How to make people want to do things they have to do

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This report identifies several approaches, case studies, previous literatures describing the factors how people, especially patients, are committed in their routines. In this paper, we apply a typology of consumer loyalty program to treatment or medication program.Then, we discuss potential factors for facilitating the higher level of adherence by employing self-determined motivation and factors affecting medication adherence.

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How to make people want to do things they have to do

  1. 1. How to Make Patients Want to Do Medication They Have to Do Anna Jo(blessedanna.j@gmail.com) Jiyoung Ryu(jyryu1@gmail.com)Summary As solvers of this challenge, we identify that the seeker for this challenge isinterested in several approaches, case studies, previous literatures describing the factors howpeople, especially patients, are committed in their routines. The aim of this challenge is tosummarize the current knowledge in the field of overcoming the poor adherence problem inorder to make people “want” to do things they “have” to do. Our approaches begin with howto overcome poor adherence according to targeted people. Secondly, we apply a typology ofconsumer loyalty program to treatment or medication program. Based on the information, weadditionally investigate prior studies which describe several cases of medication adherenceand the medication program. Then, we discuss potential factors for facilitating the higherlevel of adherence by employing self-determined motivation and factors affecting medicationadherence. We introduce five sets of factors: social/economic factors, provider-patient/healthcare system factors, condition-related factors, therapy-related factors/ patient-relatedfactors. Finally, we discuss strategies to overcome each barrier based on potential factors andconclude how to achieve in order to achieve higher level of medication adherence.
  2. 2. Table of contentsSummaryThe Main Issue I. A Detailed Description of an Approach, Program, Case Study 1. Several Approaches according to targeted people 2. Loyalty Program Implemented by Consumer-Oriented Companies 3. Case Study: Treatment or Medication Adherence II. A Discussion of Potential Factors for Facilitating the Higher Level of Adherence 1. Self-determined motivation 2. Factors affecting medication adherence III. A Discussion of How the Input from This Particular Case Could be Implemented for Achieving Higher Level of Sticking to Medication 1. Methods of measuring adherence 2. Achieving higher level of medication adherenceConclusionReference
  3. 3. The Main IssueI. A Detailed Description of an Approach, Program, Case Study1. Several approaches according to targeted people(1) Who don’t consider their personal health a prioritya. One of the factors is lack of understanding the gravity of their illness or the benefit that themedication will provide.=>Warning for the amount of damages and physical loss in the case of a unexpected relapseof the condition of a diseaseb. Education concerning the phase and symptom of disease when patients passed theirtherapy (Table 2. Case study 1, 2, 3)c. Offering interview with a terminal patients(2) Who are not sure they even want to deal with their conditiona. Motivating patients by presenting and sharing success stories of other similar patients(Table 2. Case study 4)b. Providing statistical information or experimental results describing the gravity of theirillness.=> Research says that lack of understanding about seriousness of the disease would result inlack of motivation.(Steven Baroletti, PharmD, MBA, etc. Medication Adherence in Cardiovascular Disease,Circulation. 2010; 121: 1455-1458)(3) Who are not always convinced in the value of medicationa. Informing patients about medication benefit will help patients to convince about theirmedication value.=> In this case, communication plays critical roles for success of convincing patients.Doctors may adopt following communication skills for discussing evidence with patientssuch as using non-technical language or drawing diagrams with comfortable environments.(Table 2. Case study 1, 2, 3)
  4. 4. (Reference: Ronald M. Epstein, MD, etc. , Communicating Evidence for ParticipatoryDecision Making, JAMA. 2004;291(19):2359-2366. doi: 10.1001/jama.291.19.2359)b. Giving an opportunity to take part in clinical demonstration such as animal tests(4) Who have lower levels of confidence in themselves and their doctorsa. Encouraging patients by keeping in touch with them and their family using SNS servicesb. Providing governmental periodical verification and rating service in homepage of NationalHealthcare Service regarding hospitals and doctors before patients see a doctor=> An in-depth interview studies show that patient-doctor relationship, Outside influence,Professional expertise are three major areas that should be considered for patients’ beliefs andpreferences regarding how doctors decide to recommend a medication. Following factorsmay affect the trust of patients toward medication recommended by doctors and fulfillingthese factors will guard or enhance patient-doctor relationship. n Patient-doctor relationship: Trust, Familiarity with