[5.2] 6136 - Social Behavioral Theories in Pharmaceutical Care part 2

THEORIES OF BEHAVIOR CHANGE

• Behavior change

• is often a goal for staff working directly with constituents, organizations, governments, or communities

“Pharmacist”

An individual who renders pharmaceutical care

Pharmaceutical care.

is defined as the responsible provision of drug therapy for the purpose of achieving definite outcomes that improve a patient’s quality of life

“Pharmacist” goal

Responsible provision of drug therapy; To do all activities pertaining to a pharmacist’s role in the healthcare team (dispense, counsel, compound, etc.) to improve patient outcomes.

Interventionists

Individuals whose goal it is to design and implement programs or interventions that produce the desired behavioral changes

Interventionists goal

To provide programs or activities that will help support and reinforce towards a permanent behavior thereby ensuring positive health outcomes.

Can pharmacists be interventionists?

• Pharmacists can indeed be interventionists as they would be the best people to plan and have goals for achieving a better quality of life for their patients. 

• However, this also entails a pharmacist to hurdle through several challenges including workload, spending time with the patient (practice of patients only “dropping by”), and issue of space in the pharmacy (need to discuss the therapeutic plan to your patient and engaging the patient to meaningful discussions about their health status)

Pharmacist interventionists

are intentional healthcare providers that focus on helping individuals achieve a level of behavior that ensures positive health outcomes.

KEY ELEMENTS OF BEHAVIOR CHANGE

• Threat

• Fear

• Response Efficacy

• Self-Efficacy

• Barriers

• Benefits

• Subjective Norms

• Attitudes

• Intentions

• Cue to Action

• Reactance

Threat

• definition

A danger or a harmful event of which people may or may not be aware.

Threat

• strategies for behavior change

Raise awareness that the threat exists, focusing on severity and susceptibility.

Fear

• definition

Emotional arousal caused by perceiving a significant and personally relevant threat.

Fear

• sttrategies

Fear can powerfully influence behavior and, if it is channeled in the appropriate way, can motivate people to seek information, but it can also cause people to deny they are at risk.

Response Efficacy

• definition

Perception that a recommended response will prevent the threat from happening.

Response Efficacy

• strategies

Provide evidence of examples that the recommended response will avert the threat.

Self-Efficacy

def

An individual’s perception of or confidence in their ability to perform a recommended response

Self-Efficacy

strat

Raise individuals’ confidence that they can perform response and help ensure that they can avert the threat.

Barriers

def

Something that would prevent an individual from carrying out a recommended response.

Barriers

strat

Be aware of physical or cultural barriers that might exist, attempt to remove barriers.

Benefits

• def

Positive consequences of performing recommended response

Benefits

• strat

Communicate the benefits of performing the recommended response.

Subjective Norms

• def

What an individual thinks other people think they should do

Subjective Norms

• strat

Understand with whom individuals are likely to comply.

Attitudes

• def

An individual’s evaluation or beliefs about a recommended response.

Attitudes

• strat

Measure existing attitudes before attempting to change them.

Intentions

def

An individual’s plans to carry out the recommended response

Intentions

strat

Determine if intentions are genuine or proxies for actual behavior

Cue to Action

• def

External or internal factors that help individuals make decisions about a response.

Cue to Action

• strat

Provide communication that might trigger individuals to make decisions

Reactance

• def

When an individual reacts against a recommended response.

Reactance

• strat

Ensure individuals do not feel they have been manipulated or are unable to avert the threat.

THEORIES OF PLANNED BEHAVIOR

• Suggests that behavior is dependent on one’s intention to perform the behavior. 

THEORIES OF PLANNED BEHAVIOR

Intention is determined by

• an individual’s attitude (beliefs and values about the outcome of the behavior)

• and subjective norms (beliefs about what other people think the person should do or general social pressure).

THEORIES OF PLANNED BEHAVIOR

• Behavior is also determined by

• an individual’s perceived behavioral control, (an individual’s perceptions of their ability or feelings of self-efficacy to perform behavior). 

THEORIES OF PLANNED BEHAVIOR
This relationship is typically dependent on the

type of relationship and the nature of the situation. 

