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Overview The Theoretical Basis for PracticePractice-Relevant Medication Use Research: What is theory, the functions theories serve, and common mistakes people make when using or not using theory Guiding principles derived from theory Skeleton theoretical framework for future research PatientPatient-Centered/Behavioral Theories Susan J. Blalock, PhD, MPH UNC Eshelman School of Pharmacy University of North Carolina at Chapel Hill 1 2 What is Theory Functions of Theories A theory is a set of concepts and propositions that specify how certain variables are thought to influence other variables. A B C Improved Medication Use Integrate findings from past research Generate hypotheses for future research Help understand the determinants of health behavior Help identify information required before an intervention can be designed Help identify intervention targets 3 4 Common Mistakes ¾ Ignore theory ¾ Give lip service to theory ¾ Use theory as a substitute for knowledge gained from experience and careful analysis of the problem of interest Guiding Principles: #1 ¾ 5 There are no perfect theories 6 1 Guiding Principles: #2 ¾ Guiding Principles: #3 Behavioral science theories are probabilistic not deterministic ¾ When trying to influence a health behavior, the health behavior of interest must be defined precisely So, what do we mean when we talk about “medication use” use” 7 8 Medication Use Medication Use Adherence Not fill an original prescription Omit doses Take wrong amount, too little or too much Take at wrong time of day Space doses incorrectly Not follow instructions concerning administration (e.g., with or without food) Take drug holidays Discontinue regimen 9 Dimensions of Behavior Action: Target Obtain original prescription and refill authorizations Obtain medication Integrate medication into daily routine Use the medication in ways that minimize potential harms (e.g., sideside-effects, unintentional poisonings) Monitor potential medicationmedication-related problems Resolve medicationmedication-related problems 10 Guiding Principles: #4 Medication SelfSelf-Management ¾ Oral medications versus injectables Medications with different risk profiles, side effects, costs Medications for prevention versus symptomatic relief Etc Many factors outside of patient control influence patient medication use Ecological Models of Health Behavior Context Adherence Medication SelfSelf-Management Taking medication at home versus at work or school Taking medication while traveling Number of different medications used Etc Time Acute versus chronic condition Once versus multiple daily dosing 11 12 2 Prototypical Ecological Model Examples of Ecological Models Social Policy Governmental Regulations Social Learning (Cognitive) Theory, Bandura, 1986 Ecological Model of Health Behavior, McLeroy et al, 1988 Social Ecology Model of Health Promotion, Stokols, Stokols, 1992 Family, Friends, Small Groups StructuralStructural-Ecological Model, Cohen et al, 2000 Providers Theory of Triadic Influence, Flay & Petraitis, Petraitis, 1994 Model of Community Food Environments, Glanz et al, 2005 Resources and Skills for SelfSelf-Management, Fisher et al, 2005 Community Health Care System Patients 13 14 Ecological Models: Core Tenets Health behavior is influenced by multiple sources, operating at different levels Influences on behavior interact across levels MultiMulti-level interventions should be most effective in facilitating behavior change Ecological models should be behaviorbehavior-specific Sallis JS, Owen N, Fisher EB. Ecological models of health behavior. In Glanz K, Rimer BK, Viswanath K (eds (eds)) Health Behavior and Health Education: Theory, research, and practice. San Francisco:, JosseyJossey-Bass, 2008. Guiding Principles: #5 ¾ The importance of individualized assessment. 15 16 Barriers to Optimal Medication Use Guiding Principles: #6 Lack of knowledge Lack of motivation Lack of skills or resources Health insurance Transportation Physical abilities Cognitive abilities Social support etc No two people are the same ¾ Patient motivation is a fundamental ingredient, especially when maintenance of long term behavior is the goal Value Expectancy Theories 17 18 3 Examples of Value Expectancy Theories ValueValue-Expectancy Theories: Core Tenets Field Theory (Lewin, 1942) Social Learning Theory (Rotter, 1954) Health Belief Model (Hochbaum,1958) Theory of Reasoned Action (Fishbein & Ajzen, 1975) Social Cognitive Theory (1977) Conflict Theory (Janis & Mann, 1977) Common Sense Model of SelfSelf-Regulation ( Leventhal et al, 1980) Transtheoretical Model of Change (Prochaska & DiClemente,1983) Protection Motivation Theory (Prentice(Prentice-Dunn & Rogers, 1986) Precaution Adoption Process Model (Weinstein, 1988) Theory of Planned Behavior (Ajzen, 1991) Behavior is under voluntary control People are more likely to adopt a recommended behavior if they believe that the benefits outweigh the costs People are more likely to adopt a recommended behavior if they believe that they will be able to enact the behavior successfully People weigh the benefits and costs associated with different behavioral options before acting 19 20 Examples of: PatientPatient-Provider Communication Theories Guiding Principles: #7 ¾ Health care providers can have a profound effect on patient medication use and this effect can operate through several possible causal pathways Paternalism, Parsons, 1951 Models of PhysicianPhysician-Patient Relationships, Szasz & Hollender, Hollender, 1956 Consumerism, Reeder, 1972 Cognitive Model, Ley, Ley, 1988 Model of Empathic Understanding, Squier, Squier, 1990 Types of PhysicianPhysician-Patient Relationships, Roter & Hall, 1992 Uncertainty Theory, Mishel, Mishel, 1999 Model of Decision Making, Charles et al, 1999 Uncertainty Management Theory, Brashers, Brashers, 2001 Linguistic Model of Patient Participation in Care, Street 2001 Patient Agency Model, O’ O’Hair et al, 2003 Integrative Model of Shared Decision Making, Makoul & Clayman, Clayman, 2006 21 22 Theoretical Causal Pathways Communication Functions Proximal Outcomes Intermediate Outcomes Theoretical Causal Pathways Distal Outcomes Communication Functions Exchange information Respond to emotions Foster relationship Make decisions Enable selfself-management Exchange information Respond to emotions Manage uncertainty Foster relationship Make decisions Enable selfself-management 23 Proximal Outcomes Intermediate Outcomes Distal Outcomes Knowledge Trust Rapport Satisfaction Access to care Tailored medication regimens 24 4 Theoretical Causal Pathways Communication Functions Exchange information Respond to emotions Manage uncertainty Foster relationship Make decisions Enable selfself-management Proximal Outcomes Knowledge Trust Rapport Satisfaction Access to care Tailored medication regimens Intermediate Outcomes Theoretical Causal Pathways Distal Outcomes Communication Functions Proximal Outcomes Exchange information Respond to emotions Manage uncertainty Foster relationship Make decisions Enable selfself-management Medication adherence Medication persistence Medication selfself-management Knowledge Trust Rapport Satisfaction Access to care Tailored medication regimens Intermediate Outcomes Distal Outcomes Medication adherence Medication persistence Medication selfself-management Morbidity Mortality Emotional WellWell-Being Health Related Quality of Life 25 Guiding Principles: #8 ¾ 26 Prototypical Conceptual Model When planning an intervention to optimize patient medication use, it is important to develop a conceptual model that links intervention inputs to the outcomes that are desired. Proximal Outcomes Intervention 1-Time Counseling Session Conducted by Pharmacist This model should guide the evaluation plan 1 Intermediate Outcomes Distal Outcomes Improved adherence Improved persistence Improve selfself-management 2 ? 3 Specific Health Status Indicators 27 28 Guiding Principles for Medication Use Research 1. 2. 3. 4. 5. 6. 7. 8. There are no perfect theories Behavioral science theories are probabilistic not deterministic When trying to influence a health behavior, the health behavior of interest must be defined precisely Many factors outside of patient control influence patient medication use No two people are the same. Individualized assessment is crucial crucial Patient motivation is a fundamental ingredient, especially when maintenance of long term behavior is the goal Health care providers can have a profound effect on patient medication use and this effect can operate through several possible causal pathways When planning an intervention to optimize patient medication use, use, it is important to develop a conceptual model that links intervention inputs to the outcomes that are desired. 29 Ecological Model for Optimal Medication SelfSelf-Management Level Intervention Goals Patient Build trust and rapport Identify individual needs and resources Provide patient education Establish goals collaboratively Enhance patient selfself-management skills Facilitate patient access to medication Provide followfollow-up and support Providers Enhance provider knowledge and skills Intervention Components Health Care System Enhance access to services Enhance reimbursement for services Social Policy, Governmental Regulations Enhance access to medications Improve quality of patient education materials 30 5 Thank You for Your Time and Attention 31 6
