Adherence: What is it, and why does it matter?
It’s no secret that preventing or managing diabetes means regularly engaging in a lot of (often complex) lifestyle and medical behaviors, like losing weight, eating healthily, checking your blood glucose, taking medications, going to medical appointments, and so on.
At one point in your journey, you may have come across these exercise recommendations from the American Diabetes Association:
- People with diabetes should engage in regular aerobic exercise.
- For adults with type 2 diabetes, bouts of aerobic activity should ideally last at least 10 minutes, with the goal of around 30 minutes per day or more, most days of the week
- People with any type of diabetes should engage in daily exercise, with no more than 2 days off taking place between exercise days.
- Over time, activities should increase in intensity, frequency, and duration to at least 150 minutes per week of moderate-intensity exercise.
Even if you know these recommendations are good for you (perhaps your doctor has even said so), it can be tough to stick to the guidelines. In fact, sticking to recommended treatment plans is a problem not just for people with diabetes, but for people with all sorts of chronic health conditions. The World Health Organization reports that only half of people with chronic conditions in developed countries are “adherent” to their treatment plans — meaning that their behavior (lifestyle changes, diet, taking medications) follows the recommendations from their health care providers.
So why don’t people just do what their health care providers tell them? It would make everyone’s lives a lot easier. The short answer is that simply telling people what to do doesn’t translate very well into behavioral change. For meaningful, long-term behavior changes to take place, people not only need to know what to do, but also how to overcome barriers that may get in their way.
Motivation as a barrier to adherence
Every person managing a chronic condition is different, so every person may encounter a different barrier or set of barriers. Some people may not have the skills necessary to carry out their self-management plans. Others may not have all the required information or knowledge to do so. Others may struggle with beliefs or attitudes that get in the way. For others, motivation may be an issue.
Just because people are told by their doctors that they need to manage diabetes does not mean that they’re immediately motivated to do so. When it comes to exercise, 30 minutes per day can feel like a tall order, and many people may not start off with the intrinsic motivation to stick to this plan. Intrinsic motivation is the personal motivation that comes from within, versus extrinsic motivation, which comes from factors in the environment, like other people. Intrinsic factors, like wanting to feel better, help sustain longer-term change and are more influential than extrinsic factors in self-managing diabetes.
How do I know what my motivation level is when it comes to exercising?
There’s a handy framework called the Stages of Change Model that can help you work out where your motivation is at for making behavior changes, such as engaging in regular physical exercise. The model assumes that people change their behavior in a cyclical way, rather than in a quick and decisive way. The Stages of Change Model reckons that people progress through five stages of change — outlined below — but that people do not necessarily have to move through these in a linear way, jumping backwards and forwards between stages.
Which stage of change do you resonate with most in terms of exercise?
- Precontemplation: People in this stage do not intend to start healthy behavior within the next 6 months. They’re usually not aware that their current behavior may be causing issues for them. They may overestimate the disadvantages of changing their behavior and underestimate the advantages. They may feel ambivalent about changing their behavior. They have conflicting motivations; they both do and do not want to change.
- Contemplation: People in this stage are intending to start healthy behavior in the next 6 months. They’re aware that their behavior may be an issue, and are weighing the costs and benefits of changing their behavior. Like people in the Precontemplation stage, people in this stage may feel ambivalent about changing their behavior.
- Preparation: In this stage, people are ready to start healthy behavior in the next 30 days. They believe that changing their behavior can lead to a healthier life.
- Action: People in this stage have changed their behavior in the last 6 months, and intend to keep changing their behavior.
- Maintenance: In this stage, people have sustained their behavior change for more than 6 months, and intend to keep maintaining the changes.They are working to prevent relapse.
Growing intrinsic motivation for exercise through motivational interviewing
If you are in the Precontemplation or Contemplation stage when it comes to exercise, that’s more than okay — ambivalence is a totally normal part of the behavior change process. You may experience ambivalence as having a hard time motivating yourself to exercise consistently, or having a hard time getting started with exercising in the first place.
The good news is that you can help nudge yourself towards out of ambivalence and towards a higher stage of change by drawing on techniques from Motivational Interviewing (MI.) MI is an approach to health behavior change counseling that focuses on developing the ‘whys and hows’ of change, with the goal of increasing patients’ readiness for and commitment to a healthier lifestyle.
MI practitioners recognize that persuading, lecturing, and advice-giving can only go so far in terms of helping patients to manage chronic health problems. Instead of relying on these techniques, MI practitioners engage in high-quality listening, providing opportunities for patients to assess for themselves what changes might be possible, and how they might achieve these changes. Through effective listening, MI counselors develop “discrepancy” between a patients’ current behavior and their values, goals, and interests. This discrepancy is considered the key driver of behavior change. The goal in MI is to boost intrinsic motivation for change (“I will change because I want to”) by helping patients become aware of differences between their deeply held personal values and goals and their current behaviors.
How can techniques from MI boost my motivation for exercise?
A classic MI intervention you can use to explore and resolve your ambivalence is called the decisional balance tool. If you have been struggling to exercise consistently or to get started with exercising, try filling out this chart using exercise as your specific behavior change. You can get even more specific if your goal is to exercise a certain number of days per week, at certain times, and using a certain method (e.g. walking, biking, etc.) What are the pros and cons of maintaining the status quo in terms of your physical activity for you? What are the pros and cons of making a change to your level of physical activity?
Another tried-and-true MI technique to help increase intrinsic motivation is the importance and confidence ruler. Ask yourself how important it is for you right now to make a change in terms of your physical activity. On a scale of 0 to 10, what number would you give yourself? Let’s say you give yourself a 6. Instead of beating yourself up for not being at a higher number, ask yourself why you are at that number, and not a lower number. Then ask, “What would it take me to get from a 6 to a 7 or 8?” Then do the same thing for the confidence ruler. If you are lower on the importance ruler than you would like to be, you can turn back to your decisional balance tool to review and add to your cons for maintaining the status quo and pros for making a change.
MI asks patients to examine their current behaviors and evaluate how these correspond to their core values. A core value is a general life direction that is important to you. In terms of bolstering your intrinsic motivation for physical activity, it can be very helpful to identify what your core values are, and how they relate to exercise. There are many values inventories available online that can help you sort out what your core values are. After picking out your top five or ten, you can make connections between your values and exercise. For example, if you value being a good parent, exercise may be important to you so you can engage in physical activity with your kids. Another way to identify your values when it comes to physical activity is to ask yourself, “What sort of person do I want to be in terms of my health, physical wellness, and exercise, and why?”
When you have fleshed out your values and how they connect to exercise, it can be helpful to capture this connection as a “motivational statement.” Write down your statement on a card or a post-it note and place it in a location where you are likely to need a boost of exercise motivation (e.g. your nightstand, your exercise bike.) You can also record it on your phone and listen to it once per day or whenever you need a motivation reminder.
The Road Ahead
Keep in mind that ambivalence — being unsure about making a behavior change — is a completely normal part of managing a chronic condition. If you believe you are in the precontemplation or contemplation stage of change when it comes to physical activity, fear not. By working through some of the strategies from MI above, you can bump up your intrinsic motivation, which will help kick-start you on your exercise journey or help you exercise more consistently. Gently acknowledging where you are at, exploring the pros and cons of exercising, and connecting exercise to your cherished personal values can go a long way toward building and sustaining your motivation for physical fitness.