How Can This Theory Inform Practice?

• Intention has been shown to be the

• most important variable in predicting behavior change, suggesting that behaviors are often linked with one’s personal motivation. 

How Can This Theory Inform Practice?

• Intention has been shown to be the most important variable in predicting behavior change, suggesting that behaviors are often linked with one’s personal motivation. 

• Strategy: present information to help shape positive attitudes towards the behavior and stress subjective norms or opinions that support the behavior.

• Evidently showing support towards the person and their intent of change pushes them to act on the behavior itself.

For perceived behavioral control to influence behavior change, much like with self-efficacy,

a person must perceive that they have the ability to perform the behavior.

• For perceived behavioral control to influence behavior change, much like with self-efficacy, a person must perceive that they have the ability to perform the behavior. 

• Strategy: strengthen perceived control over opportunities, resources, and skills needed is an important part of the change process. 

• Help them realize that they are capable of such change by building self-trust and self-confidence towards their move to perform the behavior.

 GOAL SETTING THEORY

• Involves establishing specific, measurable and time-targeted objectives. 

• To elicit some specific form of behavior from others, it is important that the person has a clear view of what is expected from him/her.

Why Set Goals?

• Goals focus attention towards goal-relevant activities and away from goal-irrelevant activities 

• Goals serve as an energizer; higher goals will induce greater effort while low goals induce lesser effort 

• Goals focus attention towards goal-relevant activities and away from goal-irrelevant activities 

• When you know your goal, everything that you do will be towards that goal. If you want to reduce weight, a strict diet and physical exercises would be employed which are relevant to your goal.

• Goals serve as an energizer; higher goals will induce greater effort while low goals induce lesser effort 

• Small increments are allowed in goal making and eventually improved until you reach larger points to achieve.

• Step by the step

5 Principles of Goal Setting

• Clarity (measurable and unambiguous) 

• Challenge (anticipated accomplishment) 

• Commitment (level of buy in) 

• Feedback (progress, adjustments) 

• Task complexity (potential to be overwhelmed) one of the largest problem

The possible down sides with goal setting is the

assumption of the principle that people know what their goals are!

LEARNING THEORY

• Emphasize that learning a new, complex pattern of behavior (e.g. changing from a sedentary to an active lifestyle), normally requires modifying many of the small behaviors that compose an overall complex behavior. 

• Behaviors that are steps toward a final goal need to be reinforced and established first, with rewards given for partial accomplishment if necessary. 

LEARNING THEORY

• A further complication to the change process is that new patterns of physical activity behavior must

• replace or compete with former patterns of inactive behaviors that are often satisfying (e.g., watching television), habitual behaviors e.g., parking close to the door), or behaviors cued by the environment (e.g., the presence of an elevator). 

LEARNING THEORY

• Reinforcement describes the

• consequences that motivate individuals either to continue or discontinue behavior. 

LEARNING THEORY

Most behavior, including physical activity, is learned and maintained under

fairly complex schedules of reinforcement and anticipated future rewards.

Future rewards or incentives may include

• physical consequences (e.g., looking better)

• extrinsic rewards (e.g., receiving praise and encouragement from others, receiving a T-shirt),

• and intrinsic rewards (e.g., experiencing a feeling of accomplishment or gratification from attaining a personal milestone). 

LEARNING THEORY

• It is important to note that although providing praise, encouragement, and other extrinsic rewards may help people adopt positive lifestyle behaviours,

• such external reinforcement may not be reliable for sustained long-term change .

ECOLOGICAL APPROACHES

• Focus on sociocultural (people & processes) and physical environmental (infrastructure) influences on behavior.

• Interest has developed in ecological approaches to increasing participation in physical activity.

ECOLOGICAL APPROACHES

• In a health context, the concept of a health-promoting environment has been demonstrated by

• describing how physical activity could be promoted by establishing environmental supports, such as bike paths, parks, and incentives to encourage walking or cycling to work.  

