Improving competencies in behaviour change support in chronic disease: the case of medication adherence

An interprofessional European competency framework, linked with behaviour change techniques from an established taxonomy, can be used to optimise medication adherence in persons living with chronic disease.

Hospital pharmacists contribute to inpatient and outpatient medications and care through a unique expertise by, for example, medication reconciliation, management of drug-related problems and patient education. In this setting, pharmacists improve medication management at the hospital-to-home interface, supporting the patients routinely taking medication and their adherence, and contributing to better outcomes.¹

This paper presents an overview of a European competency framework for health and other professions to support behaviour change for the self-management of chronic disease,² and its application to medication adherence, a key behaviour in self-management.^{* *}

The article comprises three key sections. First, it sets the scene for the need and relevance of the competency framework as a tool to create standards of practice and guide training. Second, it describes the development of the competency framework to support behaviour change in persons living with chronic disease.² Then, it turns to the case of supporting medication adherence, by providing examples of the application of behaviour change techniques (BCTs) from an established taxonomy. Using BCTs in medication adherence consultations facilitates the provision of tailored interventions by hospital pharmacists, while fostering comprehensiveness and consistency. Moreover, it renders hospital pharmacists’ interventions more explicit.

Background

Chronic diseases are a global epidemic, responsible for 40.5 million deaths in 2016, corresponding to 71% of deaths worldwide.³ Changing and sustaining desirable lifestyle behaviours is key in preventing and managing chronic diseases. 

Self-management is defined as tasks performed by an individual to minimise the impact of one’s disease, with or without the support of health professionals.⁴ Tasks can holistically be categorised under medical management (for example, taking medication, adhering to a diet, engaging in physical activity), role management (for example, redefining life roles in light of a chronic disease) and emotional management (for example, dealing with anger and frustration), and are related to a set of skills.⁴ This definition captures the idea that self-management encompasses a variety of health behaviours in which individuals should engage.

Healthcare and other professionals are expected to support behaviour change for the self-management of chronic disease, including, for example, interventions to improve medication adherence or increase physical activity. However, effective interventions targeting a range of health behaviours are still not the norm routinely. Evidence shows that health professionals perceive a lack of confidence in their own skill set and ability to deliver behaviour change interventions, focusing seldom this aspect on consultations.^5,6 It appears that perceived knowledge and skills relating to the implementation of behaviour change interventions is a global workforce problem, which is imperative to address. 

A BCT is “an observable, replicable, and irreducible component of an intervention designed to alter or redirect causal processes that regulate behaviour”.⁷ BCTs include setting goals, self-monitoring of behaviour, social support etc. A seminal British guidance on individual-level health behaviour change interventions recommended detailing the BCTs by using standardised classification systems, so that interventions can be replicated and include techniques shown to be effective at changing behaviour.⁸ This guideline from the National Institute for Health and Care Excellence (NICE) has recommended that behaviour change practitioners recognise BCTs in the interventions they are delivering and have the relevant skills to deliver them.⁸ The BCT Taxonomy (version 1 – BCTTv.1) is the most well-known classification of BCTs. It has gained international acceptance as a valid tool for specifying the content of behaviour change interventions.^7,9 Notably, a recent scoping review found that BCTs remain underused in self-management interventions.¹⁰ One reason that might explain this shortcoming is the poor permeation of behavioural science and BCTs, in particular, into the education and training of health and other professionals.

Train4Health (www.train4health.eu) is a strategic partnership involving seven European institutions across five countries, which seeks to improve behaviour change support competencies for the self-management of chronic disease. The Train4Health consortium comprises higher education institutions (nursing, pharmacy and sports sciences), an IT partner and the European Students’ Union. Hallmarks of the Train4Health project (2019 -) include drawing on behavioural science and co-production of educational products with users. The project envisages a continuum in behaviour change support education, in which an interprofessional competency framework, relevant for those currently practising, guides the development of a learning outcomes-based curriculum and an educational package for future professionals (today’s undergraduate students). The educational package, comprising case studies, a massive open online course and a simulation software package, is aligned with the European Union policy on digital transformation in education and training.

Pursuing the Train4Health aim required an interprofessional competency framework agreed across disciplines and European countries, focused on self-management in chronic disease and linked to a set of BCTs from a standardised taxonomy.⁷

Overview of the Train4Health competency framework 

Previous work² had the primary aim of developing an interprofessional competency framework to support behaviour change in persons self-managing chronic disease (Figure 1). A secondary aim was to derive a set of standardised BCTs to link with framework competencies that directly support behaviour change (Figure 1).

