As chronic illness continues to dominate the healthcare landscape, more and more people are being charged with taking active roles in managing their condition and treatment. Laura Moore, Ed.D., CHES, Lead Health Psychology Specialist at Atlantis Healthcare, believes the field of health psychology holds a key to unlocking the challenges of self-management for these individuals, especially in regard to treatment adherence.
The Cost of Nonadherence
Treatment nonadherence represents one of the biggest costs associated with chronic illness. The Annals of Internal Medicine estimates that a lack of adherence causes 10% of hospitalizations, and costs the healthcare system between $100 billion and $289 billion a year. It is also reported that 20% to 30% of medication prescriptions are never filled and approximately 50% of medications for chronic disease are not taken as prescribed.
Beyond the statistics, nonadherence impacts all healthcare stakeholders directly, including patients (in a worsening of their condition), healthcare providers (increased time spent), payers (in escalating costs), and pharma (in lost revenue). As a result, there is a tremendous need — and opportunity — for helping people create, understand and adhere to their treatment plans.
According to Dr. Moore, a key first step to improving treatment adherence is to understand exactly what the term adherence means.
“Sometimes, pharma and physicians use the terms adherence and compliance interchangeably," Dr. Moore says. “The terms may seem the same, but the concepts are actually very different, especially when it comes to patient behavior. Compliance is defined as conformity to a recommendation, or doing something that someone tells you to do. For example, when a doctor says you need to eat healthier foods or you need to take all your medication as prescribed. The intention is good and the message is clear, but it’s a one-way conversation, sometimes with no suggestions on how to accomplish that goal.
“Adherence, on the other hand, is more of a two-way street," Dr. Moore continues. “It’s a discussion that engages the patient and results in an agreement on a path forward. The patient participates in a dialogue with the HCP to better understand the rationale for the diagnosis and treatment. They mutually agree in principle on a path moving forward. It shifts the patient from being passive to being active. There is discussion and a plan. That’s a huge difference."
To illustrate this point, Dr. Moore uses the example of a patient who needs to regulate her cholesterol. The doctor may say to the patient: “your cholesterol is too high, you need to lose 30 pounds, and you need to take this medication. Then I want to see you again in three months."
“That’s a lot of marching orders without a conversation," Dr. Moore says. “To some people, hearing they have to lose 30 pounds might as well be like having to lose 175 pounds. So, the question is how do we get the patient to lose the weight, take her medication, or in some cases, take multiple medications to control multiple chronic conditions? What are the little pieces that relate to why the patient might not want to do this? Does she think the doctor’s not 
right because she feels fine and her cholesterol really isn’t that high? Does she not want to give up the foods she’s eating? Does she not know how to go about creating a weight loss plan to getting started? Unless the patient knows why she’s doing what she has to do, or what her barriers are, she’s not going to be able to successfully move forward."
Leveraging Health Psychology
Health psychology is ideally suited to supporting this concept of a two-way dialogue, involving the active voice of an individual who is working to manage their condition. Both an academic and applied discipline, the field of health psychology focuses on how biological, psychological, behavioral and social factors influence health and illness. This includes the notion that understanding the factors that impact a patient’s journey with a chronic illness can address a multitude of challenges, including adherence.
Dr. Moore was intrigued by the discipline of health psychology because it wasn’t black and white. It allowed for differences between individuals and she could see multiple academic and clinical applications for its use. “Health psychology is inherently patient-centric. It provides the tools and framework to better understand and help people throughout their journey, including promoting healthy behaviors and treatment adherence. “
Promoting Behavior Change
Dr. Moore has spent 20 years working with children and adults living with chronic illness. She draws on her ongoing clinical experience to create innovative programs in health education and support. Her expertise combines a thorough understanding not only of health psychology models, but also of the psychosocial issues, patient experiences, and epidemiology to build effective patient-support programs that promote behavior change.
When patients are living with a chronic condition, or multiple conditions, the expectation is they engage in a wide range of behaviors to better manage their condition. These behaviors can include healthy eating and exercising, as well as broader behaviors such as communication and accessing support from caregivers, healthcare professionals, and advocacy associations. Collectively, these are known as self-management behaviors.
Treatment adherence is also one of these behaviors. Key to improving behaviors is creating support programs that empower patients to make positive changes – and health psychology frameworks help accomplish this.
