Review Article

Behavioral Interviewing: Techniques to Improve Patients’ Medication Adherence

Danielle M. Miller, PharmD, RPh, BCACP
Tayla Rose, PharmD, RPh, BCACP, CDE
Jenny A. Van Amburgh, PharmD, RPh, BCACP, CDE
Volume 56 - Issue 8 - August 2016

ABSTRACT: With an increase in the aging population and the use of multiple prescription medications, over-the-counter products, and vitamin/nutritional supplements for chronic health problems, maximizing medication adherence is of the utmost importance to ensure that patients achieve optimal health outcomes while minimizing adverse drug effects. Medication adherence involves the patient’s perspective and willingness to take medications, which must be considered when prescribing medication regimens. A variety of intentional and nonintentional factors influence a patient’s medication adherence. Several communication techniques, strategies, and tools are available to assist health care providers in improving patients’ medication adherence.

KEYWORDS: Medication adherence, medication concordance, behavioral interviewing, transtheoretical model

Medication adherence, defined by the World Health Organization1 as “the extent to which a person’s behavior—taking medication, following a diet, and/or executing lifestyle changes, corresponds with agreed recommendations from a health care provider,” is a significant problem for many patients. Medication compliance is often used interchangeably with medication adherence; however, the term adherence assumes that the patient is in agreement with the provider’s plans, whereas compliance suggests that the patient passively does as the provider instructs.2 Medication concordance is a newer term appearing in the medical literature. This term implies that the prescriber and the patient come to an agreement about the regimen the patient will take, and that the patient should take greater responsibility in the process.3 To recognize the importance of incorporating the patient’s decision as part of the health care planning process when discussing how a patient takes his or her medications, the preferred terms are medication adherence or medication concordance.

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Medication adherence rates average approximately 50% but vary depending on the condition(s) being treated.2 In patients who have experienced a cardiovascular event, medications with known safety profiles and beneficial outcomes, such as antihypertensives, have adherence rates between 50% and 80%.2 From 25% to 50% of patients taking statins and antiplatelet therapies discontinue them within the first year, and nonadherence rates are as high as 75% after 2 years.2

Medication adherence is not just a patient’s problem; rather, it is the collective health care team’s concern, but it should include the patient’s preferences. It is imperative to realize that poor medication adherence rates are attributable to a multitude of factors, including social and economic barriers (eg, limited English proficiency, cultural beliefs, medication and medical expenses, accessibility), therapy-related barriers (eg, complexity of the regimen, adverse effects outweigh the benefits), patient-related barriers (eg, swallowing, thoughts about the conditions, cognitive or hearing impairments), condition-related barriers (eg, lack of symptoms, depression, severity of the disease), and health-system factors (eg, relationship between provider and patient, long wait times, restricted formularies).2,4

Patients will modify their medication regimens to save money, with those between the ages of 18 and 64 years being twice as likely to not take their medication as people aged 65 years or older. This same population is also more likely to delay filling a prescription (7.2%) compared with patients aged 65 years or older (3.4%).5 Patients may exhibit intentional nonadherence, meaning they consciously decide to not take their medication, or unintentional nonadherence, where the patient may have forgotten to take it or did not fully understand the directions, or was confused about the instructions.4 Regardless of the reason for it, medication nonadherence needs to be identified and managed appropriately in order to avoid treatment failure; to prevent additional treatments; to prevent disease exacerbation and/or progression; to mitigate frustration experienced by patients, their family, and/or the provider; and to avoid increased health care costs or death.2 From 33% to 69% of medication-related hospitalizations are associated with poor adherence, with an annual estimated US health care cost of $100 billion.6

One way providers can empower patients to become active participants in their health care is through the use of techniques such as motivational interviewing (MI).