The competency framework comprises 26 competency statements, classified into two categories: 12 foundational competencies (F) and 14 behaviour change competencies (BC).² These were consensualised through an e-Delphi panel, composed of 48 participants from 12 European countries and a variety of disciplines: pharmacy, nursing, sport sciences/physiotherapy, general practice, nutrition, psychology and public health.² 

General communication competencies and professionalism are encompassed in the foundational category (for example, F6: Ability to communicate effectively in partnership with people and families; F11: Ability to demonstrate professional behaviour, respectively). Competencies that directly support behaviour change in the self-management of chronic disease are represented in Figure 2. The central part of the figure depicts, from a behaviour change perspective, the traditional assessment – planning – intervention – monitoring cycle, familiar to health and other professionals. BC1, BC2, BC3 and BC4, depicted on the left side of Figure 2, indicate knowledge required to deliver behaviour change support in chronic disease. On the right side, BC6, BC7, BC9 and BC14 are communication and relationship abilities, essential across the assessment–planning–intervention–monitoring cycle.

In what pertains the secondary aim, a core set of 21 BCTs common to the five target behaviours in high priority chronic diseases (Table 1) was derived and associated to Train4Health competency statements.² The core set of 21 BCTs can be found elsewhere.² 

Applying BCTs in medication adherence consultations

Tailoring the intervention to medication adherence barriers increases the likelihood of success.¹⁸ For example, a pillbox or reminders will do little for a person deciding not to take a medication due to concerns about side effects; such barrier requires techniques increasing knowledge or understanding, such as information about health consequences (5.1), or inducing a feeling to stimulate action, such as pros and cons (9.2). These BCTs consist of, respectively, highlighting the positive and negative consequences of taking the medication and advising the person to compare reasons for wanting and not wanting to perform the behaviour.⁷ Examples of how to apply BCTs in relation to common adherence barriers are presented in Table 2 for forgetfulness and in Table 3 for beliefs about lack of necessity and concerns about medicines.

Increasing the likelihood of success of adherence interventions also requires tailoring BCTs and its application to the person’s unique combination of morbidities, functional status, activities of daily living, preferences, and resources. An important consideration is that it might be unnecessary and potentially inappropriate to deliver all BCTs listed in Table 2 to a person forgetting to take a medication (likewise for Table 3 for BCTs addressing beliefs about medication). The patient as a unique person should be considered when selecting a BCT addressing a medication barrier. For example, social support may not be suitable for a person living alone and having a restricted social network. Operationalising a selected BCT also requires considering the patient as a unique person; for instance, advising a person to set reminders in a mobile phone to take the medication (prompts/cues (7.1)) might not be appropriate for older persons unfamiliar with these devices. In such case, helpful alternatives may include using a post-it on the fridge door.

Another important consideration is about the combined use of BCTs. Table 4 presents examples of BCTs bundles to enhance medication adherence. If used in a bundle, different BCTs are usually applied in more than one occasion. This is exemplified by the BCT Feedback on the outcome(s) of the behaviour (2.7), which might be more effective if the person firstly monitors and records the outcome(s) of the behaviour (Self-monitoring of outcome(s) of behaviour (2.4)). 

Conclusions

The Train4Health competency framework is a resource for pharmacists and other professionals to set standards and guide training on behaviour change support in chronic disease, including medication adherence. A next step for using this resource is deciding on the best approach to assess competencies in practice, to ensure that professionals fulfil their role; being cognisant of their own competencies through self-assessment is also important for improvement. Training focused on standardised BCTs is emerging as a trend; the Train4Health educational products provide learning opportunities on this topic that professionals may find helpful, such as a massive open online course (MOOC) and a simulation software.

Authors

Isa Brito Félix MSc
Nursing Research, Innovation and Development Centre of Lisbon (CIDNUR), Nursing School of Lisbon, Lisbon, Portugal

Marta Moreira Marques PhD
Comprehensive Health Research Centre (CHRC), NOVA Medical School, Lisbon, Portugal

Afonso Miguel Cavaco PhD
Faculty of Pharmacy, University of Lisbon, Lisbon, Portugal

Mara Pereira Guerreiro PhD
Nursing Research, Innovation and Development Centre of Lisbon (CIDNUR), Nursing School of Lisbon, Lisbon, Portugal

Centro de Investigação Interdisciplinar Egas Moniz (CiiEM), Instituto Universitário Egas Moniz, Monte de Caparica, Portugal

**Footnote

The work reported in this paper was developed as part of the Train4Health project. The “Background” and “Overview of the Train4health Competency Framework” sections are based on a previously published article (https://doi.org/10.1186/s12909-021-02720-w), licensed under a Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/). The “Applying BCTs in medication adherence consultations” section is licensed under a Creative Commons Attribution Non Commercial-Share Alike 4.0 International (CC BY-NC-SA 4.0, https://creativecommons.org/licenses/by-nc-sa/4.0)

Acknowledgements

This project received funding from the Erasmus+ Programme of the European Union under the grant agreement no. 2019–1-PT01-KA203–061389. The Funder had no role in the design of the study and collection, analysis, and interpretation of data and in writing the manuscript. The European Commission’s support for the production of this publication does not constitute an endorsement of the contents, which reflect the views only of the authors, and the Commission cannot be held responsible for any use which may be made of the information contained therein. 

Professor Judith Strawbridge (Royal College of Surgeons in Ireland) and Dr Cathal Cadogan (Trinity College Dublin) are co-authors of the European competency framework for health and other professionals to support behaviour change in persons self-managing chronic disease.

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