Nieli Langer, PhD
Be kind, for everyone you meet is fighting a harder battle.
—Plato
Key Points
• Women with diabetes in pregnancy need person-centered customized medical and behavioral goals to enhance treatment compliance.
• Person-centered diabetes care may improve patient satisfaction.
• Culturally competent patient/physician communication may enhance adherence and clinical outcomes.
INTRODUCTION
The struggle to cope with diabetes in pregnancy is continuous since diabetes management requires constant vigilance. No single helping strategy meets all the varied needs and situations that confront persons with diabetes. Many of the problems and crises of diabetes management in pregnancy have emotional and psychosocial sources rather than medical ones. Pregnant diabetic women often feel anxious and even depressed when faced with trying to balance a diabetic regimen, the pregnancy state, and the need to maximize quality of life. Many studies have shown a correlation between glucose control and psychological factors such as mood disturbances.1-3 We1 found that the use of self-monitoring blood glucose (SMBG) with multiple determinations appears to positively affect the emotional state of the patient who maintains the established levels of glycemic control.
Pre-existing diabetes is a chronic disorder in which the woman is exposed to the seemingly random metabolic glucose fluctuations and is constantly faced with an ongoing struggle to control the illness without letting it control her life. We2 reported that chronically ill pregnant diabetic women display significantly greater anxiety and hostility in comparison to non-diabetic women. However, regardless of the level of glycemic control achieved or the severity of the disease, mood states were not affected in these diabetic subjects. Many chronically ill patients are often unable and/or unwilling to achieve established medical goals due to physical, social, cultural or psychological limitations; they have become resigned to their situation.
Near normal glycemic control is associated with decreased complications for both gestational diabetes mellitus (GDM) and pregestational women. The established levels of glycemic control in pregnancy may be achieved with a strict management approach using either insulin or glyburide therapy. The quality of glucose control often affects psychological adjustment while psychological adjustment affects glycemic control.4 Patients work hard to achieve the established levels of glycemic control only to experience a sudden loss of control with a hypoglycemic episode. Therefore, the care of the pregnant diabetic patient involves both medical and psychological care, that is, “whole-person care.” When providing this type of care, it is necessary for the physician to have an understanding of the “lens” through which patients view their lives and the disease that inhabits their lives. Physicians are able to provide enhanced whole-person care when they focus on patients’ capabilities, assets, and positive attributes rather than problems and pathologies. However, sometimes provider care focuses on the “d-words”.. .decline, disease, disability rather than on the “h-words”... hope, help, harmony. When physicians focus only on patient deficits, interventions often remediate, minimize, or compensate; when the attention centers on patient strengths and assets, interventions maximize and expand upon these strengths. We as health professionals must look past the superficial characteristics of our patients and aim high. To set low standards and low expectations is a disservice to everyone we counsel. In other words, assume that each of your clients is intelligent, motivated, and eager to apply exactly what you teach. Then, no one will be underserved.
While long thought of as a “soft science,” communication is increasingly understood to be at the root of many health cares’ failures. Care providers need to be reminded that patients are often afraid, confused, and always anxious. They want reassurance that the people providing care really understand what it is like to be a patient. Patients want better communication between themselves and care providers as well as enhanced communication between providers so they feel that someone is taking responsibility for their care.5 Miscommunication has resulted in patients often not understanding or retaining what doctors say, that is, patients don’t always read or understand information in a consent form; they often forget information they have been given as soon as they leave the office; and, what patients recall after leaving the physician’s office is often incorrect.6 Physicians need to recognize that some interactions will not go well, but that they can walk away with the feeling that they did the best they could to maintain their professionalism and compassion despite challenges coming from multiple directions. Once these stresses are acknowledged, health promotion can then focus on maximizing a person’s desire for independence by promoting self-reliance rather than dependency or learned helplessness.
Kobasa7 hypothesized that people with the greatest control over events in their lives will remain healthier than those who feel powerless. However, an understanding of inner strength as it encompasses well-being and self-nurturing practices is necessary for health professionals to facilitate and enhance the health and quality of life for patients. Strengths perspective communication between practitioner and patient involves working together to seek and implement the best solution (after considering several alternatives) for patient management of a diabetic protocol.