ECOLOGICAL APPROACHES

• In a business setting,

• this might be about the concept of a learning organization, where multiple approaches to learning are used: e.g. in in-house coaching schemes, different and varied approaches to training and learning, including face-to-face and online, the provision of enough time for reflective learning people in the 

BEHAVIORAL CHANGE STRATEGIES

• using technology to change behavior

• nudging

USING TECHNOLOGY TO CHANGE BEHAVIOR

• Technology can help by sending reminders and offering tools for learning and practicing new behaviors.

• The age of technology widens the possibilities for changing behavior.

USING TECHNOLOGY TO CHANGE BEHAVIOR

• E-health interventions,

• delivered using the internet, are increasingly common. They are often cited as being cost-effective, but there is a lack of data to assess this. 

USING TECHNOLOGY TO CHANGE BEHAVIOR

• The most effective internet-based interventions for changing behavior appear to be

• more extensively based on theory (particularly the theory of planned behavior) and use a number of techniques. 

USING TECHNOLOGY TO CHANGE BEHAVIOR

• The use of additional communication methods, particularly

• SMS (short message service) or text messaging to send motivational messages e.g. reminders of the benefits of exercise, facilitates behavior change. 

USING TECHNOLOGY TO CHANGE BEHAVIOR

• Mobile phones

• are good candidates for the delivery of behavioral interventions. 

USING TECHNOLOGY TO CHANGE BEHAVIOR

• The advancement of mobile technology to include internal sensors of user location, movement, emotion, and social engagement

• raises the prospect of continuous and automated tracking of health-related behaviors. 

NUDGING

• primarily drawn from behavioral economics, has attracted interest in recent years. 

• It aims to ‘nudge’ people’s choices, not by removing the less healthy ones, but by making the healthier option easier. 

• Another example is the reformulation of products, when recipes are modified to improve their nutritional content 

• guides behavior without restricting choices, making the preferred option easier, more appealing, or more convenient.

The concept of reducing health care costs and improving quality of life for

individuals with chronic conditions by preventing or minimizing the effects of the disease through integrated care.

Programs are designed to improve the health of persons with chronic conditions and reduce associated costs from avoidable complications by

identifying and treating chronic conditions more quickly and more effectively, thus slowing the progression of those diseases. 

A system of coordinated health care interventions and communications

for defined patient populations with conditions where self-care efforts can be implemented.

Empowers individuals, working with other health care providers to

manage their disease and prevent complications.

Emerged as a promising strategy for improving care for those individuals with chronic conditions. People with chronic conditions usually use

more health care services which often are not coordinated among providers, creating opportunities for overuse or underuse of medical care

DISEASE MANAGEMENT…

is a proactive, multidisciplinary, and systematic approach to health care delivery

Disease management is a proactive, multidisciplinary, and systematic approach to health care delivery that: 

• Includes all members of the healthcare team 

• Supports the provider-patient relationship and plan of care 

• Optimizes patient care through prevention and proactive interventions based on evidence-based guidelines 

• Incorporates patient self-management

• Continuously evaluates health status 

• Measures outcomes 

• Strives to improve overall health and quality of life, and lower the cost of care

COMPONENTS OF DISEASE MANAGEMENT PROGRAMS

1. Population identification processes

2. Evidence-based practice guidelines

3. Risk identification and matching of interventions to need

4. Patient self-management education

5. Process and outcomes measurement and evaluation

6. Tracking and monitoring system

1. Population identification processes

• Demographic characteristics (who), health care use (what), and health care expenditures (how much) are generally reviewed to identify individuals who will benefit from a disease management program.

  • The population needs to be identified so we should be informed about the who is included, what do they need and how much is the medicine

Programs target individuals with a specific disease that is chronic in nature and costly. Individuals with multiple conditions may also benefit from a disease management program.

