Training general practitioners in behavior change counseling to improve asthma medication adherence

https://doi.org/10.1016/j.pec.2005.06.001Get rights and content

Abstract

Objective:

Adherence to asthma medication regimens is problematic in general practice. We developed and evaluated a communication training for general practitioners (GPs) to help them address medication adherence during routine consultations. This paper describes the development of the training and evaluation results of a pilot study.

Methods:

The training was based on behavior change counseling (BCC), a technique derived from motivational interviewing. We developed a five phases BCC consultation model. Participating GPs answered questions at baseline (T0), directly after (T1) and 4–10 months after (T2) the training that assessed their attitudes and confidence regarding adherence communication. They completed evaluation forms at T1 and T2.

Results:

The 19 participating GPs were positive about the course and the feasibility of BCC in GP consultations. Also, after the training, their attitudes and confidence had improved (p < 0.05) and all reported to use BCC skills at least sometimes 4–10 months after the training.

Conclusion:

These positive effects provide us with some hope that the training positively influenced the GP's communication behavior.

Practice implications:

If further data on physician behavior and patient outcomes justify implementation of the training, it would then be worthwhile to also involve practice nurses.

Introduction

Despite the increased safety and efficacy of available drug therapies [1], medication adherence is generally low among patients with asthma [2]. For instance, in a recent study, 70–73% of patients seeking specialized asthma care used less inhaled corticosteroids than guidelines prescribed [3]. Non-adherence may increase morbidity, mortality, direct and indirect costs, and personal suffering [4], [5]. Guidelines recommend the discussion of medication adherence during general practice consultations [6], but no feasible and effective adherence intervention for general practice is available yet. We developed and tested a course for general practitioners (GPs) to help them address medication adherence with their patients. This paper explains the background of the training, its development and outline, and the evaluation it received from participants in the pilot study.

The training was based on behavior change counseling (BCC) [7], a technique derived from motivational interviewing [8], [9]. Motivational interviewing is a communication style with proven effectiveness in the addiction field [10]. It has been defined as ‘a directive, client centered counseling style for eliciting behavior change by helping clients to explore and resolve ambivalence’ [11]. Four central elements are (1) to express empathy, (2) to develop discrepancy between a client's current behavior and his or her broader goals and values, (3) to ‘roll with resistance’ rather than to oppose it, and (4) to support the client's confidence in the possibility of change [12]. Specific techniques are used to motivate clients, but even more important is the spirit of ‘collaboration, evocation and autonomy’ [12]. Collaboration refers to the partnership (rather than expert–recipient relationship) between the counselor and the client. Evocation means that arguments for change are elicited from the client, rather than brought forward by the counselor. Autonomy refers to the explicit respect of the counselor for the client's responsibility and freedom of choice. Motivational interviewing was described and tested extensively in numerous papers, which are summarized in a bibliography at the motivational interviewing website (www.motivationalinterview.org).

W.R. Miller developed motivational interviewing from his therapeutic experience with alcohol dependent clients [8]. Since that time, it has been applied to a variety of other problems and settings dealing with behavior change. The effectiveness of these ‘adaptations of motivational interviewing’ was assessed in two comprehensive reviews [13], [14] and a meta-analysis [10]. Their effectiveness was convincing in the substance abuse domain, but results were contradictive for smoking cessation and exercise, and did not support their use in HIV risk reduction [10], [13].

For the present project, we were especially interested in the use of motivational interviewing to improve medication adherence. The review by Zweben and Zuckoff [14] focused on adherence effects, but included only one study on medication adherence [15]. In October 2004, by means of PubMed searches with the terms ‘motivational interv*’ ‘AND’ either ‘patient compliance’ or ‘medication adherence’, and the checking of references in relevant articles, we retrieved 10 relevant published articles [15], [16], [17], [18], [19], [20], [21], [22], [23], [24]. Three described an intervention [22], [23], [24], the other seven were outcome studies [15], [16], [17], [18], [19], [20], [21], of which four [18], [19], [20], [21] were small sample (pilot) studies with non-significant results. The three larger outcome studies [15], [16], [17] showed positive adherence effects of the interventions. Thus, adaptations of motivational interviewing might help to improve medication adherence. However, all 10 papers concerned either HIV or psychiatric patients, and in all cases especially trained counselors (rather than the patient's own health care provider) delivered the intervention.