The strengths perspective model assumes that
• People are responsible for and capable of making their own decisions.
• People are often able to direct their lives more than they realize; they have some freedom to choose even if their options are restricted by environmental variables or inherent biological or personality predispositions.
• People are continually motivated to address their needs from basic physiology to abstract self-actualization.
• People are capable of learning new behaviors and unlearning existing behaviors; they strive for reinforcements that are meaningful and congruent with their personal values and belief systems.8 The author captured the rationale for the strengths perspective with the following challenge:
• At the very least, the strengths perspective obligates practitioners to understand that, however downtrodden or sick, individuals have survived (and in some cases thrived). They have taken steps, summoned up resources, and coped. We need to know what they have done, how they have done it, what they have learned from doing it, and what resources (inner and outer) were available in their struggle to surmount their troubles. People are always working on their situations, even if just deciding to be resigned to them; as helpers, we must tap into that work, elucidate it, and find and build on its possibilities.
This chapter offers care providers an approach to person- centered diabetes management as a way to improve patient satisfaction and clinical outcomes.
BACKGROUND
Patient nonadherence (noncompliance) with therapeutic regimens is recognized as a challenge to the successful delivery of health care. However, patients and care providers look at compliance through very different lenses. Medical paternalism (physician- directed practice) at one end of the care continuum and patient self-determination at the opposite end need to create a balance in the form of whole person care that will foster patient compliance. Doctors value compliance as a necessary component to treatment. The compliance model, synonymous with concordance or adher- ence,9 also promotes the idea that health professionals know best and that patients have an obligation to follow the direction of professionals since the benefits of compliance outweigh the impact (e.g., social, psychological, economic) on the patient’s life. For the physician, patients’ noncompliance is synonymous with disobedience. Noncompliant or nonadherent patient behaviors include:
• No-show to appointment
• Not having the prescription filled
• Not taking the correct dose or forgetting to take the requisite number of doses
• Not taking the medication in a timely manner
• Discontinuing the medication without medical consultation
Traditionally, medical training has focused on diagnosis and treatment of a disease with the notion that if these two factors are satisfactorily managed, the desired outcome will inevitably follow. When it does not, physicians often attribute failed outcome to patient noncompliance. Perhaps the first and most important step in creating the foundation for empowerment for patient diabetes management lies in an examination by the physician of his own expectations and an understanding of the role these expectations play in the physician-patient relationship. Unfilled expectations on the part of the physician can lead to labeling the patient as noncompliant and her behavior as inappropriate and unreasonable, when, in reality, the behavior demonstrated may be completely acceptable in the patient’s sociocultural location. Labeling a patient as uncooperative or noncompliant due to the physician’s unfulfilled expectations can destroy the trust and respect necessary for effective interaction. Physician expectation that the patient will accept the medical model is a central problem with the way they think about compliance because patients are often unwilling or unable to comply with physician instructions.10
Patients have a responsibility to participate in their own health care. A patient’s failure to do so might be considered contributory negligence in the event of a poor outcome. The reality, however, is that it is the physician who is expected to take the ultimate responsibility and who will be sued in the event of adverse perinatal outcome. A missed or canceled appointment could mean an irresponsible patient. It could, however, also be a sign that there is a breakdown in the communication between the physician and patient. No-show patients should never be ignored. Today, it is recommended that physicians document a no-show. It is also prudent to find out why the patient did not keep the appointment and to document her explanation.
Patients value convenience, money, cultural beliefs, habits, body image, and so on. They are at liberty to reject medical advice, and often do, even though they might not tell the physician. Patients use their judgment when presented with medical advice even though they may not have the professional expertise claimed by physicians. Failure to heed advice from other professionals, that is, lawyers or accountants may have serious consequences but these professionals see this independence as part of clients’ rights. They do not see it has client deficiency but rather as an indication, perhaps, that they may need to improve the services they offer.
