Medication adherence interventions have recently gained a valuable instrument in the new taxonomy of behavior change techniques ( BCTs ), a common theory- and evidence-based language that facilitates description of active ingredients of health behavior change interventions 1 .

1 ) The information-motivation-behavioral skills ( IMB ) model 2 , which suggests that adherence-related information about HIV and treatment , as well as personal and social motivation regarding adherence , affect the acquisition of adherence-related behavioral skills , which in turn affect the performance of adherence behaviors . In a previous project , the model was adapted to the target population and a questionnaire was developed for assessing adherence barriers specific to the target population ( LW-IMB-AAQ-Rom ) 3 .

3 ) The Intervention Mapping ( IM ) protocol 4 , used in developing health intervention programs . IM provides health promotion program planners with a 6-step systematic framework for effective decision-making throughout the intervention development process . The steps are : ( 1 ) assessing the context-specific needs and resources , ( 2 ) defining the objectives , ( 3 ) selecting the methods based on prior theory and evidence , ( 4 ) developing the program , ( 5 ) planning implementation , and ( 6 ) planning evaluation .

Fig 1 . The theory and practice of adherence to treatment ( manual for clinicians ) describes PIA- Romanian version .

The ways of coping with emotional challenges are identified using COPE 5 projective cards . Demonstration of the behaviour The patient watches a short clip that demonstrates an easy and efficient way to take the pills .

Table 1 . Extract from HIV General Adherence Plan .

Figure 2 . Selection of techniques from the BCTv1 taxonomy from the HIV Medication adherence intervention

Table 2 . Benefits and limitations of using pathology-specific toolboxes .

Ana-Maria Schweitzer 1 , Luiza Vlahopol 1 , Simona Stanciu 1 , Alexandra Dima 2 , Annemiek Linn 2

Baylor Black Sea Foundation at the Centrul Clinic de Excelenţă , Spitalul Clinic de Boli Infecţioase Constanţa , Baylor College of Medicine , Texas Children ’ s Hospital , Abbott Fund , Constanţa , Romania

Amsterdam School of Communication Research ASCoR , University of Amsterdam , the Netherlands .

Notes : 1 Michie , S ., Richardson , M ., Johnston , M ., Abraham , C ., Francis , J ., Hardeman , W ., Eccles , M . P ., Cane , J ., Wood , C . E .: The behavior change technique taxonomy ( v1 ) of 93 hierarchically clustered techniques : building an international consensus for the reporting of behavior change interventions . Ann Behav Med 2013 , 46:81-95 . 2 Amico , K . R ., Toro-Alfonso , J ., Fisher , J . D .: An empirical test of the information , motivation and behavioral skills model of antiretroviral therapy adherence . AIDS Care 2005 , 17:661-73 3 Dima , A . L ., Schweitzer , A . M ., Amico , K . R , Wanless , S . The information-motivation-behavioural skills model of ART adherence in Romanian young adults ( 2013 ) - Journal of HIV / AIDS & Social Services , 12 ( 3-4 ), 274-293 4 Bartholomew , K ., Parcel , G ., Kok , G ., & Gottlieb , N . ( 2001 ). Intervention Mapping : Developing theory and evidence-based health education programs . Mountain View , CA : Mayfield 5 COPE Cards stimulate creativity and communication . They ’ re a cross between a game and a book . ( http :// www . oh-cards-na . com )

Applying Behaviour Change Techniques in Adherence Interventions : Experiences from the “ Partnership in Adherence ” Pilot

Introduction

Medication adherence interventions have recently gained a valuable instrument in the new taxonomy of behavior change techniques ( BCTs ), a common theory- and evidence-based language that facilitates description of active ingredients of health behavior change interventions 1 .

However , it is still unclear how BCTs can be selected and translated into practical activities in specific settings , which could hamper implementation .

We developed an intervention toolkit that maps setting-specific HIV medication adherence determinants to BCTs and applications , and procedures for tailoring to individual patients . We aimed to test the feasibility of this toolkit and thus identify practical benefits and limitations of using the taxonomy .

Methods

Five psychologists developed content for an evidence-based medication adherence intervention for young HIV + adults in Constanta , Romania : Partnership in Adherence – PIA , that was included in a manual for clinicians ( see fig . 1 ). The process involved using prior research , clinical experience and three complementary frameworks :

1 ) The information-motivation-behavioral skills ( IMB ) model 2 , which suggests that adherence-related information about HIV and treatment , as well as personal and social motivation regarding adherence , affect the acquisition of adherence-related behavioral skills , which in turn affect the performance of adherence behaviors . In a previous project , the model was adapted to the target population and a questionnaire was developed for assessing adherence barriers specific to the target population ( LW-IMB-AAQ-Rom ) 3 .

2 ) The recently-developed BCTv1 taxonomy , which includes 93 BCTs clustered hierarchically in 16 groups . The advantages of using the taxonomy apply to designing the interventions , reporting its content and replicating effective interventions .

