FACTORS AFFECTING CHANGE

There are three primary factors that affect change—motivation, knowledge/skills, and support—along with many potential barriers.

Motivation

Motivation is the willingness to do something or that which causes this willingness. Motivation is also described as enthusiasm for doing something (Cambridge Dictionary, 2019). Without motivation, health-related behaviors are unlikely to change. Therefore, it is important for healthcare professionals to help motivate their patients.

The following strategies have been found to be helpful when motivating patients:

  1. Implement shared decision-making. This enables patients to be active participants in the development of their plan of care and to make informed choices that are respected by the healthcare team. The healthcare professional should not assume ownership of the patient’s health. Patients must assume ownership of their own health status.
  2. Use motivational interviewing. Motivational interviewing is a conversation between patients and healthcare professionals to facilitate a patient’s motivation and commitment to change. Techniques such as using open-ended questions, affirmations, reflective listening, and summarization are important parts of the motivational interviewing. (See also “Motivational Interviewing in the Healthcare Setting” later in this course.)
  3. Use the “5 As” behavior change model, or assess, advise, agree (collaboratively), assist, and arrange follow-up care.
    (NIDDK, n.d.)
EXERTING AND DEPLETING WILLPOWER

Willpower is related to motivation. It is also referred to as determination, drive, resolve, self-discipline, and self-control. The American Psychological Association defines willpower as:

  • The ability to delay gratification, resisting short-term temptations in the interest of achieving long-term goals
  • The ability to override unwanted thoughts, feelings, or impulses
  • The implementation of conscious, effortful, regulation of the self

Willpower can be depleted. Research shows that frequently employing willpower to resist temptations (such as smoking or eating a high-calorie diet) takes a mental toll on patients and may affect brain function. Exertion of willpower may also lower glucose levels (APA, 2019a).

Research also indicates that willpower depletion can be kept in balance by personal beliefs, attitudes, and behaviors. For example, patients who felt forced to exert willpower were more easily depleted compared to patients who exerted willpower based on internal goals and desires.

Certain strategies have been shown to build up self-control. Patients can be encouraged to:

  • Focus on one goal at a time. Research shows that it is more effective to focus on one goal at a time rather than working on achieving multiple goals at once.
  • Avoid temptations. In other words, do one’s best to limit distractions.
  • Make a plan. Having a realistic plan helps to maintain equilibrium. Decide beforehand how to react to circumstances that can interfere with one’s goals.
  • Monitor behavior, with focus on the end goal. Develop an objective, realistic plan to meet goals and monitor one’s progress on goal achievement.
  • Reward oneself. When milestones are reached, reward oneself for achieving them.
  • Get adequate sleep and rest. Sleep deprivation affects energy, focus, and determination.
  • Seek support. Develop adequate support systems of trusted people who can provide support as one works on their goals.

(APA, 2019c)

Knowledge and Skills

Another major factor in helping patients commit to a plan with proven results is the acquisition of the right knowledge and problem-solving skills (APA, 2019b). The healthcare professional is often the source for such knowledge, offering appropriate resources, including formal training, to enhance skills needed to accomplish and maintain behavioral change. Patients’ knowledge and skills should be matched to the behaviors to be changed (AOTA, n.d.).

Likewise, healthcare professionals themselves must acquire knowledge of the complex and dynamic interactions among individual patients, their environments, and the activities that are part of their daily lives.

Support

A support system is defined as having a network of people that can provide practical and/or emotional support. Multiple studies have shown that social support is a significant influence on a person’s ability to make a successful behavior change. Individuals who receive support for change can strengthen willpower and stay on track toward meeting their goals (Hood, 2020).

With the proper support system, patients can learn how to make long-term changes in lifestyle and behavior. For example, if a patient is adopting a new diet because of a recently diagnosed health problem, loved ones can offer appropriate foods and avoid preparing meals that are blatantly contraindicated.

As change agents, healthcare professionals realize that even when their patients are well along on the path toward their objective, they must also provide support to help to prevent relapse. Though patients are confident they can continue their identified change, they are still vulnerable. For this reason, caregivers must arrange and encourage follow-up measures to help people maintain the changes they have worked so hard to achieve, such as ongoing visits, membership in support groups, participation in managed care that emphasizes wellness, and mentoring.