As the literature on noncompliance indicates, the medical model that expects patient compliance (adherence) is not effective in diabetes care.9,11,12 Patients are not interested in diabetes; patients are interested in their diabetes. The changing cultural environment is increasing its insistence on a more cooperative relationship between doctor and patient, with the patient taking a more active and informed role than ever before.13 Empowerment recognizes that a patient needs to learn the skills, acquire the knowledge, and therefore, achieve the power, to enable her to play a leading role in her own diabetes management. To manage diabetes successfully, patients must be able to set goals and make decisions that are both effective and fit their values and lifestyles while addressing physiological and psychosocial factors. This paradigm recognizes that in the patient-provider relationship, the doctor and patient each bring his/her own expertise to the medical encounter and each respects the ideas of the other. In diabetes, this means the recognition that while health professionals are experts on diabetes care, patients are experts on their own lives. The role of a patient is to be a well- informed active partner in her care. The role of the professional is to help patients achieve goals and overcome barriers through education, appropriate care recommendations, and support.
Knowing about an illness is not the same as knowing about a person’s life, and since the disease affects the person’s life, patients need to be the primary decision makers. Patients are the best sources of information about the attitudes, beliefs, and lifestyle issues that affect their acceptance of medical treatments. Patients often feel overwhelmed by the huge amount of effort involved in staying well. They often have the experience of doing everything right and still failing. People with diabetes often view life in “black and white” terms, that is, perfection or failure. Therefore, they may sometimes avoid all diabetes issues, tests, and even visits to the doctor. These issues should not be confused with apathy; they are angry and conflicted about their disease. They know that they need to manage their diabetes, but they don’t want to. Listening for patients’ meanings and values then becomes the starting point for gaining patients’ adherence. Although the idea of empowerment seems to be an ideal in helping people with chronic diseases, with a noncompliant patient, care providers often do not know where to start. One physician in desperation asked his unmotivated, noncompliant, and uninterested diabetic patient, “Well, what would you like to do?” Working with the patient to reach agreement on a treatment plan that makes sense in the context of her life will facilitate her adherence to selfmanagement when she leaves the physician’s office and resumes her day-to-day life.12,14,15 Satisfaction, communication, and consultation style are all factors in the doctor-patient relationship. Research on adherence is converging on the doctor-patient interaction with patient satisfaction and communication style critical to patient outcomes. Empowerment, resulting in whole person care, makes good human, clinical, and economic sense.
VARIABLES RELEVANT TO PATIENT MANAGEMENT
There is paucity of consistent evidence to demonstrate that the factors of age, gender, or socioeconomic status are associated with adherence.16 Likewise, no personality type has been found to be consistently related to nonadherent behavior. However, research in the area of patient perception of social support has indicated a positive association to adherence to a medical regimen. When patients perceive sufficient levels of practical, emotional, and cognitive social support and when relationships within the patient’s circle of family and friends are stable, then adherence levels are high. Emotional and moral support from the family may help to reduce the patient’s anxiety about medical appointments; cognitive support from family may help the patient understand her medical condition. It may also enhance the rationale for maintaining the diabetic protocol and keeping medical appointments.17,18
The Health Belief Model is the patient’s belief in his/her own susceptibility to a disease or illness. It is the belief regarding the degree of severity of the illness and the consequences for health and daily functioning; belief in the efficacy of the treatment for the illness; belief about the barriers and costs related to treatment; and cues to action. Each of the components has been shown to influence the degree to which a patient will/will not adhere to a treatment regimen.19 The model has valuable retrospective value in measuring adherence to a regimen but disappointing prospective value.
The type of illness and levels of adherence have also been found to have a minor relationship. Treatment variables that significantly affect adherence include side effects, intrusiveness, complexity, and duration. The weight of evidence suggests that the presence of side effects may decrease adherence; anticipatory fear of side effects can also affect proper adherence to medical regimens.20 In addition, if the potential diabetic treatment intrusions are high, such as interruption of daily activities, and if emotional and financial costs are high as well, nonadherence will more likely occur.
Researchers have reported that patients either deliberately falsify or accidentally misreport adherence data. Mazze et al.21 first reported this problem in studies related to ambulatory SMBG in which a memory chip in meters substantiated patient self-reports. Researchers asked patients to record the results of blood glucose results in a logbook. The patients were not told that the glucose meters they were using had a memory capacity. The researchers compared the logbook values with the values stored in each meter’s memory. Findings indicated that >70% of the patients overreported glucose readings and that >30% of the entries were fabricated. The results indicated a pattern of fabrication and imprecision that significantly altered the actual clinical profile of the individual with diabetes. When investigators informed the women of the memory capabilities of the meters, recording accuracy dramatically improved.