patient, Shared decision Making(Addressing equipoise -no clear scientific evidence for 1 treatment choice over another), Communication honesty n Outside influence: Distrust toward pharmaceutical detailing(Doctor receiving gifts from detailers), Cost(Drug equivalency, HMO Regulations, Transparency) n Professional expertise: Medication knowledge (Effectiveness, Side effects), Knowledge that the doctor is stayed familiar with current medication information through lifelong learning strategies such as journal reading and conferring with colleagues.2. Loyalty Program implemented by consumer-oriented companies l Types of consumer loyalty programs and application of treatments or medication adherence based on the loyalty programs There are four broad categories of loyalty programs which are ways for retailers toencourage repeat purchasing of customers (Berman 2006). In Table 1, type I program is anelementary connector for customer relationship, in that occasional customers receive samediscount deals as a firm’s best customers. According to Berman(2006), however, type Iprogram familiar with supermarket program do not guarantee sustainable customer loyalbehavior. In a type II program, consumers get quantity discount based on their total purchaseand easily self-manage their purchase. The reward getting a free good such as a free hair cut
  5. 5. is motivating another purchasing. Type III programs are membership programs which offerreward points based on the past purchase records of consumers. Major providers of type IIIprograms are airlines, hotels, credit card companies. Because the type III programs facilitate amembers accumulating points and increase the variety of reward options, they effectivelypromote consumer loyalty. In type IV programs, individual members receive specializedpromotions and rewards based on their purchase history beyond discounts. Therefore, thetype IV programs lead consumer commitment to a firm and enable to provide the mostrelevant deals. Characteristics of Application of Program Type Loyalty Program Treatment or medication adherence based on the loyalty programsType I: Members receive -Membership open to all -Periodicals which issueadditional discount at customers Treatment discount couponregister -Each member receives the same discount regardless of purchase history -There is no targeted communications directed at membersType II: Members receive 1 -Membership open to all -When patients begin theirfree when they purchase n customers medication, hospitals orunits -Firm does not maintain a clinics induce them to pay customer database linking for the entire cost of their purchases to specific medication including 1 free customers medication.-Type III: Members receive -Seeks to get members to -Treatments or medicationsrebates or points based on spend enough to receive in one hospital or clinicscumulative purchases qualifying discount include reward programs so that patients can accumulate points which are available on
  6. 6. their health check-upType IV: Members receive -Members are divided into -Patients receive specializedtargeted offers and segments based on their healthcare information basedmailings purchase history on their past diagnosis and -Requires a comprehensive diseases. customer database of customer demographics and purchase historyTable 1. A Typology of Loyalty Program (resorting to the table in Berman(2006)) As with customer relationship marketing, healthcare service providers needs toconsider how to attract people maintain high level of treatment adherence once they start it.In table 1, we summarized plans to promote treatment or medication adherence for patientsbased on each type of consumer loyalty program. Even though consumer loyalty programssuggest successful adherence schemes, treatments or medication require clsoser individualcare such as disease management.3. Case Study: Treatment or medication adherence Representative cases for treatment or medication adherence have been individualizedcommunication and intervention by telephone or in-person. As described in consumer loyaltyprograms, a few cases employ financial incentive programs to enhance efficiency of diseasemanagement. Case1 Title JAMA, October 13, 2004—Vol 292, No. 14 Influence of Patient Literacy on the Effectiveness of a Primary Care–Based Diabetes Disease Management Program Methodology 1) Individualized communication, one-to-one educational sessions including counseling and medication management, helps manage glucose and cardiovascular risks by allowing pharmacists to both initiate and titrate blood pressure and glucose lowering medications, including telephone reminders and, when needed,