“At the end of the day," Dr. Moore says, “we only talk to people in bite-sized pieces of time in their journey with a chronic illness. Health psychology gives us a framework to help them with in that time, but it also gives us the ability to teach them the tools they can use to work through challenges they may face when they are on their own. Being able to share the tools that can lead to building independent self-management skills is arguably the most valuable part of utilizing health psychology."
Recognizing the Individual
Dr. Moore firmly believes that behavior change needs to be individualized to the person – what might motivate one person might not work for someone else. To impact a behavior, first there needs to be an understanding of what influences a person’s motivation and his or her ability to carry out the action.
“Very often, pharma sees a patient only in buckets – perhaps their diagnosis or their treatment – not recognizing that each person is unique and that various aspects of their life will impact their ability to follow prescribed treatment." Dr. Moore says. “Health psychology helps us acknowledge the fact that people don’t live in a bubble. A person is more than a patient taking medication – they are parents, employees, spouse, athletes, teachers, and business owners. Looking beyond diagnosis means an assessment of other life factors, including social support, caregivers, job situation and access to care. All of these factors impact health behaviors, including treatment adherence.
Once we can identify these factors, the next step is understanding how they impact the individual and, in turn, how 
they impact behavior. Once we know that, we can address those underlying reasons why someone behaves the way they behave, or why they react the way they react, or feel the way they feel. Then we can help an individual think differently about a challenge, change the behavior and help them better self-manage their condition. The goal is to understand the connection between our minds and our behavior. It’s getting to the bottom of why do we do what we do," she says. “Even for people of the same age and gender with the same diagnosis and on the same medication, the why can be dramatically different."
A successful patient support program gives people the knowledge and support to help them understand the factors and beliefs behind the condition and treatment. But it also provides the tools they need to think about and change the behavior. In fact, this combination is key to helping patients continue healthy behaviors for the long-term.
Helping Patients Help Themselves
Understanding and supporting the whole person, learning more about the why, is what drew Dr. Moore to health psychology in the first place; figuring out the how, in terms of supporting patients, is what continues to drive her.
At Atlantis Healthcare, she works as part of a global team of health psychology experts to apply this evidence-based thinking and patient-centricity to patient support programs on behalf of pharma. It all starts with research to uncover the why. Using health psychology frameworks, Dr. Moore and her team conduct research to understand why or why not individuals are adhering to their treatment. Once they understand the overarching population belief themes and drill down to the individual beliefs, they tap into one or more of nearly 100 behavior change techniques to develop personalized programs to mitigate those barriers. These techniques can include goal setting, action planning, reframing, and pros/cons lists. Importantly, not every behavior change technique works for every situation, and it takes skilled specialists to understand how to apply academic rigor to individual needs to build successful programs.
“The key to any successful behavior change program is that the messaging be relevant to the individual," she says. “Imagine if you were worried about a specific side effect and got messages about how to fill your prescription. Or, if you were worried about using specialty pharmacy to fill a prescription, and got messaging on concerns about side effects. At best you would be confused or opt out of a support program. But you also run the risk of creating a problem or a concern where there wasn’t one originally."
The Team Approach
“It’s also important that physicians, nurses, educators and pharma work together to create the solution," Dr. Moore continues. “We find it’s incredibly helpful if everyone is working with at least the same basic understanding of motivators and barriers for an individual patient. This allows all stakeholders to engage in effective and supportive dialogue with each patient. It also means the patient is hearing the same types of messages from a variety of sources."
In fact, Dr. Moore notes that many of the programs created by Atlantis Healthcare are designed to engage the patient in a conversation with their physician about their condition and treatment, help them address potential barriers, and agree on and track treatment goals. To support this objective, many of the programs include patient-HCP dialogue tools, informed by condition-specific research and the principles of health psychology. These dialogue tools use BCTs that have been demonstrated to support active patient involvement. One commonly used set of techniques is to support the HCP to establish a behavioral contract with the patient and to elicit the patient’s commitment to the behavior change.
In the end, health psychology has given Dr. Moore a road map to better understand and influence patient behavior.
“Through health psychology, we have the models and tools to promote positive long-term health behaviors," she says. “My goal is always to help people manage their condition as a part of their life, and not let the condition dictate how they need to live their life." n
This article was created for and commissioned by Atlantis Healthcare.