In diabetes, pregnant patients are expected to follow a complex set of behavioral actions to care for their diabetes on a daily basis. The treatment for diabetes often involves a complex regimen that varies across patients and in different situations. Self-care in diabetes is fluid rather than static, and the regimen resembles more of a series of “if-then” statements rather than a standard medical prescription.22 Lifestyle behavior may include meal plans and physical activity; adherence to a medical regimen (insulin or oral hypoglycemic agent) when indicated; monitoring blood glucose; and seeking individually appropriate medical care for diabetes and other health-related problems. Regimens vary from patient to patient. In addition, patients with diabetes are often required to make very complex treatment decisions.
They may be required to vary their self-care behavior from situation to situation with often no standard behavioral model to follow. This all-encompassing protocol then needs to be integrated into a patient’s daily life.
CULTIVATING SKILLS THAT PROMOTE PATIENT SATISFACTION AND CLINICAL OUTCOMES
Strengths perspective communication fits well with patient empowerment. The strengths perspective focuses on capabilities, assets, and positive attributes rather than problems and pathologies. This generative model enhances patients’ resources for problem solving, coping, and healing. It appears to add an element of control, at least internally, which is very important to a sense of well-being. Listening and attending behaviors that communicate empathy, encouragement, support, respect, and nonjudgmental acceptance are the most effective in implementing an environment of empowerment and potential adherence.
Probably the most basic and powerful way to connect to another person is to listen. Perhaps the most important thing we ever give each other is our attention. We connect through listening. Active listening refers to nonverbal communication such as eye contact—look at patients when they speak. It involves verbal behavior such as responding to the patient by reflecting: using comments such as “I see what you mean” signaling that you are listening and encourages the patient to continue. It also involves avoiding sending discouraging messages by interrupting, changing the subject, or not acknowledging what the patient says. Patients are empowered because they feel worthwhile as human beings, feel accepted by the care provider, and are, therefore, comfortable to explore how to achieve adherence. Unhelpful communication behaviors may include interrupting the patient’s explanation, preaching, blaming, extensive probing, and questioning, especially with “why” questions and adapting a patronizing attitude. These behaviors are hindrances because they put patients on the defensive and make them feel so worthless that they will naturally choose avoidance rather than approach behaviors that facilitate adherence.23,24 Empowerment is not just an abstract philosophical concept. A practical attitude and environment is attainable when conditions of genuineness, respect, and empathy are generated and used to facilitate whole person care.
For most patients, physician competence and communication are equally important. Researchers have linked poor communication to misdiagnoses, the ordering of unnecessary tests, and the failure of patients to follow treatment plans. An article in the New York Times (June 2004) reported the results of a series of studies that good doctor-patient communication resulted in lower blood sugar levels in diabetic patients and lower blood pressure in hypertensive patients. The message conveyed that if patients believe they are in a good relationship with their doctors, there is a strong chance their health will benefit, too.
“Technology has become a religion within the medical community. As a result, it is easy to lose sight of the fact that still, in the 21st century, it is believed that 80-85% of the diagnosis is in the patient’s story.”25 Yet medical educators say that doctors are insufficiently trained to listen to those stories. After all, there is no reimbursement category on insurance forms for listening. Medical ethicist Arthur Frank describes the process of a patient seeking care from a doctor as one of “agreeing to tell her story in medical terms.. .”26
Actively listening to the patient’s experiences and using them as the starting point for gaining adherence may be the first step. When a patient’s concerns are validated, perceived problems become less of an issue. The lost art of listening has been the inspiration behind a growing movement in medical schools throughout the country to comprehend the health care needs of patients: storytelling or narrative medicine. Communicating by storytelling is fundamental to the human experience and is a powerful medium for communicating, learning, and problem solving, whatever the language or culture. The story as a linguistic form has specific characteristics such as: it requires both a narrator and a listener whose different viewpoints are brought to bear on how it is told; it focuses on characters—what they do, and what happens to them; and it includes an emotional dimension, that is, how the characters feel about what is happening. Stories presented in this context are often negative, full of problems, and difficulties.