  7. 7. addressing difficulties with transportation, communication, and insurance. 2) Intervention by telephone or in person every 2 to 4 weeks (more frequently if indicated). Communication to patients was individualized using techniques that enhance comprehension among patients with low literacy, including predominantly verbal education with concrete, simplified explanations of critical behaviors and goals; “teach-back” to assess patient comprehension; and picture-based materials. Main topics, revisited throughout the follow-up period, included treatment goals, identification of hypoglycemic and hyperglycemic symptoms, prevention of long-term complications, and self-care. Results - Among patients with low literacy, intervention patients were more likely than control patients to achieve goal. Patients with higher literacy had similar odds of achieving goal HbA1c levels regardless of intervention status. Improvements in systolic blood pressure were similar by literacy status.Case2 Title AIDS Care. 2003 Feb;15(1):125-35. A pilot study of the effects of a behavioural intervention on treatment adherence in HIV-infected patients Methodology 1) Individualized education about antiretroviral medication and their side effects; positive reinforcement and encouragement; individualized counseling weekly; follow-up calls; and lifestyle assessment and the identification of adherence barriers Results - Enhanced adherence rates from a mean percentage of 80.27 at baseline to a mean of 97.5% at the end of follow- up (six months time point)Case3 Title BMJ 325 : 925 doi: 10.1136/bmj.325.7370.925 (Published 26
  8. 8. October 2002) Interventions used in disease management programs for patients with chronic illness which ones work? Meta-analysis of published reports Methodology 1) More than one intervention. 2) Provider education, feedback, and reminder 3) Patient education, reminders, and financial incentives Results - Studied interventions were associated with improvements in provider adherence to practice guidelines and disease controlTable 2. Analysis of disease management in representative studies In addition, several medical programs have carried out efficiently perceivedmedication regimen under healthcare service provider education, feedback, and reminder. Wesummarize three cases including interventions used in disease management programs. Case1 Title JAMA, October 13, 2004—Vol 292, No. 14 Influence of Patient Literacy on the Effectiveness of a Primary Care–Based Diabetes Disease Management Program Methodology 3) Individualized communication, one-to-one educational sessions including counseling and medication management, helps manage glucose and cardiovascular risks by allowing pharmacists to both initiate and titrate blood pressure and glucose lowering medications, including telephone reminders and, when needed, addressing difficulties with transportation, communication, and insurance. 4) Intervention by telephone or in person every 2 to 4 weeks (more frequently if indicated). Communication to patients was individualized using techniques that enhance comprehension among patients with low literacy, including predominantly verbal education with concrete,
  9. 9. simplified explanations of critical behaviors and goals; “teach-back” to assess patient comprehension; and picture-based materials. Main topics, revisited throughout the follow-up period, included treatment goals, identification of hypoglycemic and hyperglycemic symptoms, prevention of long-term complications, and self-care. Results - Among patients with low literacy, intervention patients were more likely than control patients to achieve goal. Patients with higher literacy had similar odds of achieving goal HbA1c levels regardless of intervention status. Improvements in systolic blood pressure were similar by literacy status.Case2 Title AIDS Care. 2003 Feb;15(1):125-35. A pilot study of the effects of a behavioural intervention on treatment adherence in HIV-infected patients Methodology 2) Individualized education about antiretroviral medication and their side effects; positive reinforcement and encouragement; individualized counseling weekly; follow-up calls; and lifestyle assessment and the identification of adherence barriers Results - Enhanced adherence rates from a mean percentage of 80.27 at baseline to a mean of 97.5% at the end of follow- up (six months time point)Case3 Title BMJ 325 : 925 doi: 10.1136/bmj.325.7370.925 (Published 26 October 2002) Interventions used in disease management programs for patients with chronic illness which ones work? Meta-analysis of published reports Methodology 4) More than one intervention. 5) Provider education, feedback, and reminder 6) Patient education, reminders, and financial incentives
  10. 10. Results - Studied interventions were associated with improvements in provider adherence to practice guidelines and disease control Case4 Title Womens Health (Larchmt). 2004 Jun;13(5):616-24. Using success stories to share knowledge and lessons learned in health promotion Methodology 1) Community Change Chronicles were formed as a model to develop success stories about WISEWOMAN(the Well- Integrated Screening and Evaluation for Women Across the Nation) projects. Results - Use of the success stories by healthcare providers and organizations gaining support for successful activitiesTable 3. Representative Medical Programs to Improve Treatment or MedicationAdherence (Cutler et al. 2010) We briefly explain how various medical programs promote adherence. In CCNC,educated professionals practice coordination of care, and achieved a 5 to 7 % increase inadherence rates. GHS implements electronic survey system to collect patients medicationpreferences. In GHS, monitoring patients medication achieved a 5 to 7% reduction inmonthly costs. In the case of GHC, case managers educate patients and help them find moreaffordable medication. As a result, GHC reduces more that $476 per patient.
