Compliance with treatment, defined as the degree to which the patient follows the prescriptions, represents a little-known aspect of the patient’s behavior towards their illness, even by health professionals. Recommended or prescribed treatments may not be followed for various reasons linked to side effects, the patient’s life context, the caregiver, or even the media or the healthcare system.
Acting on this non-compliance, the cause of therapeutic failures and relapses, nevertheless proves essential when we know that it can vary from 15 to 93% (Kaplan and Simon, 1990). The WHO has also targeted improving compliance with the treatment of chronic diseases as a research priority.
Do not bet everything on the “good intentions” of patients
With regard more specifically to rehabilitation, the directives of theAmerican College of Sports Medicine suggest that optimal protocols to improve strength, cardiorespiratory function, balance or even joint mobility are generally not sufficient and require home exercises. Many documented factors contribute to noncompliance with these self-directed exercise programs, and even when there is capacity and motivation, there is a gap between a patient’s good intentions and their accomplishments.
An article takes stock of the strategies that can be used to remedy this, based on behavioral economics, a theory promoted by Daniel Kahneman and Amos Tversky in the early 2000s. This trend highlights the factors influencing economic behavior individuals, rarely consistent with rational choice, and influenced by errors of judgment (cognitive biases), emotions, as well as social norms and interactions (moral biases, conformity bias).
Several axes emerge from the article published in the journal Journal of Physiotherapy to improve adherence to self-rehabilitation: personalize objectives, plan exercises, integrate them into daily habits, involve and encourage patients.
Focus on the advantages of doing the exercises rather than the disadvantages of doing them
First, helping your patient choose personalized and meaningful goals means making it count for them. According to a large meta-analysis, it may be more effective to focus on the benefits of doing the exercises (gain-focused) than the harms of not doing them (loss-focused).
The approach thus consists of helping the patient identify tangible ways in which compliance can improve their life. Making the patient active also means adopting a collaborative approach to designing the home exercise program by building it with them. Being too ambitious (for example on the number of exercises) can hinder success, however, especially among those who have previously struggled to follow the rules.
Integration into pleasant tasks is the key to getting out of the state in which
Secondly, it is about helping the patient plan their exercises and integrate them into their daily life. Establishing new habits is difficult; we all tend to return to usual routines or stay at the state in which. Planning incentives consist of getting patients to imagine themselves in a concrete situation. This strategy has been shown to be effective in increasing vaccination rates, screening participation, medication adherence, and appointment attendance.
Furthermore, we all have daily habits that operate largely outside of our conscious thought: making coffee, brushing our teeth, and driving to work. These behaviors are linked and guided by contextual factors: location, time of day, previous actions or a person. Rather than starting from scratch when you want to create a new reflex, linking or “stacking” it to existing habits can be easier and more effective (after washing, before eating). To reinforce this, reminders or visual cues can be placed.
Another aspect, although aware of the necessity of exercises, many patients find that performing exercises is restrictive and boring. “Incentive bundling” can help motivate patients by pairing an activity they need to do with an activity they enjoy. This can take the form of exercising while watching their favorite TV show, listening to an audiobook, or calling a friend.
Encourage change with a calendar or app
Third, it’s about maintaining the habit trend. Tracking progress can help people form habits by acting as a common thread, increasing visibility of progress and providing positive feedback. Even more than tracking progress, tracking exercise (involving people checking off the requested task daily) creates greater commitment to goals, as has been shown for diet and exercise. Depending on patient preference, this may take the form of a calendar or a smartphone app.
Not letting setbacks derail membership is also important. A one-time stop can be demotivating, with patients giving up easily if they skip or forget a day/week. It is therefore important to demystify the gaps and avoid an “all or nothing” approach. However, habits are best formed in a stable context, so if people are traveling or have a lot of unforeseen events, it may be possible to encourage them to start once their daily life is stable again.
Taking advantage of the “fresh start” effects can allow you to renew membership in the program
Fourth and finally, maintaining a trusting clinician-patient relationship is paramount to achieving long-term behavior change. Therefore, therapists should celebrate successes, avoid criticism of noncompliance, and embrace collaborative problem solving. One study found that people were more likely to initiate or restart goal-directed behavior (like exercising and going to the gym) at the start of new time markers.
Study participants were more likely to start going to the gym again at the start of the week (34%), month (15%), year (12%), semester (48%), following public holidays (25%) and birthdays (8%). In short, if a patient has lost his initial momentum, taking advantage of the effects of a fresh start can allow him to regain adherence to the program.
Let’s imagine the case of Michèle who suffers from a deficiency in shoulder range of motion.
In conclusion, behavioral economics provides simple strategies that can help improve compliance with self-rehabilitation and treatments in general, such as identifying goals, designing a joint program, planning and maintaining that program. . So, let’s imagine the case of a fictitious patient Michèle with a deficiency in shoulder range of motion. You work with Michèle to plan when, where and how she will perform her self-stretching exercises.
Together you target personalized functional objectives on autonomy in combing your hair and putting on the bra. To avoid forgetting, you suggest that he integrate exercise into his morning routine, for example after brushing his teeth. You suggest he put a post-it on his mirror to remind himself, until brushing his teeth becomes a sufficient signal.
To make the process more rewarding, she decides to sometimes call a friend while doing her exercises. Michèle checks off her sessions each day on a printed calendar that you have provided to her. She found the visual reminder of her progress motivating and doesn’t want to break her streak. However Michèle struggled to maintain her momentum over the Christmas period. You reassure her that short-term disruptions are acceptable and expected, but the start of the new year is the perfect time to resume.