2. Evidence-based practice guidelines

Practice guidelines based on clinical evidence ensure consistency in treatment across the targeted population

3. Risk identification and matching of interventions to need

• Ensure correct treatment and assess the risk for the patient especially if the person has comorbidities

• Evaluating and considering whether or not the disease management program may affect the existing comorbidities

4. Patient self-management education

• Self management may include behavior modification, support groups and primary prevention

  • Inform our patient towards managing or somewhat observing themselves because we’re not with our patients 24/7

5. Process and outcomes measurement and evaluation

• A method for the measurement of outcomes may include health care service use, expenditures and patient satisfaction

  • To know your progress, costs, and patient satisfaction

6. Tracking and monitoring system

• Routine reporting and feedback loops that include patients and providers

• Appropriate use of information technology

CHRONIC DISORDERS COMMONLY MANAGED

• Diabetes Mellitus 

• Congestive Heart Failure (CHF) 

• Chronic Obstructive Pulmonary Disease (COPD) 

• Coronary Artery Disease (CAD) 

• Asthma 

• Hypertension

Disease management generally entails using

a multidisciplinary team of providers (for example, physicians, pharmacists, nurses, dietitians, and psychologists) to assist individuals in managing their condition(s). 

Disease management programs are based on the concept that

individuals who are educated about managing their disorder seek and receive better care

COMPREHENSIVE DISEASE MANAGEMENT (DM) PROGRAMS CAN:

• Improve the safety and quality of care 

• Improve access to care 

  • Because of improved health-seeking behavior leading to active seeking for interventions and healthcare providers

• Improve patient self-management 

• Improve financial cost containment without sacrificing quality or patient satisfaction 

• Enhance efforts to provide health improvement programs on a population basis

COMPREHENSIVE DISEASE MANAGEMENT (DM) PROGRAMS goal

to encourage patients to use medications properly, to understand and monitor their symptoms more effectively, and possibly, to change behavior.

Traditional Fee-for-service Settings

• Health care professionals typically focus on specific, isolated medical events and the health care status of individual patients

Traditional Fee-for-service Settings

• example

•  a physician who diagnoses and treats a patient with congestive heart failure (CHF) may believe he or she has fulfilled their responsibility once the patient's symptoms are resolved. 

• The physician would then prescribe appropriate medications (the take-home meds)  and suggest ways to manage CHF symptoms. Generally, physicians or other health care professionals only have the opportunity to evaluate patients when the patient complains of symptoms, when the patient is seen during an office visit or when the patient is hospitalized. So when the patient feels any sort of discomfort or other pains even after the program, they can revisit the physician.

Disease Management (DM) Program Settings

• Focus on multiple facets of patient care and maximize the health status of defined patient populations

Disease Management (DM) Program Settings

• example

• Coordinate care for the disease among all providers that are involved in the patient, physicians, pharmacists, hospitals, and laboratories. 

• Develop and implement a partnership with patients, because all of these individuals understand the value and relative contribution each brings to the program. 

• A health plan’s CHF patients often involve instruction for daily weigh-ins to monitor minor weight fluctuations due to fluid retention for a more focused intervention. 

• May involve a daily telephone call from a nurse verifying a patient’s weight. 

• Are then able to notify the patient’s physician of weight changes before such changes cause hospitalizations. 

• Well positioned to practice disease management because they are dedicated to comprehensive, coordinated care. 

• Focus on improving the health of entire patient populations, use available resources effectively, and are held accountable by patients, purchasers and regulators for the quality of their medical services. 

• Managed care organizations integrate key health care services, including patient and health care professional education, as well as ambulatory care, acute care, home health care and nursing home services. 

• Such integration provides greater continuity of patient care, leading to better health care outcomes. 

HEALTH OUTCOMES AFFECT BOTH THE QUALITY OF LIFE AND THE USE OF HEALTH CARE SERVICES

• Disease management programs are objectively evaluated based on previously defined outcome points/ goals that were set and the collection of baseline data on the natural course of the targeted disease. 

• Performance indicators and outcome measures should be analyzed to determine if the program is achieving quality improvement. 

• Performance indicators assess a specific performance at regular intervals and compare performance to predefined indicators. 

• These indicators measure the intermediate success of an action or intervention. 

• Outcome measures determine the end result of an action or intervention. Obtaining meaningful outcomes should improve the overall quality of the program.