  11. 11. II. A Discussion of Potential Factors for Facilitating the Higher Level ofAdherence1. Self-determined motivation determined We expect that potential factors for higher adherence in treatment or medication arehighly connected with personal motivation. Some wildly-held theories of motivation are heldunderlying the facilitating the higher level of adherence In this proposal, we mainly describe adherence.self determination theory which is tested and produce positive outcomes. There are mainlytwo reasons to take some actions: firstly, people expect to get reward such as praise, money,and achievement of goals; secondly, they want to experience positive feelings that attribute to positivelove, happiness and fulfillment. In order to explain these reasons, we adopt self lment. self-determinationtheory. Figure 1. The Self-Determination Continuum Showing Types of Motivation with Their DeterminationRegulatory Styles (Ryan and Deci 2000)
  12. 12. Self-determination theory (Ryan and Deci 2000) proposed that intrinsic motivationinvolves voluntarily taking part in an activity without external pressure. Engaging in manybehaviors attribute not to intrinsically rewarding but to helping individuals reach their self-determined motivation. Both intrinsic motivation such as a tendency to find rewarding or funand identified motivation such as acting in accordance with ones values are associated withpositive psychological outcomes including enjoyment, attitudes, values, self-perceptions, andintentions for future involvement. From these perspectives, we enlarge individual motivationto individual disease management.2. Factors affecting medication adherence According to the World Health Organization, adherence is determined by theinterplay of five sets of factors: social/economic factors, provider-patient/healthcare systemfactors, condition-related factors, therapy-related factors/ patient-related factors. In order toinvestigate the classified factors, 2006 American Society on Aging and American Society ofConsultant pharmacists Foundation summarized a myriad of published studies. 1. SOCIAL AND ECONOMIC DIMENSION 4. THERAPY-RELATED DIMENSION Limited English language proficiency Low health literacy Complexity of medication regimen Lack of family or social support network (number of daily doses; number of Unstable living conditions; homelessness concurrent medications) Burdensome schedule Treatment requires mastery of certain Limited access to health care facilities techniques (injections, inhalers) Lack of health care insurance Duration of therapy Inability or difficulty accessing pharmacy Frequent changes in medication Medication cost regimen Cultural and lay beliefs about illness and treatment Lack of immediate benefit of therapy Elder abuse Medications with social stigma attached to use 2. HEALTH CARE SYSTEM DIMENSION Actual or perceived unpleasant side Provider-patient relationship effects Provider communication skills (contributing to lack of Treatment interferes with lifestyle or patient knowledge or understanding of the treatment requires significant behavioral changes
  13. 13. regimen) 5. PATIENT-RELATED Disparity between the health beliefs of the health care DIMENSION provider and those of the patient Physical Factors Lack of positive reinforcement from the health care Visual impairment provider Hearing impairment Weak capacity of the system to educate patients and Cognitive impairment provide follow-up Impaired mobility or dexterity Lack of knowledge on adherence and of effective Swallowing problems interventions for improving it Psychological/Behavioral Factors Patient information materials written at too high Knowledge about disease literacy level Perceived risk/susceptibility to disease Restricted formularies; changing medications covered Understanding reason medication is on formularies needed High drug costs, copayments, or both Expectations or attitudes toward Poor access or missed appointments treatment Long wait times Perceived benefit of treatment Lack of continuity of care Confidence in ability to follow 3. CONDITION-RELATED DIMENSION treatment regimen Motivation Chronic conditions Fear of possible adverse effects Lack of symptoms Fear of dependence Severity of symptoms Feeling stigmatized by the disease Depression Frustration with health care providers Psychotic disorders Psychosocial stress, anxiety, anger Mental retardation/developmental disability Alcohol or substance abuseFigure 2. Factors Reported to Affect Adherence (2006 American Society on Aging andAmerican Society of Consultant Pharmacists Foundation) These 5 categories enlighten how healthcare providers and government agenciesdesign their overcoming strategies to facilitate higher level of adherence. We discuss thespecific barriers and strategies at the next part.
