Patients taking medications to manage their long-term conditions show different attitudes over time. We have demonstrated time and again that patient’s motivations to adhere to their treatment obey to their necessity beliefs and concerns regarding their medication and those beliefs drive their behaviours. The fact that these behavioural drivers exist means that behavioural changes following an intervention on a cohort leads to changes on the overall adherence. Obvious!… but is it predictable?
The Necessity beliefs and Concerns Framework (NCF™) has a two-dimensional spatial representation for mapping patient’s location into 4 quadrants each one representing one of 4-states [Sceptical (low Necessity beliefs, high Concerns), Ambivalent (high, high), Indifferent (low, low), Accepting (high, low)] based on their answers to the Beliefs about Medication Questionnaire (BMQ™). This is certainly not a static situation over time and it is at the core of SoS behavioural change methodology to create informed patients, so their choice guide their “movements” across the 4-states NCF™ map. Why? Because patients’ adherence to their treatment is strongly dependant on their psychological state… and there is obviously an ideal state [Accepting] where their necessity beliefs are high and have low concerns about their medication which leads to superior adherence levels, which improves their health. This does not mean that patients in the other 3 states are not adherent at all, but it is so much simpler to achieve the highest levels of adherence no matter the disease area when patients are in this Accepting state (for instance, 6 times more for patients with type 2 diabetes mellitus) that it worth all necessary efforts and costs from healthcare stakeholders.
Remember: no patient’s location in the 4-state NCF™ map is eternal, so the good thing is that we can design interventions to change patient’s behaviour to help them become more adherent, and the bad thing is that there are counteracting external forces that negatively impact on their motivations to “move”. Patients conscious and unconscious choices lead to “movement” across the 4-state NCF™ map. Understanding patients’ intrinsic and extrinsic motivations through the Perceptions and Practicalities Approach (PAPA™) is key to laying the pathway for change and proceeding with bespoke patients’ behavioural change programme is an integral part of any Patient Support Programme.
For those of you who think “the shortest distance between 2 points is the straight line” … Yep! This is not always evident, at least in the 4-state NCF™ map for those Sceptical patients who face a dilemma: can they both reverse their low Necessity beliefs and high Concerns at the same time? Possible but difficult. Transitions tend to occur sequentially so it is likely patients “move” from a Sceptical state to an intermediate state [Ambivalent, Indifferent] through behavioural change programmes rather than “jumping” directly towards the Accepting state.
And here is your food for thought: Which is the optimum pathway to acceptance, is it more difficult to first raise a patients’ low Necessity beliefs or lowering their high Concerns. And a related thought: Should you aim to first “move” those patients in an Indifferent state towards the Accepting state by heighten their Necessity beliefs or transforming Ambivalent patients into Accepting patients by lowering their Concerns. If these questions are bothering you, as you look to create optimally effective Patient Support Programme, then we look forward to hearing from you.
The Perceptions and Practicalities Approach (PAPA™) works by conceptualising nonadherence as a complex behaviour. A complex behaviour can have multiple causes, in the same patient, at any one time. Those causes can be intentional, when the patient actively chooses not to adhere as a response to their beliefs or perceptions. Or the causes can be unintentional, when the patient faces some practical barrier to optimum adherence.
We design our programmes according to our proprietary framework (PAPA™), which outlines the key features most likely to ensure the programme’s efficacy. These essential features address the perceptions underlying medicines behaviour, i.e. their motivation to adhere. These key features also address the practicalities facilitating or hindering optimal adherence, i.e. the patient’s ability to adhere.
We tailor the support needed to the needs of the individual. When patients feel that their perspective has been taken into account, they are more likely to engage with an adherence support programme, because they don’t feel preached to or, even worse, preached at.
Programme design is more precarious than it seems. If you address the wrong perceptions (how patients perceive the risks of their illness rather than of their treatment), you will generally fail, because perception alone cannot mediate adherence behaviour. If you assess perceptions without addressing them, you will generally fail as your efforts at meaningful communication with the patient will fall short of directly dismantling the barrier.
If you do not refine your strategy to target the salient barriers to be overcome, for example by using practical solutions to resolve perceptual barriers (or vice versa), you will generally fail because communication will ring hollow. For best effects, we use PAPA™ in tandem with our other approaches and frameworks to design an effective, constantly-evolving adherence support programme, co-created with patients, that makes the most of your medicine.
So when you want to transform adherence? PAPA™, don’t preach.