HEALTH OUTCOMES CAN BE MEASURED FROM SEVERAL PERSPECTIVES

• Clinical outcomes and health care utilization, such as a change in the incidence of medical outcomes, e.g., heart attacks, increase or decrease in use of medications 

• Humanistic outcomes (quality of life) measure the patient's own assessment of the impact of the program on his or her physical, social and emotional well-being 

• Economic outcomes, defined as the cost of the intervention less any savings from health improvements 

MEDICATION THERAPY MANAGEMENT (MTM) PROGRAMS:

• Is a distinct service or group of services that optimize therapeutic drug outcomes for individual patients. 

• Services are independent of, but can occur in conjunction with, the provision of a medication. 

• Are not intended to focus on one disease state but cover the full spectrum of medications a specific patient may be taking.

ROLE OF PHARMACIST IN DM PROGRAMS

• Can provide education, as well as screening and medication monitoring services. 

• Involved in disease management programs in numerous ways.

PHARMACISTS ROLE VARY ACCORDING TO EACH PRACTICE SETTING

• Assist in the identification of individuals 

• Conduct monitoring for specific diseases, for example, diabetes, cholesterol, blood pressure 

• Provide patient education (Glucose monitoring, Peak flow monitoring) 

• Assist with medication adherence 

• Provide direct patient care 

• Evaluate outcomes of programs

A trained pharmacist:

• Can evaluate medication therapies,

• Identify and manage drug-related problems for the patient,

• Provide advice on a disease and its management

Asthma Management

• Provide educational programs to patients about the disease, 

• Conduct periodic review of the patient's inhaler technique, 

• Perform ongoing monitoring of peak-flow function tests, 

• Managechronic medication use, including compliance assistance.

Diabetes Management

• Provide educational programs to patients about the disease, 

• Regularly monitor both self-tested and laboratory tested blood glucose levels, 

  • Some drugstores offer these services

• Educate patients on how to use home blood glucose monitoring equipment, 

• Monitor patient compliance with prescribed therapies and scheduled clinic and laboratory appointments, 

• Screen for drug/drug, drug/food, drug/lab and drug/disease interactions and adverse drug reactions, 

  • See and find particular medicines that your patient is taking as well as what they eat. From here you can advise them on how to regulate their intake.

• Provide medication management and review. 

Hypertension and Cholesterol  Management

• Educate patients about these silent diseases, 

  • These diseases do not have manifestations which indicate that you are already sick. Not until such as the time you get your laboratory workup.

• Monitor compliance with medications, diet and exercise regimens, 

• Screen for drug/drug, drug/food, drug/lab and drug/disease interactions and adverse drug reactions,

• Perform periodic blood pressure checks, 

• Perform periodic cholesterol level checks. 

  • You can advise the patient to go to their doctors for a laboratory request.

HEALTH CARE PROFESSIONAL’S INTERACTION

• Target high-risk and high-utilizing patients for education and/or intervention, 

• Conduct outcomes research to form the basis for treatment guidelines, 

• Ensure the ongoing involvement of the pharmacy and therapeutics (P&T) committee in the disease management process, 

• Influence prescribing patterns, e.g. in health centers

• Educate other pharmacists and physicians about treatment guidelines, 

• Provide expert information on medications and pharmacotherapy, 

• Use health system databases to track drug expenditure patterns and health care professionals' adherence to health care management regimens. 

  • For now, it is not happening in the near future. But as part of the healthcare system we have the obligation to contribute to the health systems performance.

• Perform patient assessment for medication-related factors. 

• Order laboratory tests necessary for monitoring outcomes of medication therapy. 

  • Not applicable in the Philippines

• Interpret data related to medication safety and effectiveness. 

• Initiate or modify medication therapy care plans on the basis of patient responses. 

  • Needs to be coordinated with a doctor or physician

• Provide information, education, and counseling to patients about medication-related care.  

• Document the care provided in patients’ records. 

  • Particularly in hospitals

• Identify any barriers to patient compliance.

• Participate in multidisciplinary reviews of patients’ progress. 

  • A pharmacist's input is important in these reviews.

• Communicate with payers to resolve issues that may impede access to medication therapies. 

  • If your pharmacy is PhilHealth accredited.

Communicate relevant issues to physicians and other team members.