Barriers to Change

The American Medical Association (AMA, 2020) has published “8 Reasons Patients Don’t Take Their Medications.” These reasons can also be applied to most noncompliance issues:

  1. Fear. Patients may be afraid of potential side effects. Some patients may have experienced side effects with other treatments, witnessed side effects experienced by family or friends, or heard about potential side effects from other patients. Patients need objective, factual information about both risks and benefits.
  2. Cost. Cost of treatments (e.g., medications, equipment) is often a major barrier to compliance. It is important that healthcare providers consider the cost of treatments and search for alternatives as necessary.
  3. Misunderstanding. Patients may not know how to comply with treatment plans. How to use equipment, how to perform procedures, or when to take mediations may be confusing to patients and families. Therefore, patient/family education is critical. Patients should, for example, demonstrate how to use equipment or describe how to recognize medication side effects. Learning must be objectively measured.
  4. Too many medications/treatments. Multiple treatments and/or medications can make for a complex schedule. Patients’ schedules should be as streamlined as possible.
  5. Lack of symptoms. Patients may stop treatment (e.g., taking medications) when they start to feel better. They might assume that their problem is resolved and that there is no need to continue treatment. Or they might think that the treatment is not helping. Patients must be taught the importance of adhering to treatment.
  6. Mistrust. Patients may not trust the healthcare system. Media coverage of negative aspects of healthcare and negative personal experiences or experiences of family and friends can contribute to a sense of mistrust. Ongoing negativity can cause patients to be suspicious of their own healthcare providers in particular and the healthcare system in general.
  7. Worry. Patients may worry about the effectiveness of treatments, their costs, and fears of becoming dependent on medications. Healthcare providers must communicate objectively and patiently and evaluate patients’ understanding of their treatment regimens.
  8. Depression. Patients who are depressed are less likely to adhere to their treatment regimens. Patients must be screened for depression, assessed for the need for intervention, and evaluated to determine the success of any intervention initiated to treat the depression.
CASE

Factors Affecting Change

Mark is a 19-year-old college student and former elite-level athlete. He was injured in a car accident a few months ago and sustained a serious leg injury that resulted in amputation of his left lower leg. He is receiving both occupational and physical therapy services on an outpatient basis.

Mark is angry and showing signs of depression. He hates wearing his prosthesis but does not want to use crutches. He feels that he is different from all of his former teammates and that they regard him as someone to be pitied. He is finding it difficult to accept the fact that resuming his role on the college team will not be possible for him. Mark also distrusts members of the healthcare team, believing that they are all “too old” to remember what it was like to be young and healthy and, as he says, “disfigured.”

Mark is noncompliant with his prescribed at-home exercises and balance techniques. He falls frequently at home and in his college dormitory.

Discussion

Mark is coping with a great deal in life, not just his injury. At this developmental stage of late adolescence, he is contemplating adulthood. But like most adolescents, he doesn’t want to be “different” from his friends. He also sees himself as “disfigured” and no longer able to dream of a future in sports.

To help decrease the barriers interfering with Mark’s therapy, the clinician addresses the factors that may be affecting him:

  • Suggest that Mark visit his college’s office of disability services and inquire about support groups, where he will meet others who have experienced the loss of a limb and are close to him in age. Having the opportunity to talk to someone he can relate to can be very helpful. (Support)
  • Determine priorities from Mark’s point of view. He doesn’t want to be “different.” Implementing his exercise regimen can help to reduce falls and facilitate prosthesis use. (Motivation)
  • Find out what about his prosthesis is so difficult for Mark. Does it cause pain? Does he feel that it doesn’t fit properly? (Knowledge and skills)
  • Emphasize what adhering to treatment regimens can do to return Mark to a more “normal” life. (Motivation)
  • Refer Mark to occupational therapy in order to address concerns about how the loss of a limb may interfere with career goals. (Motivation; Support)
  • Recommend a mental health consultation. Mark is showing signs of depression, and mental health interventions are important to help Mark maintain/achieve mental health, which should facilitate compliance. (Support)