Applying Motivational Interviewing

MI is a communication style that evokes enthusiasm for change in a patient’s life. It has been defined as “a patient-centered, collaborative, directive counseling style that elicits and strengthens the patient’s internal motivation for change by evaluating and resolving ambivalence or resistance to change.”7 MI considers that a patient’s behavior is influenced internally by what he or she believes, and that these feelings directly affect his or her ability to evoke change.8 MI strives to remove any ambivalence a patient may have toward change and to build upon his or her predisposition toward change. Through this process, providers are able to help the patient define and attain his or her own health care goals, rather than using deterioration of a medical condition as an external motivating factor, for example.9

MI consists of 3 essential components: collaboration, evocation, and autonomy. Together, this triad is known as the “spirit” of MI.7 When MI is used as a foundation, interactions become more patient-centered, collaborative, nonjudgmental, and directive.7,10 It is imperative for the provider to acknowledge that the patient’s opinions and perceptions direct the changes needed. Because the patient ultimately makes the final decision regarding his or her health care, the provider’s goal is to collaboratively help the patient understand his or her own motivation(s) for change and develop a plan to commit.

Since motivation is considered a mental state that is subject to change, evocation is used to induce internal motivation from the patient by gathering essential information during the MI process.11 The provider should allow the patient to communicate and discuss his or her beliefs, attitudes, and values in order to better understand the patient’s view(s).7

Autonomy also has an important role in MI, because change ultimately resides within the patient. It is the patient who works with the provider to identify and resolve barriers or problems to achieve the desired health outcome. Providers should support and respect patient autonomy by affirming the patient’s rights and ability to make self-directed health care decisions.7,12 Supporting patient autonomy can be done by asking patients for permission to provide information rather than delivering it in an authoritative, traditional, counseling-style format.

NEXT: Stages of Change and Skills: OARS

Stages of Change

The transtheoretical model (TTM), or stages of change, is well-known in health care and aligns well with the use of MI. 

TTM is defined as an integrative model of behavior change that focuses on the decision-making of the individual.13-15 TTM assumes that health behavior change occurs incrementally, and that the stages of change correlate with an individual’s readiness to enact change at that time. The stages of change are precontemplation, contemplation, preparation, action, maintenance, and termination. MI helps patients realize the need for health-related behavior change and provides a way to prepare for such change.

Assessing a patient’s readiness is necessary to determine his or her confidence and ability to change a targeted behavior. Often, assessment of readiness occurs in the precontemplation and contemplation phases, and proper assessment of readiness can be achieved through targeted questions. Once the patient’s concerns and thoughts have been revealed, the provider may then offer a tailored approach. When patients achieve a level of readiness to enact change, often seen in the preparation phase, the role of the provider transforms from facilitator to coach as the patient progresses through the remaining stages. As one author put it, MI is “a prelude to coaching.”12

Skills: OARS

To successfully conduct MI, providers need to employ techniques that will facilitate dialogue and foster collaboration with patients in a positive, empathetic, and nonjudgmental environment. Such techniques include open-ended questions, affirmation, reflective listening, and summarization (OARS).7 Open-ended questions help the provider understand a patient’s apprehensions, fears, or ambivalence surrounding the health behavior change. Knowing the patient’s standpoint is vital not only to evoke the patient’s buy-in, but also to allow the provider to adequately guide the conversation and facilitate change.

Recognizing patient ambivalence is key; patients must see for themselves the difference between their current behaviors and their goals. While talking with the patient, the provider should guide the conversation to allow the patient to identify the discrepancy between his or her views or beliefs and reality. Allowing patients to advocate for themselves results in greater commitment to change and more successful outcomes.16

Use of reflective listening during MI involves the provider listening intently to what the patient has to say and repeating back the information. The benefit of this technique is 2-fold. First, it provides the patient an opportunity to rectify any errors that the provider may have made in trying to understand the patient. Second, it builds a trusting patient-provider rapport while reinforcing that the patient is in control of the conversation. To be effective, reflective listening requires empathy; the listener must respect the patient’s motivations without judgment. It is crucial during this part of the conversation for the provider to identify opportunities for “change talk,” a pivotal moment during the conversation when the patient is self-influenced by something he or she says vs something the provider says.17,18 Use of open-ended questions enables the patient to think or speak out loud about a behavior change, resulting in an opportunity for change talk.19