3 ) The Intervention Mapping ( IM ) protocol 4 , used in developing health intervention programs . IM provides health promotion program planners with a 6-step systematic framework for effective decision-making throughout the intervention development process . The steps are : ( 1 ) assessing the context-specific needs and resources , ( 2 ) defining the objectives , ( 3 ) selecting the methods based on prior theory and evidence , ( 4 ) developing the program , ( 5 ) planning implementation , and ( 6 ) planning evaluation .

Based on the above frameworks , the project team developed a General HIV Adherence Plan that includes adherence determinants , change objectives , behavior change techniques and practical applications . The practical applications were created using the clinical experience of the psychologists , shaped by their professional training , by the characteristics of the target group , and context-appropriate features .

Teoria și practica aderenței la tratament – manual pentru clinicieni –

Fig 1 . The theory and practice of adherence to treatment ( manual for clinicians ) describes PIA- Romanian version .

Change objective

The patients express confidence that they can take the pills in the long term .

The patients are able to describe their future plans .

Behaviour change techniques

Reduce negative emotions

Practical applications

A routine behaviour from daily life that has been performed successfully by the patient is identified and analyzed . An analogy is made between this behaviour and taking the pills regularly .

The ways of coping with emotional challenges are identified using COPE 5 projective cards . Demonstration of the behaviour The patient watches a short clip that demonstrates an easy and efficient way to take the pills .

Goal setting ( outcome ) The patient lists personal wishes / future objectives ( exercise : the tree of wishes ). Action planning

The therapist analyses with the patient how these future goals can be achieved , and specific actions and deadlines are established for those .

Table 1 . Extract from HIV General Adherence Plan .

PIA was subsequently piloted on the target group via individual counseling plans structured in 6 sessions . The pilot experience was used to reflect on the feasibility of applying the BCT taxonomy .

Behaviour Change

BCT Taxonomy : 93 techniques

Results

Conclusion

Predefining an intervention plan targeted for patients with a specific health condition ( HIV ) offered the implementers a framework with 29 BCTs , to further tailor individual interventions to patient characteristics and practitioners ’ experience . The framework was comprehensive enough to allow 6 individual PIA pilot interventions to apply 13 BCTs on average within 6 sessions .

PIA General Adherence Plan

Partnership in Adherence Pilot

Intervention Toolkit : 29 techniques

6 interventions : 13 techniques

Figure 2 . Selection of techniques from the BCTv1 taxonomy from the HIV Medication adherence intervention

Practitioners ’ everyday work can be supported through the development of pathology-specific toolboxes with predefined BCTs and applications , which facilitate adherence interventions in a busy clinic .

Benefits of Using the Toolkit

Comprehensive approach to a the array of possible barriers of adherence to HIV treatment

Allows quick selection and implementation of individual interventions

Tailors the intervention to patient-specific barriers and skills of practitioner

Prepares diverse ready-to-use materials that increase practitioner ’ s flexibility during individual interventions

Allows detailed recording of interventions content

Table 2 . Benefits and limitations of using pathology-specific toolboxes .

Limitations in Using the Toolkit

Requires extensive training of practitioners for implementation

Relies on limited evidence regarding the effectiveness of specific applications in similar contexts

Raises the challenge to motivate patients to follow the complete therapeutic program

Authors

Ana-Maria Schweitzer 1 , Luiza Vlahopol 1 , Simona Stanciu 1 , Alexandra Dima 2 , Annemiek Linn 2

Baylor Black Sea Foundation at the Centrul Clinic de Excelenţă , Spitalul Clinic de Boli Infecţioase Constanţa , Baylor College of Medicine , Texas Children ’ s Hospital , Abbott Fund , Constanţa , Romania

Amsterdam School of Communication Research ASCoR , University of Amsterdam , the Netherlands .

Notes : 1 Michie , S ., Richardson , M ., Johnston , M ., Abraham , C ., Francis , J ., Hardeman , W ., Eccles , M . P ., Cane , J ., Wood , C . E .: The behavior change technique taxonomy ( v1 ) of 93 hierarchically clustered techniques : building an international consensus for the reporting of behavior change interventions . Ann Behav Med 2013 , 46:81-95 . 2 Amico , K . R ., Toro-Alfonso , J ., Fisher , J . D .: An empirical test of the information , motivation and behavioral skills model of antiretroviral therapy adherence . AIDS Care 2005 , 17:661-73 3 Dima , A . L ., Schweitzer , A . M ., Amico , K . R , Wanless , S . The information-motivation-behavioural skills model of ART adherence in Romanian young adults ( 2013 ) - Journal of HIV / AIDS & Social Services , 12 ( 3-4 ), 274-293 4 Bartholomew , K ., Parcel , G ., Kok , G ., & Gottlieb , N . ( 2001 ). Intervention Mapping : Developing theory and evidence-based health education programs . Mountain View , CA : Mayfield 5 COPE Cards stimulate creativity and communication . They ’ re a cross between a game and a book . ( http :// www . oh-cards-na . com )