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Health Behavior Change and Treatment Adherence
Evidence-based Guidelines for Improving Healthcare
M. Robin DiMatteo, Ph.D.
"Health Behavior Change and Treatment Adherence" (Second Edition) is a comprehensive text that explores the strategies behind improving patient adherence to medical treatments and changing health behaviors. It offers a multidisciplinary perspective, drawing on research from psychology, sociology, medicine, and public health. This edition provides an updated view on how behavioral science can be applied to health care, including new interventions, models, methodologies, and technologies.
M. Robin DiMatteo, Ph.D.
Dr. M. Robin DiMatteo is a leading expert in healthcare delivery, specializing in enhancing communication, patient adherence, and treatment engagement. She works with medical systems, health plans, and providers to improve healthcare outcomes and reduce medical costs.
Her most recent book, with her colleagues Dr. Leslie R. Martin and Dr. Kelly Haskard-Zolnierek, examines a broad array of issues that impact healthcare, including health knowledge and beliefs, the pressures of social influence, and the role of the treatment process in the delivery cf care. This book is for students and teachers of healthcare at every level of training in medicine, nursing, psychology, and allied health fields.
About Our Book
Learn about our book
A Textbook for Health Science and Psychology Classes
This book is for a broad array of disciplines
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Oxford University Press
You can request a sample copy to consider our book for use in your classes; : you can fill out the form directly on the OUP website.
This book is for a broad array of disciplines
A Textbook for Health Science and Psychology Classes
This book is for a broad array of disciplines
Our book is for a broad audience of healthcare professionals, in practice and training, in fields such as nursing, medicine, allied health, chiropractic, physical therapy, dentistry, clinical/health psychology, social work, healthcare administration, and public health. With thousands of research references, this book is also for researc
Our book is for a broad audience of healthcare professionals, in practice and training, in fields such as nursing, medicine, allied health, chiropractic, physical therapy, dentistry, clinical/health psychology, social work, healthcare administration, and public health. With thousands of research references, this book is also for researchers, and graduate and advanced undergraduate students in the social and behavioral sciences. It is a valuable resource for health education and coaching and in healthcare systems and health policy.
A Textbook for Health Science and Psychology Classes
A Textbook for Health Science and Psychology Classes
A Textbook for Health Science and Psychology Classes
Each chapter contains Tools for Instruction and Self-study. including: Learning Objectives (based in Bloom’s Taxonomy), Review Questions, Prompts for Discussion and Further Study, and additional Suggested Reading. We have made this material accessible to students and their instructors in a broad range of disciplines, and we are ready to
Each chapter contains Tools for Instruction and Self-study. including: Learning Objectives (based in Bloom’s Taxonomy), Review Questions, Prompts for Discussion and Further Study, and additional Suggested Reading. We have made this material accessible to students and their instructors in a broad range of disciplines, and we are ready to assist instructors in their class preparations and students in their mastery of the material.
Research and Writing: M. Robin Dimatteo
The work of M. Robin DiMatteo, often involving co-authors, spans several decades and is largely centered on the psychological, social, and behavioral determinants of patient adherence (or compliance) to medical recommendations, frequently utilizing rigorous meta-analytic techniquesto synthesize decades of research.
DiMatteo's research fo
The work of M. Robin DiMatteo, often involving co-authors, spans several decades and is largely centered on the psychological, social, and behavioral determinants of patient adherence (or compliance) to medical recommendations, frequently utilizing rigorous meta-analytic techniquesto synthesize decades of research.
DiMatteo's research focuses on quantifying the relationship between various patient and provider factors and adherence outcomes across diverse disease populations, including cancer prevention and treatment, chronic diseases such as heart disease, diabetes, and hypertension, and HIV infection.