Reflective listening is also used by the provider to summarize what the patient is saying throughout the conversation. Key elements for providing a summary include explicitly indicating that he or she is doing so, mentioning any observed patient ambivalence, getting permission to ask additional questions, and concluding with an invitation for the patient to provide clarification, make comments, ask questions, or voice concerns. This creates an opportunity for change talk and allows the patient to lead the conversation, potentially in a different direction.

Affirmations are “genuine statements of recognition of and appreciation for the patient’s efforts and perspective.”7 Affirmations help maintain a collaborative patient-provider relationship while continually encouraging positive health behavior changes by recognizing, congratulating, and providing continual support. To prevent discouragement or resistance and to keep patients engaged, affirmation should be provided regardless of the magnitude of change. Providing affirmations to patients with past failed attempts at change is pivotal in assisting them to successfully make future change.12,20

NEXT: Principles of Change, Strategies to Improve Adherence, and Conclusion

Principles of Change

To effectively engage in MI, providers should practice the following 4 principles of change: expressing empathy, developing discrepancy, rolling with resistance, and supporting self-efficacy.7,8,12 Empathy is vital to MI; it encourages patient-centered care in a nonjudgmental and collaborative environment. Expressing empathy demonstrates a genuine attempt to recognize and respect a patient’s personal situation, beliefs, and values, which in turn helps alleviate anxiety and build trust in the patient-provider relationship. It is important to remember that empathy is not sympathy; empathy focuses on the patient and his or her uncertainty in any given situation. Expressing empathy is a learned skill that requires a conscious effort to truly understand a patient’s feelings without passing judgment. However, with practice, the use of empathetic statements such as, “It sounds like the situation has been upsetting to you,” becomes an unconscious effort.

The next principle, discrepancy, allows the patient to see inconsistencies that he or she may not otherwise recognize. A patient may have mixed emotions about change without realizing that a difference in mindset exists. In this situation, the provider should actively listen as the patient discusses personal health care goals and what he or she values most, paying close attention to any concerns or difficulties with change. By asking questions, patients develop discrepancy between where they want to be and where they are now. When patients, not providers, verbalize the reasons for change, there is an increased likelihood of successful change.

The next clinical principle in MI is the ability to roll with resistance. Providers are trained to provide care, and their initial reaction to address or “fix” what is wrong with the situation is known as the “righting reflex.”19 To roll with resistance, providers must resist the urge to make things “right,” which makes this principle challenging. However, forcing information on patients can lead to a caustic relationship—one that is not patient-centered, and one in which the patient refuses to discuss issues openly. Rolling with resistance requires providers to identify various types of resistance, resist the righting reflex, and avoid arguing.

Supporting self-efficacy is critical to effective MI and can be demonstrated by affirming any changes the patient has made, regardless of simplicity. Supporting self-efficacy acknowledges a patient’s ability to change and instills confidence in the patient to continue progressing. Supportive providers help the patient brainstorm an action plan, using the patient’s own experiences and skills to find positive ways to implement change. This self-directed “ah-ha” moment serves as an internal driver of motivation to change.

Strategies to Improve Adherence

In addition to MI techniques, several comprehensive strategies have been described that providers can use to improve medication adherence. Atreja and colleagues21 devised SIMPLE, an acronym comprising 6 ways to improve adherence: simplifying the patient’s medication regimen, informing the patient about the purpose of his or her medications, modifying behaviors and beliefs utilizing TTM and reflective MI, providing patient-provider communication that builds trust, leaving biases and customizing education to the patient’s health literacy level, and evaluating medication adherence in a consistent and recurring manner. While measuring adherence is challenging in real-world situations, simply asking the patient about adherence in a direct manner can be effective.