We aimed to train general practitioners (GPs) to deliver the intervention, but found only two projects where GPs (rather than for instance diabetes nurses) provided a complete intervention to their own patients, without extra support (vouchers, telephone calls) from other professionals [25], [26], [27], [28]. Butler and colleagues [25], [26] trained GP registrars in a smoking cessation intervention. Mean consultation time including the intervention was less than 10 min, but the effects on patient outcomes were modest. The fidelity of GPs to the intervention was not assessed. Stott et al. [27], [28] offered a tailor made training to 29 general practice diabetes teams, to help them address several aspects of lifestyle change with their patients. An RCT 2 years later showed no effect on patient outcomes, probably because only 19% of the trained professionals continued to apply the intervention. Thus, there may be barriers for GPs to learn and apply motivational interviewing skills. Time constraints and limited baseline competence in therapeutic communication skills have been mentioned in this respect [29].

Adaptations of motivational interviewing have come to be so diverse that it has become hard to compare their effects and to distil any ‘active ingredients’ of motivational interviewing. For that reason, Rollnick et al. proposed a taxonomy to categorize interventions [30]. According to this taxonomy, our intervention should be considered as behavior change counseling (BCC), because of the length of the consultations (10–15 min), the goals of the intervention (e.g. identify client goals, build motivation for change), the interactional style (counselor–active participant), and the aim to exchange (rather than provide) information. We will use the term BCC when we refer to the intervention. The ultimate aim of our training was to have GPs acquire skills for discussing medication adherence with their patients in a constructive way, i.e. which would enhance medication adherence.

A needs assessment meeting with three non-participating GPs showed that at least a select group of GPs might value training in BCC, especially with active role-play and an actor present. The issue of asthma medication adherence was of no special interest to the GPs, but the broader issue of lifestyle change was. The GPs advised to keep the number of training sessions to a minimum, and to obtain accreditation with continued medical education (CME) points.

In accordance with these findings, we mentioned the broader applicability of BCC during GP recruitment and arranged for only two 4.5-h meetings (with one optional individual feedback appointment). Participants would receive nine CME points. Two of the authors (FBE and MMC), both experienced trainers and psychotherapists, further developed the course, on the basis of their experience in teaching patient centered communication to healthcare professionals and their knowledge of motivational interviewing.

In an attempt to apply BCC to short medication adherence consultations, we distinguished five consultation phases (see Table 1).

This ‘five phases model’ leaned heavily on the work of Rollnick, Butler and colleagues [7], [25], [26]. The first phase, agenda setting, consisted of introducing the subject of medication adherence, asking if the patient was willing to discuss medication adherence, and asking if the patient had other issues that he or she would like to address. The purpose was to introduce the topic of medication adherence without provoking resistance from the patient. Would a patient not be willing to discuss medication adherence, the GP could explore the patients reasons for this, and ‘roll with resistance’ (e.g. convey understanding, acknowledge the patients autonomy, etc.).

The second phase, explore the patient's reasons for (non-) adherence, took place after the patient's current pattern of medication use had been assessed. By means of exploration, the GP aimed to understand the patient's perspective and motives, to build rapport, and to reduce resistance.

A third phase was information exchange. The ‘elicit-provide-elicit’ model (Rollnick and Rose, personal communication) was used: ask if the patient is interested in information, if yes, provide this information neutrally, and then invite the patient to interpret the information (to consider individual consequences of the information). This was a way to avoid the ‘expert trap’, which could induce resistance and damage the rapport.

The purpose of the fourth phase was to build motivation and confidence. We used the two 0–10 scales with questions [25], [26] for this purpose (see Table 1). The aim of the first scale was to invite the patient to speak out any arguments pro medication adherence, to reinforce these arguments and thus strengthen the patient's motivation. ‘Status quo’ arguments (barriers to adherence) were acknowledged. In the same way, the aim of the second scale was to assess and strengthen the patient's confidence in the own ability to use the medications as prescribed.

We named the fifth phase brainstorm and contract. The GP invited the patient to engage in an active brainstorm on possible ‘solutions’. The goal was to develop a mutually agreed treatment plan, which could work for this patient under these (medical and psychosocial) circumstances.

Throughout the course we paid attention to the spirit of BCC, by modeling and supporting a patient-centered empathic attitude and respect for the patient's values, motives, and autonomy.