A cornerstone of DiMatteo's work is the development and quantitative synthesis of measurement tools related to adherence:
• Meta-Analysis Expertise: DiMatteo and colleagues emphasize the use of meta-analysis for integrating statistical research findings from many individual studies, providing stable estimates of effects, and generalizing findings to related populations. She has contributed to the methodology of meta-analysis, discussing recent developments in quantitative methods for literature reviews.
• Adherence Rates: A quantitative review of 569 studies published between 1948 and 1998 found that the average nonadherence rate is 24.8% (or an average adherence rate of 75.2%). Adherence was found to be significantly higher in more recent and smaller studies, and among those involving medication regimens and adult samples.
• Scale Development: She was a lead author in the description and initial validation of the 38-item self-report Adherence Determinants Questionnaire (ADQ), designed to assess seven elements influencing adherence to cancer control regimens. The ADQ examines factors such as perceptions of interpersonal care, beliefs about disease threat (susceptibility/severity), perceived utility of adhering, subjective social norms, intentions to adhere, and perceived supports/absence of barriers.
• General Adherence Measures: Her work has utilized and validated the General Adherence Scale for generic measures of adherence, which summarizes a patient's overall tendencies to adhere to medical recommendations. She also contributed to the Medical Outcomes Study (MOS) which assessed antecedents of adherence in patients with chronic medical diseases.
DiMatteo's work systematically investigates key predictors and determinants of adherence including the cognitive, motivational, social, and behavioral variables influencing whether patients follow medical recommendations.
A primary area of her research is the link between physician-patient communication and patient outcomes.
• Communica
DiMatteo's work systematically investigates key predictors and determinants of adherence including the cognitive, motivational, social, and behavioral variables influencing whether patients follow medical recommendations.
A primary area of her research is the link between physician-patient communication and patient outcomes.
• Communication Effects: A meta-analysis of 106 correlational studies and 21 experimental interventions found that physician communication is significantly positively correlated with patient adherence. Patients whose physician communicates poorly have a 19% higher risk of non-adherence compared to those whose physician communicates well.
• Communication Training: Training physicians in communication skills results in substantial and significant improvements in patient adherence, increasing the odds of patient adherence by 1.62 timescompared to patients of untrained physicians.
• Nonverbal Communication: DiMatteo co-authored research emphasizing that effective interpersonal communication relies on both verbal and nonverbal cues. Nonverbal behaviors (such as those signaling empathy and rapport) contribute to positive patient outcomes such as satisfaction, adherence, and psychological well-being.
• Vulnerable Populations: Her research highlights that socio-culturally vulnerable patients are less likely to express emotions or disagree with physicians, and consequently, physicians may be less likely to recognize their health literacy issues or aspiration for relational communication.
DiMatteo's meta-analyses have quantified the impact of mental health issues on adherence:
• Depression: Depression is a significant risk factor for noncompliance with medical treatment. The odds are three times greater that depressed patients will be noncompliant compared with nondepressed patients.
• Disease Severity and Beliefs: Adherence is significantly correlated with patients' beliefs in the severity of their disease (or disease threat). Interestingly, better adherence is associated with objectively poorer health only for diseases lower in seriousness; among conditions deemed higher in seriousness, worse adherence is associated with objectively poorer health, suggesting that the most severely ill patients with serious diseases may be at greatest risk for nonadherence.
Social support, encompassing both structural (e.g., marital status) and functional (e.g., practical, emotional) dimensions, has been shown in DiMatteo’s research to be a strong predictor of adherence:
• Practical Support: A meta-analysis of 122 studies found a significant average effect size linking adherence to various forms of social support. Practical support bears the highest correlation with adherence, showing a 27% higher adherence rate when patients had practical social support.
• Family Functioning: Adherence is 1.74 times higher in patients from cohesive families and 1.53 times lower in patients from families in conflict.
DiMatteo has also studied the unique challenges of adherence in pediatric and adolescent populations, noting that successful adherence is often lower in this age group than in adults and younger children.
