho, J. R. C., & Hoga, L. A. K. (2016). Non-pharmacological and non-surgical treatments for female urinary incontinence: An integrative review. Applied Nursing Research, 31, 146-153. doi:10.1016/j.apnr.2016.02.005

REFERENCESDumoulin, C., Alewijnse, D., Bo, K., Hagen, S., Stark, D., Van Kampen, M., . . . Dean, S. (2015). Pelvic-floor-muscle training adherence: Tools, measurements and strategies-2011 ICS state-of-the-science seminar research paper II of IV. Neurourology and Urodynamics, 34(7), 615-621. doi:10.1002/nau.22794 Dumoulin, C., Hay-Smith, J., Frawley, H., McClurg, D., Alewijnse, D., Bo, K., . . . International Continence Society. (2015). 2014 consensus statement on improving pelvic floor muscle training adherence: International continence society 2011 state-of-the-science seminar. Neurourology and Urodynamics, 34(7), 600-605. doi:10.1002/nau.22796 Frawley, H. C., McClurg, D., Mahfooza, A., Hay-Smith, J., & Dumoulin, C. (2015). Health professionals' and patients' perspectives on pelvic floor muscle training adherence-2011 ICS state-of-the-science seminar research paper IV of IV. Neurourology and Urodynamics, 34(7), 632-639. doi:10.1002/nau.22774 Hay-Smith, J., Dean, S., Burgio, K., McClurg, D., Frawley, H., & Dumoulin, C. (2015). Pelvic-floor-muscle-training adherence "modifiers": A review of primary qualitative studies-2011 ICS state-of-the-science seminar research paper III of IV. Neurourology and Urodynamics, 34(7), 622-631. doi:10.1002/nau.22771McClurg, D., Frawley, H., Hay-Smith, J., Dean, S., Chen, S. Y., Chiarelli, P., . . . Dumoulin, C. (2015). Scoping review of adherence promotion theories in pelvic floor muscle training - 2011 ICS state-of-the-science seminar research paper i of iv. Neurourology and Urodynamics, 34(7), 606-614. doi:10.1002/nau.22769

REFERENCESBorello-France, D., Burgio, K. L., Goode, P. S., Ye, W., Weidner, A. C., Lukacz, E. S., . . . Pelvic Floor Disorders Network. (2013). Adherence to behavioral interventions for stress incontinence: Rates, barriers, and predictors. Physical Therapy, 93(6), 757-773. doi:10.2522/ptj.20120072 Carrasco, D. G., & Cantalapiedra, J. A. (2012). Effectiveness of pelvic floor muscle training in urinary incontinence: A systematic review. Fisioterapia, 34(2), 87-95.Hines, S. H., Seng, J. S., Messer, K. L., Raghunathan, T. E., Diokno, A. C., & Sampselle, C. M. (2007). Adherence to a behavioral program to prevent incontinence...including commentary by milne J and gray M with author response. Western Journal of Nursing Research, 29(1), 36-56.Lennard, F. J. (2009). Reasons why patients referred to physiotherapy with continence or pelvic floor dysfunction fail to complete treatment. Journal of the Association of Chartered Physiotherapists in Women's Health, (105), 56-63.Messer, K. L., Hines, S. H., Raghunathan, T. E., Seng, J. S., Diokno, A. C., & Sampselle, C. M. (2007). Self-efficacy as a predictor to PFMT adherence in a prevention of urinary incontinence clinical trial. Health Education & Behavior, 34(6), 942-952.

REFERENCESHaynes, R. B., Ackloo, E., Sahota, N., McDonald, H. P., & Yao, X. (2008). Interventions for enhancing adherence to prescribed medications. Cochrane Database Syst Rev, (2), Art-No.Michie, S., Richardson, M., Johnston, M., Abraham, C., Francis, J., Hardeman, W., ... & Wood, C. E. (2013). The behavior change technique taxonomy (v1) of 93 hierarchically clustered techniques: building an international consensus for the reporting of behavior change interventions. Annals of behavioral medicine, 46(1), 81-95.

Chiarelli, P., & Cockburn, J. (2002). Promoting Urinary Continence In Women After Delivery: Randomised Controlled Trial. BMJ: British Medical Journal, 324(7348), 1241-1244. Gillard, S., & Shamley, D. (2010). Factors motivating women to commence and adhere to pelvic floor muscle exercises following a perineal tear at delivery: The influence of experience. Journal of the Association of Chartered Physiotherapists in Women’s Health, 106, 5-18.Shannon, M. B., Adams, W., Fitzgerald, C. M., Mueller, E. R., Brubaker, L., & Brincat, C. (2018). Does Patient Education Augment Pelvic Floor Physical Therapy Preparedness and Attendance? A Randomized Controlled Trial. Female pelvic medicine & reconstructive surgery, 24(2), 155-160.Alewijnse, D., Mesters, I., Metsemakers, J., & van den Borne, B. (2003). Predictors of long-term adherence to pelvic floor muscle exercise therapy among women with urinary incontinence. Health Education Research,18(5), 511-524.

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REFERENCESAbraham, C., & Michie, S. (2008). A taxonomy of behavior change techniques used in interventions. Health psychology, 27(3), 379.Michie, S., Van Stralen, M. M., & West, R. (2011). The behaviour change wheel: a new method for characterising and designing behaviour change interventions. Implementation science, 6(1), 42.Rosenstock, I. M., Strecher, V. J., & Becker, M. H. (1988). Social learning theory and the health belief model. Health education quarterly, 15(2), 175-183.Asklund, I., Samuelsson, E., Hamberg, K., Umefjord, G., & Sjostrom, M. (2019). User experience of an app-based treatment for stress urinary incontinence: Qualitative interview study. Journal of Medical Internet Research, 21(3), e11296. doi:10.2196/11296

Kinouchi, K., & Ohashi, K. (2018). Smartphone-based reminder system to promote pelvic floor muscle training for the management of postnatal urinary incontinence: Historical control study with propensity score-matched analysis. Peerj, 6, e4372. doi:10.7717/peerj.4372Chen, S. Y., & Tzeng, Y. L. (2009). Path analysis for adherence to pelvic floor muscle exercise among women with urinary incontinence. Journal of Nursing Research, 17(2), 83-92.