“Restorying” is about developing patient stories in new directions. The new story makes action and change possible. People grow from strength, not from weakness. Positive regard and respect for the patient are essential for growth and adjustment. When the physician develops with the patient a list of strengths and assets gleaned from the dialogue, he will find that he can draw on these assets later for possible resolution of concerns and problems related to the management of the diabetes.
Aspiring doctors need to learn to pay attention to what their patients are saying and to understand the way their own emotions affect their perceptions and ultimately their clinical practice. How often does a patient try to tell a doctor what happened in a sickness and the doctor interrupts with, “What was the pain like, sharp or dull?” The interruption prevents the patient from unfolding the account and inhibits the physician from gleaning diagnostic accuracy from a full picture. Doctors have continually been admonished that they do not understand what their patients’ experience. Today, medical schools are attempting to insert the missing communication skills in medical school syllabi that may facilitate more humane patient-care provider interaction.25
There is a growing academic literature that gives theoretical basis for the narrative as a more sophisticated tool for recording and analyzing an illness than the conventional clinical interview. Research has shown how the narrative is suited to revealing worlds that are otherwise closed to professional practitioners— such as those burdened with a chronic disease. It is conceivable that the narrative will enable professionals and their agencies to convert stories into action that may help facilitate the provision of a new service. There is paucity of information in the literature on how best to use storytelling as a means for gaining a holistic understanding of patient predicaments and its impact on the individual and his/her community. However, there is reason to take note that although stories are simple human forms of expression and communication, they have the potential to be powerful tools for achieving understanding, building a shared perspective on a medical problem, and catalyzing change.27
Although many medical schools have introduced some form of communication training, so have the organizations that run the continuing medical education courses required for renewal of medical licensure. Even health maintenance organizations, recognizing that doctors who are good communicators improve the bottom line (their patients generally stick with the health insurance plan and do not doctor shop), have begun investing significant resources into training doctors to be better communicators. Allowing patients the time to talk can lead to shorter appointments. When patient complaints are ignored or their expressions interrupted, the focus of attention is again on the care provider and the patient feels ignored.
In September 2003, a study released by the World Medical Association28 described a fundamental shift in the patient- physician relationship away from an authoritarian paternalistic model and toward a partnership approach to care, that is, patient empowerment. The study reported that patients appeared to be more confident and empowered, while physician confidence in patient self-management remained more modest. The researchers conducted 2506 interviews with patients and 1201 interviews with primary care providers in 2002 in 6 countries—the United States, United Kingdom, Canada, Germany, South Africa, and Japan. Some of the findings included:
• All countries agreed that authoritarian paternalistic relationships between physicians and patients were on the decline; they were being replaced by mutual partnerships.
• Compared to 10 years ago, most patients believed that they asked more questions, made more choices and actively evaluated benefit-risk to a medical regimen.
• In general, issues such as compassion, trust, understanding, patience, and listening skills were more highly rated by patients than easy access to see the doctor.
In another study, Dibben and Lean29 presented empirical research from a study of trust and cooperation between chronically ill patients and their physicians. The paper detailed models of trust and cooperative behavior designed to aid interpretative analysis. The paper presented 16 examples from interactions observed between patients and their care providers. It reported that physicians appeared to make in-clinic opportunities for building resilient trust relations with patients based on common understanding and experience, engendering more rapid patient compliance. The researchers cited significant patient empowerment and improved health-care delivery because of the compliance achieved.
However, regardless of the institutional models that have been created to address communication between care provider and patients and the studies that have shown enhanced gains in patient empowerment, one of the biggest hindrances to change may be that most training programs focus on changing doctors’ behaviors, even though it takes two to create a relationship. Studies suggest that the more equal the relationship between doctors and patients, the more likely it will translate into health benefits. Physicians need to develop cultural sensitivity that will help them identify those aspects of clients’ behavior that are determined by their cultural backgrounds, that is, “inflated” respect for authority that discourages dialogue. Patient passivity may be a risk factor in the treatment of diabetes. Patients need the opportunity to practice asking questions and interpreting the answers. Physicians need to adapt treatment plans and services that meet culturally unique needs since cultural competence is the thoughtful application of cultural data to practice.