The Information-Motivation-Strategy (IMS) Model is a clinically useful, three-factor heuristic model developed to guide practitioners in their efforts to improve patient adherence to medical recommendations. The model organizes clinically relevant findings from the extensive adherence literature, particularly those supported by meta-an
The Information-Motivation-Strategy (IMS) Model is a clinically useful, three-factor heuristic model developed to guide practitioners in their efforts to improve patient adherence to medical recommendations. The model organizes clinically relevant findings from the extensive adherence literature, particularly those supported by meta-analyses and large-scale empirical studies. It is designed to reflect the realities of medical practice and offer simple, evidence-based recommendations for assessing and enhancing patient adherence, especially in the context of managing chronic diseases. Elements of the IMS Model were first introduced in the early 1980s by M. Robin DiMatteo and D.D. DiNicola; it is grounded in classical health behavior models like the Health Belief Model (HBM) and the Theory of Planned Behaviour (TPB). The model was expanded and its clinical applications examined in work with Leslie R. Martin and Kelly B. Haskard-Zolnierek. It involves three broad categories of achievement that are essential for promoting adherence, offering a range of goals, actions, and accomplishments that can be tailored individually to a given patient:
Research and Writing: M. Robin Dimatteo
The Information-Motivation-Strategy (IMS) Model and its clinical applications:
1. Information: This component focuses on ensuring that patients have the necessary knowledge and clear understanding of what they are expected to do.
• Problem: Patients may not understand their treatment recommendations, leading to unintentional nonadheren
The Information-Motivation-Strategy (IMS) Model and its clinical applications:
1. Information: This component focuses on ensuring that patients have the necessary knowledge and clear understanding of what they are expected to do.
• Problem: Patients may not understand their treatment recommendations, leading to unintentional nonadherence.
• Clinician Actions: Providers must communicate information effectively and thoroughly. This includes listening to patients' concerns, encouraging their participation and partnership in decision-making, building trust and empathy, and enhancing recall.
• Supportive Evidence:Effective physician communication is positively correlated with patient adherence; patients whose physicians communicate poorly have a 19% greater risk of non-adherence. Patients are more likely to adhere when they clearly understand and remember what they are asked to do. Clear instructions, reviewing medication information, and special packaging have been shown to improve medication adherence considerably, particularly among older adults with cognitive decline.
2. Motivation
This component addresses the cognitive, social, and attitudinal factors that influence a patient's commitment to the treatment plan.
• Problem: Patients are not motivated or do not believe in the necessity or efficacy of the treatment recommendations.
• Clinician Actions: Providers should help patients believe in the efficacy of the treatment. This requires eliciting and discussing any negative attitudes toward the treatment, determining the role of the patient's social system in supporting or contradicting the regimen, and helping the patient build commitment and self-efficacy (belief that they are capable of doing it). This stage is best viewed as a cyclical, ongoing stage that should be revisited frequently.
• Supportive Evidence:Adherence depends heavily upon a strong therapeutic relationship and shared decision-making ("informed collaborative choice"). Greater physician-patient collaboration is significantly associated with better adherence. Patients are motivated by beliefs about the severity of the disease (or disease threat), the utility (benefits/risks) of the treatment, and their confidence in overcoming practical barriers.
3. Strategy
This component involves assisting patients in overcoming practical barriers and developing a workable, long-term plan for disease management.
• Problem: Patients lack the tools, capacity, or strategy to effectively carry out the recommended course of action, often due to practical barriers like cost, regimen complexity, or lack of support.
• Clinician Actions: Help the patient overcome practical barriers. This involves identifying individuals who can provide concrete assistance (practical social support), finding resources for financial aid or discounts, providing written instructions/reminders, linking patients to support groups, and utilizing electronic reminders. Clinicians should also assess and treat underlying mental health issues like depression and anxiety, which are major barriers.
