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Although the elements of the Information–Motivation–Strategy Model© (IMS Model) were first introduced in the early 1980s, there was insufficient empirical research on which to build support; now, many large-scale empirical trials and meta-analytic reviews provide evidence for the framework of the model. The primary purpose of the IMS Model is to provide health care providers with a valid and practical rubric for remembering and using three broad elements of care that are essential for improving patient adherence. The three components of the IMS Model are Information, Motivation, and Strategy. They reflect the fact that patients can follow only treatments they have been informed about and which they understand; patients will adhere only to treatments they are motivated to adhere to; and patients only do what they are able to within their resource limitations and available strategies.
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The information component emphasizes the importance of the knowledge held by patients about their condition and its treatment, and suggests that this knowledge depends most upon effective provider–patient communication. Patients are unlikely to follow a treatment unless its importance is clear to them and they fully comprehend the care instructions. Unintentional nonadherence commonly stems from failure at this stage in the process of care. Research from hundreds of studies indicates that for many patients, their level of health literacy is low and their ability to understand the health information they receive is inadequate. Therefore, health care providers have a responsibility to communicate effectively with their patients and to inform them thoroughly, as well as to check on how well patients understand the information that they are given. A meta-analysis found that in more than a hundred empirical studies, good physician communication skills were associated with increased patient adherence. To encourage patient adherence, health care providers should focus considerable attention on communicating information effectively and on determining patients’ degree of understanding of the treatment regimen. When interacting with vulnerable patients, adequate communication is especially challenging because low health literacy, language barriers, and low levels of education can hinder patients’ full and accurate understanding of what they must do to care for themselves. Health professionals need to identify any specific barriers to communication and attempt to build patient trust in the therapeutic relationship, promote shared decision making, listen to patients, and allow patients to offer essential information on how they plan to follow through with their medical recommendations (see Chapter 18)(Figure 20-1).
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The motivation component of the model highlights the notion that patients will only follow treatments that they believe in and are motivated to pursue. Therefore, a major goal of health care providers should be to work with each patient to develop a treatment plan to which the patient can be fully committed. Health care providers should keep in mind that patients’ beliefs about the value of a treatment (such as about the risks, benefits, and efficacy of treatment) and their sense of confidence that barriers to adherence can be overcome are crucial to influencing their motivation to adhere. In addition, patients’ beliefs in the consequences of nonadherence are important; if nonadherence is perceived as likely to produce problematic health outcomes, patient adherence will be higher than if consequences are not believed or fully understood. Cultural factors, including social group norms, may also impact adherence; providers need to be aware of and sensitive to their patients’ cultural beliefs and practices so that treatment recommendations do not conflict with cultural norms. Furthermore, it is important to note that motivation to adhere may be especially compromised in disadvantaged patients who experience cultural barriers between them and their physicians. If patients and their physicians are not of a similar cultural background, for example, physicians should learn about their patient’s culture to find the best way to help motivate them to adhere; providers should be careful to avoid introducing cultural impediments to adherence (see Chapter 15). Lastly, patients often desire to participate in the process of caring for their health; thus, it is beneficial to promote shared decision making between physicians and patients within the context of a strong therapeutic relationship. Doing so would allow providers to openly discuss patients’ beliefs, concerns, confusions, and apprehensions about treatment regimens.
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Finally, the strategy component of the model underscores the fact that patients must be capable of adhering and have the resources necessary to follow the prescribed treatment. Patients need the tools and strategies necessary for effectively following their treatment, as well as the capacity to overcome any barriers to adherence that may arise. Thus, another important task for health care providers is to help patients identify and surpass obstacles to adherence. The concrete barriers patients face might include the financial cost of a medication, difficulties in remembering the medication schedule or in dealing with the treatment complexity, coping with unpleasant side effects, and the challenge of accommodating changes in lifestyle such as diet and exercise. Social support from family and friends is instrumental in helping patients adhere to treatments. In this context, social support is useful in terms of the assistance that individuals who are close to a patient can provide. A patient’s relative, for example, can help overcome barriers to adherence by providing transportation, helping with medication affordability, offering child care to attend medical appointments, and reminding the patient to take medications. Past research has found that family cohesiveness can positively influence patient adherence, and that family conflict can threaten it severely. Providers should know their patients well enough to evaluate whether and how the people who are close to a patient can assist in promoting adherence; providers should also help their patients identify other formal systems of aid, including workplace-based interventions and community-based resources. Obtaining aid is particularly valuable for patients of low socioeconomic status. Disadvantaged patients may need help from their health care providers in building a social support network (if, e.g., they are recent immigrants) and with acquiring financial resources for covering the cost of medical care expenses (such as the costs of medications and medical devices if no insurance coverage is available).
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Understanding how the three components of the IMS Model can be applied to promote patient adherence may be facilitated by the use of a case illustration.
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CASE ILLUSTRATION
Lucy is a 62-year-old married Hispanic female with hypertension, adult-onset diabetes mellitus, and obesity. She lives with her husband who is ill and has two loving and supportive adult children who live nearby. She has not been feeling well for the last couple of weeks and decided to see her physician, Dr. Ruiz, at the nearby publicly funded clinic. Lucy has seen Dr. Ruiz twice before and she likes her and feels that they are developing a good relationship. Dr. Ruiz sees Lucy as a friendly and generally optimistic person.
During their second medical visit, Dr. Ruiz determined that Lucy has not been adhering to the treatment regimen prescribed by her previous physician. Dr. Ruiz prescribed two medications to control her diabetes and hypertension, offered Lucy a detailed explanation of how to take the medications, and described any serious side effects that Lucy should report. Next, Dr. Ruiz discussed the behavioral changes that Lucy would need to engage in—to check her blood sugar levels daily (before and after each meal), improve her diet (e.g., consume less sugar and salt and more vegetables), and incorporate light exercise into her daily routine (e.g., 30-minute walks). As Dr. Ruiz explained these changes to Lucy, she realized that Lucy had trouble understanding how to take her medications and how to interpret her blood sugar levels. Lucy did not believe that she needed to take medications when she felt well. Furthermore, Lucy was concerned about how she would be able to cook healthier meals and go out for walks; her time and attention were consumed by concerns for her husband’s health.