The challenge to health-care practitioners is to develop sensitivity that recognizes that knowledge, understanding, and acceptance of cultural and human diversity are prerequisites for effective work with minority patients. It is an ethical obligation for physicians to develop sensitivity to cultural differences if they hope to make interventions that are consistent with the values of their patients. The physician’s role is to assist patients in decision making that is congruent with the patients’ worldview, not to convince patients to live by the physician’s values. Unless the patient’s social and cultural context is taken into consideration, it is difficult for physicians to appreciate the nature of patients’ struggles with diabetes. Patients may be very slow to disclose information and have different expectations about the patient- physician interaction. Patients may come to you with varying beliefs related to social roles and identity. For example, in many cultures, a woman’s identity within her family and her self-esteem are in large measure dependent on her reputation as a good cook. Plumpness is also associated with healthiness and a large appetite is regarded as normal in many cultures. Different people will place different emphases on the importance of healthy eating and even upon the importance of good health itself. A woman’s culinary expertise may be at odds with the diabetic regimen recommended by her care provider for self-care as well as family care.
The awareness of the dynamics that result from cultural differences such as value preferences, perceptions of illness, health beliefs, and communication style will help practitioners adapt treatment plans that meet culturally unique needs. The integration of these factors into professional decision making may enhance patient adherence. Failure of patients to return for visits or adhere to a health-care regimen is a major barrier to the delivery of effective medical services. Disregard for patients’ cultural norms often results in increased patient dissatisfaction and nonadherence. The lack of awareness of cultural issues increases social distance, breaks down communication, and precipitates misconceptions between minority patients and their care providers.
Contemporary interaction between care provider and patient originated in Euro-American culture and is grounded on a core set of values. It is a myth that these approaches are value-neutral and are applicable to all human beings. For example, some of the values implicit in most traditional interactions include an emphasis on individualism, the separate existence of the self, individuation as the foundation for maturity, and decision making and responsibility as resting with the individual rather than the family. There is a danger of imposing these values of individual choice and autonomy as being the only “right” values and as having universal applicability. In some cultures, the key values are collectivist and consider what is good for the family. Regardless of the care provider’s orientation, it is crucial to listen to patients and determine how best to deliver the care they need that is appropriate for them in their cultural milieu. In interviews with compliant minority patients, they attribute their progress of adherence to a medical protocol to feelings of trust in their care provider, being understood by him/her, and the feelings engendered when they felt empowered to make informed choices on their own behalf.13 Providing a backdrop of acceptance and support by listening and acknowledging the patient’s social and cultural background often leads to negotiation and facilitation of interaction leading to adaptation of a regimen that is most likely to result in adherence.
An empathetic care provider who is also culturally competent will strive to understand patient needs and avoid forcing patients into a preconceived mold.
Health-care providers are helping patients kick bad habits and start new regimens by turning the tables on the traditional doctor-patient relationship. They are using a technique called motivational interviewing, which is developed and used in the 1980s in substance abuse and addiction counseling. It has since been adapted for chronic disease management, medication adherence, and weight-loss counseling by health systems including Aetna and Weight Watchers.30 Instead of telling patients what to do and scolding them when they are not compliant, care providers ask the individual what changes he/she is willing and able to make and then promotes the patient’s desire, confidence, and commitment to treatment compliance. Doctors who lecture or give scary warnings can cause patients to become defensive and disengage. When people are struggling, they don’t like to be told what to do or be blamed for noncompliance. Care providers are being trained to offer choices rather than prescriptions and avoid terms such as “should,” “must,” and “have to.” Many doctors will struggle with this approach to finding the right balance between supporting patient choice and autonomy and meeting their obligations to make informed recommendations. However, rather than push a person beyond what they think they can do, the approach aims to encourage patients to set their own minimum goals.