• Supportive Evidence:Practical social support is crucial; its absence is a significant barrier to adherence. Complex treatment regimens are a consistent barrier, so regimens should be kept as simple as possible (e.g., once-daily dosing improves adherence for hypertensives). Furthermore, depression is a risk factor, as the odds of nonadherence are three times greater for depressed patients compared to non-depressed medical patients. Measuring current adherence is also essential for tracking future behavior and identifying barriers.
In essence, the IMS Model simplifies the complex challenge of adherence by organizing essential clinical tasks into three key areas: ensuring the patient knows what to do (Information), ensuring the patient wants to do it (Motivation), and ensuring the patient can do it (Strategy).
Selected Speaking Engagements:
Advocate South Suburban Hospital, Chicago, IL
Advocare Laurel Pediatrics, Sewell, NJ
Albany Medical College, Dept of Urology, Albany, NY
Allina Health Systems, New Ulm, MN
Amgen Canada Inc. Rheumatoid Arthritis Program, Toronto, Canada
American Psychological Association, Annual Conference, San Diego, CA
Annadel
Selected Speaking Engagements:
Advocate South Suburban Hospital, Chicago, IL
Advocare Laurel Pediatrics, Sewell, NJ
Albany Medical College, Dept of Urology, Albany, NY
Allina Health Systems, New Ulm, MN
Amgen Canada Inc. Rheumatoid Arthritis Program, Toronto, Canada
American Psychological Association, Annual Conference, San Diego, CA
Annadel Medical Group, Santa Rosa, CA
Austin Business Group on Health, Austin, TX
Banner/Aetna Integrated Delivery, Phoenix, AZ
Baptist Health System, Birmingham, AL
Benefits in Action (http://www.benefitsinaction.org), Denver, CO
Blue Cross Blue Shield, Birmingham, AL
Broward Health, Ft. Lauderdale, FLA
California Association of Physician Groups, Annual Conference, Palm Desert, CA
California Collaborative Adherence Project, Pfizer/RAND Corporation, Santa Monica, CA
California Society of Health-System Pharmacists, Golden Gate Chapter, San Francisco, CA
Capital District Physicians’ Health Plan, Albany, NY
Central Ohio Primary Care, Columbus, OH
Central Utah Clinic, St. George, UT
CHI Health, Omaha, NE
Chinese Hospital Physician Medical Staff, San Francisco, CA
Choice Medical Group-Physicians and Medical Plan Directors, Apple Valley, CA
Christiana Care Health System, Newark, DE
Columbus Clinic, Columbus, GA
ConnectiCare, Farmington, CT
Cooper Medical School of Rowan University, Residency Programs in Internal Medicine and Hospital Medicine, Camden, NJ
Dallas Business Group on Health, Dallas, TX
Dallas-Fort Worth Business Group on Health, Dallas, TX
Desert Oasis Medical Center, Palm Springs, CA
Desert Oasis Medical Group, Rancho Mirage, CA
Department of Surgery Grand Rounds, County Regional MC, Riverside, CA
Diabetes and Obesity Global Therapeutic Expert Forum, Merck, Philadelphia, PA
Digestive Health Specialists, Tacoma, WA
Dwight D. Eisenhower Army Medical Center, Fort Gordon, Augusta, GA
Eisenhower Medical Center, Rancho Mirage, CA
Employers' Health Alliance of Arizona, Tucson, AZ
Employers’ Health Coalition Conference, Fort Smith, AR
Employers’ Health Coalition, Little Rock, AK
European Association for Communication in Healthcare, Verona, Italy
Evercare Health Plans, Phoenix, AZ
Facey Medical Group, Mission Hills, CA
Grand Rounds, Department of Internal Medicine, The Cleveland Clinic, Cleveland, OH
Greater Alabama Business Council, Montgomery, AL
Greater Detroit Area Health Council (GDAHC), Ann Arbor and Detroit, MI