At the start of the first meeting, GPs received an outline of the five phases model, some tips on how to elicit information on medication adherence from the patient, and some background reading on BCC and motivational interviewing.

Both the first and the second meeting consisted of (short) interactive theory presentations, group discussions, and at least 2 h of role-play.

The theory presentations addressed at a cognitive level, i.e. by producing gains in conceptual framework and increasing knowledge, some relevant psychology of chronically ill patients, the mechanism of patient resistance towards advice and how to successfully deal with such resistance. The interactive character of the theory presentations and the ensuing group discussions had as their goal to create insight in the mechanisms involved and as such induce attitude change in the participants. The issue of responsibility for medication use and life style changes, for example, received specific attention. Group discussions also aimed at increasing knowledge among participants. Target skills were addressed by means of role-plays and covered the five phases as described previously. Following the training, GPs were expected to be capable to set the agenda, role with resistance, explore reasons for non-adherence, use the scales to induce ‘change talk’ and to increase a sense of mastery and, finally, to negotiate a treatment plan.

A professional actor played either a paper case, or a ‘difficult’ patient as described by the participants. The participants discussed their objectives during a certain consultation phase in dyads or triads, and then two to four GPs exercised the phase and received feedback from the group and the trainers. The preparatory discussion in dyads aimed to clarify the problems as related to specific phases of the consultations and to share knowledge. Clear ground rules for role-play were negotiated to the participants [31]. These included, for example the importance of first mentioning positive comments followed by constructive criticism to minimize deskilling the participant and the use of ‘time out’ when the role-player became stuck. The group was given the responsibility of helping role-players to move forward by suggesting alternative strategies.

During the first meeting, the participants watched videotapes at the start and the end of the session. The first tape showed an increasingly frustrated internist, working very hard to motivate a diabetes patient to quit smoking, get on a diet and to engage in regular exercise. It illustrated some known ‘practitioner traps’ like confronting, advising, and stressing the importance of behavior change, and the patient's reactions to these behaviors. The aim of this video was to break the ice and open a discussion of the GP's own experiences, strategies and frustrations. This open discussion, with elements of sharing, helped to create a safe and constructive learning environment and resulted in case descriptions which could later be used in the role-plays. The video at the end of the meeting showed the same patient during a short BCC consultation with another physician, to demonstrate a consultation conducted according to the principles of the five phase model. Both meetings ended with a short evaluation of the meeting with the aim to be able to change the program of the second day and honor wishes of participants, if needed. At the end of the second meeting, evaluation forms were completed (see Table 3).

Throughout the course, the trainers modeled BCC during their interactions with the participants [32]. They created a safe learning environment, for example by being positive about useful disclosers, were empathic and respectful, invited the participants to be active, in particular the silent ones, explicitly acknowledged the participants’ expertise and autonomy, and met any perceived resistance with empathy and exploration [31].

Section snippets

Participants and procedure

Nineteen GPs participated in the training. GPs (n = 397) from a large urban area received an invitational letter, and a reminder 2 weeks later: 285 (72%) did not react, 97 (24%) declined participation, and 15 (4%) agreed to participate. Fifteen health care centers in another city were approached, and 9 (47%) allowed us a 5-min presentation of the project at their centre. This resulted in another four participants. Reasons to decline participation were: time constraints, regarding ‘motivating

Results

Of the 19 participants, 16 (84%) attended both sessions. All three GPs who missed the second session were in the first group. Two of them forgot the second meeting, and one was ill.

The mean age of the 19 participating GPs was 49 years (range 35–59). They had worked as a GP for a mean of 16 years (range 3–29), and 12 of them (63%) were male. Seven (37%) of them trained GP registrars. Six (32%) received individual feedback after the training.

Discussion

Participants were positive about the course. After the training their attitudes towards adherence communication got more in line with BCC principles, and their confidence in their own skills had grown. At follow-up, most GPs reported to use BCC skills during their consultations. These findings leave us cautiously optimistic about the effectiveness of the training.

Several reviews have addressed the effectiveness of interventions to enhance patient adherence and patient self-management (e.g. [34]

Acknowledgements

We thank the GPs for their participation and confidence in a PhD project still underway. The training was supported by a grant from GlaxoSmithKline. The first author is a member of the research school Psychology and Health.

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