Ethics is an integral part of how we think about care and caring. The respect for patient autonomy acknowledges an individual’s right to hold opinions, make choices, and take actions based on their personal values and beliefs. Autonomy provides the foundation for informed consent in which a patient fully informed about her medical condition and the available alternatives for care freely chooses to accept or decline treatment. Two conditions are essential for autonomy: (1) independence from controlling influences and (2) the ability to make choices. Although patients largely wish to be informed about their medical circumstances, many very sick, and some minority patients do not want to make their own medical decisions or even want to participate in the decision-making process. The ideal of patient autonomy is that physicians should ask their patients if they wish to receive information and make decisions or if they prefer that their families handle such matters. This position places choice in the hands of the patient.
The central doctrine in the field of bioethics and health law is that of informed consent. It is also an integral part of the patient- care provider relationship. Providing clients with information they need to make informed choices tends to promote the active cooperation of patients in their adherence plan. Informed consent occurs when a patient is competent to act, receives a thorough (disclosure) explanation, understands the explanation, is informed of available alternatives, acts voluntarily, and consents to the intervention. By educating patients about their rights and responsibilities, care providers enhance patient empowerment and ultimately patient adherence.
Behavior mediates almost every aspect of health and health care. Whether we focus on risk behaviors of individuals or the appropriate use of the latest biomedical technology, attention to behavior leads to better outcomes. To date, however, what is known about behavior is rarely incorporated into the planning and delivery of medical care. Behavioral interventions and treatments have largely been overlooked as cost-effective ways to identify and change health-related behaviors. There is evidence-based behavior change interventions available to address the behavioral risk factors associated with diabetes, that is, obesity, poor diet, sedentary life-style, and so on. There are effective interventions that improve diet, increase participation in diabetes screening programs, reinforce behaviors that prevent added risks for injury to the diabetic patient, and promote self-management of diabetes. Behavioral interventions can help change physician behavior, reduce stress-related visits to providers, and decrease client turnover.
Ashraf, a researcher at Harvard University contends that by understanding the cognitive processes underlying our health choices and applying the tools of behavioral economics, it is possible to design products and programs that encourage good health decisions and long-term behavioral change.31 Finding innovative ways to overcome barriers to change requires a fundamental shift in how program designers and providers think about health care. It starts by prioritizing the end user, a novel approach in a sector where institution-level, top-down decision making is the norm. Dr. Ashraf suggests that providers and recipients can co-create health. The incentives, behavioral nudges, and other tools of psychology used by health program designers work because they make good health decisions easier and poor ones more difficult. The best programs create new habits, replacing an undesirable behavior with a beneficial one. Therefore, what the patient values and why she makes the decisions she does is so important to successful program design.
There are two things many of us have in common: We want to slim down, and we want to make money. So why not combine them? Commitment devices are contracts or other arrangements that formalize a patient’s/client’s pledge to achieve an objective. Researchers in a poverty action initiative32 designed a commitment stratagem to help smokers quit and tested it in a randomized, controlled trial in the Philippines. Smokers in the program were offered a savings account in which they made deposits that could not be withdrawn for six months; at that time, if they passed a urine test for nicotine they got their money back. If they failed, the money was donated to charity. The study demonstrated that smokers in the commitment group were more likely to have quit than those in the control group. Participants in the commitment group were also more likely to pass a surprise nicotine test six months later. Monetary incentives can have powerful effects even after they are discontinued.
Economists Gary Gharness and Uri Gneezy33 found that when you pay people to go to the gym, they are more likely to go but are also more likely to remain committed even after the payments end. By making each trip to the gym feel less costly, incentives can lead to the formation of new habits. Weight loss participants who received financial incentives were more likely to stick with a weight loss program and lost more weight than study participants who received no incentives, according to Mayo Clinic research that was presented in March, 2013 at the American College of Cardiology’s 62nd Annual Scientific Session. Previous studies have shown that financial incentives help people lose weight, but this study examined a larger group of participants (100) over a longer period (1 year). One hundred healthy adult Mayo employees or their dependents, ages 18 to 63 with a body mass index (BMI) of 30 to 39.9 kg/m2, were assigned to one of four weight loss groups: two with financial incentives and two without. An adult who has a BMI of 30 or higher is considered obese, according the Centers for Disease Control and Prevention. All participants were given a goal of losing 4 pounds per month up to a predetermined goal weight. Participants were weighed monthly for 1 year; previous financial incentive studies followed up patients for 12 and 36 weeks. Participants in the incentive groups who met their goals received $20 per month, whereas those who failed to meet their targets paid $20 each month into a bonus pool. Participants in both incentive groups who completed the study were eligible to win the pool by lottery. Study completion rates for the incentive groups were significant compared with the nonincentive groups: 62% versus 26%. In the incentive groups, participants’ mean weight loss was 9.08 pounds, compared with 2.34 pounds for the nonincentive groups.