Harbin Clinic, Rome, GA
Harvard Vanguard Associates, Atrius Health, Boston, MA
Health Care Partners, Torrance, CA
Health Choice Health Plan, Phoenix, AZ
Henry Ford Hospital and Health System, Detroit, MI
Highmark Blue Cross Blue Shield, Medical Directors, Pittsburgh, PA
Intermountain Health Care, Salt Lake City, UT
Kaiser Hospital, Riverside, CA
Kentuckiana Health Collaborative Third Annual Conference, Louisville, KY
Kirtland Airforce Base, Albuquerque, NM
Loma Linda University School of Medicine, Loma Linda, CA
Mansfield Ohio Physicians’ Association, Mansfield, OH
Martin Army Community Hospital, Fort Benning, Columbus, GA
Mayo Clinic, Department of Medicine Grand Rounds, Rochester, MN
Medical Grand Rounds, Saint Vincent Hospital and Health System, Erie, PA
Merck and Co. US Medication Adherence Advisory Board, San Francisco, CA
Merck, U.S. Human Health Headquarters, Grand Rounds: North Wales, PA
Metro Urology, Minneapolis, MN
Millennium Physician Group, Port Charlotte, FLA
Montefiore Med Ctr, Albert Einstein College of Medicine, Rheumatology Grand Rounds, Bronx, NY
Morongo Indian Health Clinics, Banning, CA
Mount Auburn Physicians’ IPA, Cambridge, MA
Nebraska Regional Cystic Fibrosis Center, University of Nebraska Medical Center, Omaha
Nevada Employers’ Health Coalition, Reno, NV
Northwestern University; Advocate Health Care; Chicago, IL
Ohio Association of Health Plans Conference, Columbus, OH
Orange County Oncology Nurse Society, Anaheim, CA
Orchard Pharmaceutical Specialty Pharmacy Services, North Canton, OH
Parkview Hospital, Riverside, CA
Presbyterian Healthcare Services, Albuquerque, NM
Primary Care Patient Centered Medical Homes, Honolulu and Pearl City, HI
PriMed, Trumbull, CT
Prospect Medical Group, Orange, CA
Providence Little Company of Mary Medical Center, Torrance, CA
Resurrection Health, Chicago, IL
Rex Hospital-University of North Carolina Health Care, Raleigh, NC
Rhode Island Primary Care Physicians Corporation, Providence, RI
Robert Wood Johnson Barnabas Health, Somerset, NJ
Rochester General Hospital, Residency Program in Internal Medicine, Rochester, NY
Rutgers Robert Wood Johnson Medical School, Dept of Endocrinology, New Brunswick, NJ
Sanford Hospital and Health Plan, Sanford Medical School, U. South Dakota, Sioux Falls
Sharp Grossmont Hospital, Oncology; Grossmont Center for Cancer, La Mesa, CA
Sharp HealthCare, Del Mar and San Diego, CA
Sharp Rees-Stealy Medical Center- Sharp HealthCare, San Diego, CA
St Jude Health Center, Brea, CA
St Luke’s Medical Center, New Hartford, NY
Sutter Gould Medical Foundation, Modesto, CA
Sutter Health, Sacramento, CA
Sutter Health/California Pacific Medical Center Department of Oncology, San Francisco, CA
Sutter Medical Foundation, Sacramento, CA
Transplant Center, University of Nebraska Medical Center, Omaha, NE
UCSF Department of Gastroenterology Grand Rounds, San Francisco, CA
United States Southern Command, Doral, FLA
University of Minnesota Fairview Medical Center, Minneapolis, MN
University of Texas, Family Medicine Residency Program, Southwestern Medical Center, Dallas, TX
University of Utah School of Medicine, Salt Lake City, UT
University of Washington Medicine, Pharmacy Services, Seattle, WA
Wisconsin Academy of Physician Assistants, Annual Meeting, Madison, WI
Wyoming Business Coalition on Health: Wyoming Health and Wellness Employer Conference, Casper, WY
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M. Robin DiMatteo, Ph.D.
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