Bergman-Evans22 developed the AIDES model specifically for use in geriatric populations. It includes assessing the medication regimen thoroughly, individualizing the regimen to meet the unique needs of the patient, documenting modifications in a patient-friendly medication list at each encounter, educating the patient about his or her medications in a way that meets the individual’s needs, and supervising (monitoring the patient) over time to ensure that the regimen remains appropriate and that the patient’s education is maintained.

Providers may find SIMPLE and AIDES difficult to incorporate into their specific practice; however, the core tenets of both strategies are applicable across all settings. Medication regimens should be routinely assessed and minimized to the extent that is clinically appropriate, such as the overall number of pills and frequency of administration.21,22 Strategies to help achieve this include changing medications to extended-release formulations or using combination pills to decrease pill burden, assuming these interventions are not cost-prohibitive.21 If possible, all medications should be taken once daily or at times that fit conveniently into the patient’s schedule. Providers should first interview patients to elicit their knowledge about their medications and diseases, as well as their health literacy level, and leverage this information to deliver customized education. With rapport built from honest communication and the empowerment of knowledge, providers and patients can collaborate using these communication techniques to effect behavioral change.22 Finally, providers should reassess the patient’s regimen complexity, adherence, and understanding at each encounter, make adjustments as needed, and provide the patient with appropriate documentation of medication changes.

Various tools can be used to reinforce education and remind patients to take their medications. Traditional tools include the use of pillboxes, medication calendars, and prefilled blister packs, as well as synchronizing prescriptions such that all of a patient’s medications are able to be picked up from the pharmacy on the same day each month.

The use of smartphone applications (apps) to improve medication adherence is an area of growing interest because apps are interactive, are easy for patients to access at all times, and allow for storage and assessment of adherence data. Dayer and colleagues23 conducted a comprehensive review of 160 apps to determine which are most useful for patients and providers. They identified MyMeds and MyMedSchedule as most preferred; both are free and allow patients and providers to enter medication regimens online via a database at Health Insurance Portability and Accountability Act-compliant websites.23 Data entered on the websites automatically sync with the apps via cloud functionality. The apps send dose reminders to patients via text message, email, or push notification, and patients can record when they take or do not take doses. Information about missed doses can be elaborated on and shared with providers.

In a similar review, Heldenbrand and colleagues reviewed 367 apps, of which the 100 most promising were downloaded and tested.24 Apps were evaluated based on 28 unique attributes that contribute to improving adherence, medication management, and usability. Using these data, the authors created a searchable database at www.medappfinder.com. Patients and providers can use this site to identify the most useful medication adherence apps based on the attributes they most desire. Future research is needed to determine whether the use of these apps leads to better medication adherence resulting in improved health outcomes.23

Conclusion

Optimizing medication adherence is of the utmost importance to ensure that patients achieve desired clinical outcomes, to prevent adverse health care events, and to decrease health care costs. Providers should partner with patients in a collaborative relationship, utilizing MI techniques to have honest conversations about health beliefs and medication adherence, and effect behavioral change when needed. Streamlining medication regimens, delivering appropriate and customized education, and continuous follow up are crucial elements of success. With advances in health information technology, providers can recommend tools such as smartphone apps to further increase medication adherence rates.

Danielle M. Miller, PharmD, RPh, BCACP, is an assistant clinical professor in the Department of Pharmacy and Health Systems Sciences in the School of Pharmacy at the Bouvé College of Health Sciences at Northeastern University in Boston, Massachusetts.

Tayla Rose, PharmD, RPh, BCACP, CDE, is an assistant clinical professor in the Department of Pharmacy and Health Systems Sciences in the School of Pharmacy at the Bouvé College of Health Sciences at Northeastern University.

Jenny A. Van Amburgh, PharmD, RPh, BCACP, CDE, is a clinical professor and assistant dean for academic affairs in the Department of Pharmacy and Health Systems Sciences in the School of Pharmacy at the Bouvé College of Health Sciences at Northeastern University.

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