In other financial incentives to lose weight, HealthyWage. com lets you legally wager and win money for losing 10% of your body weight, successfully taking your BMI from obese to healthy or competing in a team-based weight-loss challenge. Another financial incentive for weight loss involves declining a gym membership and opting instead to reserve and pay for gym classes in advance (i.e., SoulCycle or Barry’s Bootcamp). You’re less likely to skip out on your seat session when there’s a financial amount attached to it.
Understanding people’s motivations in the co-creation of health can yield payoffs for small investments. Bags of lentils costing just a dollar each were highly effective in inducing people to get vaccinated in India.34 It would be short-sighted to overlook simple, inexpensive, and powerful behavioral interventions that can help close the gaps in the health-care delivery system.
If market-driven health-care systems are to survive, they must meet the demands of consumers, improve physician-patient communication, and develop interventions that enable consumers to take greater control of their health. Time-tested and proven behavioral change services and interventions directly respond to these needs and allow health-care plans to play a central role in primary prevention to reduce health-care risks. However, a knowledge gap exists between what health behavior research can do to help the health-care system achieve its goals. At the consumer level, patients are often unaware of behavioral approaches and fail to demand them from their health-care plans. Health-care providers continue to view pharmaceutical, diagnostic, and/or surgical interventions as easier, quicker, and more effective than behavioral procedures, or they do not expect or trust patients to comply with behavioral recommendations. At the organizational level, health-care plans have resisted integrating them fully into their service regimen because they remain unconvinced of their effectiveness. The bulk of health-care research continues to be focused largely on traditional medical models and/or interventions rather than on behavioral or combined biomedical/behavioral approaches. Perhaps with more scientific evidence to substantiate the need for behavioral interventions and their effectiveness, health-care systems will have more incentive to incorporate them into their health-care plans. If behavioral interventions are to be accepted more fully, health-care providers, researchers, funders of research, and health-care policy makers must all begin to address these interventions more optimistically. Specifically, the role of behavioral interventions is neither clear nor vital within a traditional medical model in which the primary goal is to offer a “cure” for an existing disease. However, in a risk management model of health care in which the goal is to prevent disease and reduce risk factors for multiple diseases, such interventions become key factors. Making comprehensive evidence-based behavioral interventions for health promotion and management available to consumers and practitioners will enhance the potential for improved health outcomes, expand patients’ choices, and enhance quality of life.
SUMMARY
The changing cultural environment is increasing its insistence on a more cooperative relationship between doctor and patient with the patient taking an active and informed role. Because the disease and the person with the disease cannot be separated, it follows that psychological and medical care cannot be separated. Therefore, health-care providers and patients need to pool their expertise to pattern customized treatment plans that are suitable to the patient and his/her disease. The GDM patient faces a new diagnosis and a temporary illness mode (unless she develops type 2 diabetes) that will cease with the birth of her baby. However, the patient with pregestational diabetes is wrestling with a life-long illness in which failure to maximize glucose control may seriously compromise both her and her fetus. The physician who uses understandable language, provides constructive, culturally competent advice, and creates a humane environment enhances the likelihood of adherence. In this environment, noncompliance is viewed as a temporary rather than as a permanent lapse. Ultimately, patients control what they do with the recommendations they are given. Whether the patients follow recommendations depends not only on their understanding of what they are to do but also, and probably to a greater degree, on their judgment and feelings about the meaning those recommendations have for them and their lives. The area of doctor-patient communication that facilitates patient empowerment may offer adherence research both a practical and a theoretical framework. It may provide soundly based interventions designed to improve diabetes care, one of medicine’s most pervasive problems.
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