Page 923 - Cardiac Nursing

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C HAPTER 4 0 / Adherence to Cardiovascular Treatment Regimens 899
outcome in studies of patients with coronary heart disease in DISPLAY 40-1 Guidelines to Follow in Delivering
which several of the previously described strategies were incorpo- Educational Interventions
rated into the treatment plan. 147–149 More recently, nurses have
been managing patients with heart failure through clinics and • Keep instructions specific to the activity
• Assess the reading level of material; make sure it is un-
through follow-up care at home. 150–152
derstandable, accurate, and appropriate
• Review material for cultural relevance and acceptability
Patient-Centered Counseling • Be aware of religious restrictions related to diet
• Deliver informational material over time and provide in
Patient-centered counseling is an intervention developed by Ockene small amounts
et al. 153 and is based on provider training in the technique. The • Provide verbal instructions in small amounts
counseling approach includes advising the patient about nutrition • Avoid the use of jargon or technical terms
change, assessing strengths and barriers, reviewing the patient’s FFQ • Use printed materials to supplement and reinforce ver-
that was completed in the waiting room, developing a plan for bal instructions
change, and arranging follow-up. The intervention took 8 to 10 • Permit family members or other sources of support to
minutes of the clinic visit time, has been successful in helping pa- sit in or participate in session, arrange for extra space
when this occurs
tients make dietary behavioral changes, and has potential in pri- • Encourage questions of patient and ask patient
mary care settings. These investigators have applied this model of questions to determine level of understanding; permit
care to other health conditions such as alcohol addiction. sufficient time for the person to answer
• Focus on the regimen, not the disease
Model of Self-Management of • Utilize a variety of media formats (videotapes, interac-
Chronic Disease tive computer programs, visual illustrations, reliable
websites sources, e.g., American Heart Association)
An updated approach to management of chronic disease and im- • Provide demonstrations to augment verbal instructions
proved adherence has been presented by Bodenheimer et al. 154,155 • Provide for patient or relative giving return demonstra-
tions and practice opportunities, e.g., mixing
This has been referred to as a Chronic Care Model and more re- medications, taking nitroglycerin, completing diaries,
cently a Teamlet Model of Primary Care has been presented. The counting pulse, reading prescription or food label
latter approach involves the clinician with health coach assistants; • Utilize community resources, e.g., American Heart Asso-
the latter spend time with the patient prior to and following the ciation, local health department or hospital for health
clinical visit and also provide intervisit follow-up. The health classes, cardiac rehabilitation programs
coach engages the patient in collaborative goal setting and devel-
oping an action plan for whatever regimen needs to be addressed.
Enhancement of self-efficacy is also considered.
small. A recent systematic review of intervention studies to im-
prove medication adherence reported that adherence increased
Non Face-to-Face Approaches most consistently with behavioral interventions, particularly those
Keeping in mind the barriers to face-to-face intervention (work that reduced the dosing demands. 158 Past reports have indicated
schedules, travel, childcare, etc.), recent studies have examined the ef- that educational interventions alone do not yield positive re-
159
fectiveness of interventions without face-to-face contact, such as tele- sults. Supplementing educational interventions with improv-
phone and the use of the Internet. Pierce et al. 156 reported long-term ing tolerability of the regimen and motivational approaches were
159
adherence to a high-vegetable dietary pattern with the one-on-one effective and improved adherence by 41%. A multifactorial in-
intervention delivered over the telephone. A review of weight-loss tervention approach focusing on drug adherence, lifestyle modifi-
interventions delivered over the Internet found that those programs cation and conversations with the provider (patient education)
that emphasized dietary and physical activity changes, used cogni- was more successful in BP control than provider education and
160
tive-behavior strategies and provided personalized feedback and provider education and alert, suggesting a more interdiscipli-
support were most effective. 157 Advantages of Internet-based inter- nary approach with behavioral strategies increases the effectiveness
ventions are that they are available at any time, may provide tailored of the intervention. Additionally, feedback and specific instruc-
information and messages, and provide privacy and anonymity. tions using the MEMS resulted in a higher compliance adherence
However, literacy, language, culture, and limited skills may preclude to bupropion-SR for smoking cessation when compared to the
individuals from utilizing Internet-based interventions. control group indicating that interventions using feedback may
have a positive effect on medication-taking behavior. 161 A list of
guidelines for delivering educational interventions is presented in
EDUCATIONAL STRATEGIES TO Display 40-1. It is important to also incorporate into the inter-
IMPROVE ADHERENCE vention the behavioral strategies previously described.
Didactic, cognitive interventions may be used to transmit infor- QUESTIONNAIRES RELEVANT
mation about the disease process or the treatment regimen. Often
a behavior change requires educating the patient about the regi- TO ADHERENCE-ENHANCING
men, such as how to follow a low-fat diet or initiate an exercise INTERVENTIONS
program. The underlying aim may be to increase the person’s
knowledge in the expectation that behavior change will follow. Most interventions to improve adherence focus on one or more of
However, the association between knowledge and behavior is the constructs of social cognitive theory (i.e., self-regulation and