  14. 14. III. A Discussion of How the Input from This Particular Case Could beImplemented for Achieving Higher Level of Sticking to Medication In order to make people “want” to do things they “have” to do, appropriate interventionand education for patients are key strategies. Major predicts of poor adherence to medicationare presence of psychological problems, patient’s lack of belief in benefit of treatment, poorprovider-patient relationship, complexity of treatment, etc. In Chapter II, we categorized fivekinds of factors affecting medication adherence. In this chapter, we firstly introduce methodsof measuring adherence and then summarize how to solve the barriers in each dimensionbased on the above five factors. 1. Methods of measuring adherence Based on Osterberg and Blaschke(2005), there are direct and indirect methods to measureadherence. Firstly, direct methods consist of directly observed therapy, measurement of thelevel of medicine or metabolite in blood and measurement of the biologic marker in bloodwhich are accurate and objective methods used in clinical trials. However, these methodssometimes require expensive quantitative assays and collection of bodily fluids. Secondly,indirect methods include patient self-reports, rates of prescription refills, and electronicmedication monitors. Most of the methods are simple and easy to perform and obtain data. Incontrast, these methods are susceptible to errors due to data easily altered by the patients. Inthe case of indirect methods of measuring adherence, facilitating higher medicationadherence is key to assess the patients clinical response precisely. 2. Achieving higher level of medication adherence (Source: 2006 American Society on Aging and American Society of Consultant Pharmacists Foundation) 1) Social and Economic Dimension Social support is positively associated with medication adherence because people whohave social support from family, friends, or caregivers can be assisted with medicationregimen enabling better adherence to treatment. Barriers StrategiesBurdensome schedule - Tailor medication regimen to daily routine
  15. 15. - Reminders or compliance aidsHigh cost or lack of availability - Mail order pharmacyof transport to access pharmacy - Pharmacy delivery serviceMedication cost - Switch to generics or lower-cost alternatives - Refer to local programs or agencies that provide medication assistance - Pharmaceutical assistance programs ( www.helppatients.org ) - Enroll in Medicare Part D prescription drug planCultural Belief - Establish a positive, supportive, trusting relationship with the person - Seek an understanding of the causes of illness from the persons cultural point of view - Elicit information about use of nontraditional therapies in non-judgmental way - Determine persons preference regarding group learning or individual, private instructionTable 4. Barrier and Strategies for Social and Economic Dimension 2) Healthcare System Dimension A good relationship between patient and halthcare provider influences on highmedication adherence. Barriers StrategiesProvider-patient relationship - Establish a positive, supportive, trusting relationship with the patient - Involve the patient in the decision-making process - Assess the patients understanding of the illness and treatment - Clearly communicate the benefits of treatment - Involve the patient in setting treatment goals - Assess the patients readiness to carry out the treatment plan
  16. 16. - Identify and discuss any barriers or obstacles to adherence the patient may have and formulate strategies for overcoming them with the patient - Tailor medication regimens to the patients daily routine - Reduce complexity of medication regimenProvider communication - Adopt a friendly rather than a business-like attitude - Spend some time conversing about nonmedical topics - Avoid medical jargon - Use short words and short sentences - Give clear instructions on the exact treatment regimen, preferably in writing - Repeat instructions - Make advice as specific and detailed as possible - Ask the patient to repeat what has to be doneTable 5. Barrier and Strategies for Healthcare System Dimension 3) Condition-Related Dimension It is important to consider chronic condition and lack of symptoms for patients withmental disabilities in order to achieve higher medication adherence. Barriers StrategiesTherapy for asymptomatic - Inform about disease process, importance ofconditions treatment or prevention, and consequences if not treatedPreventative therapies with no - Preventative therapies with no immediatelyimmediately discernible benefit discernible benefitChronic or long-term therapy - Simplify regimen - Refer to support group - Use reminder strategies - Involve family members
  17. 17. - Cue medication taking to daily tasks or routineLack of belief in treatments’ - Discuss efficacy of medicationseffectivenessFear of side effects - Review most common side effects - Reinforce that most people do not have to stop therapy because of side effects - Reassure person that over time side effects should be less of a problemPatient-related - Cognitive therapy - Education about the illness - Education about the treatment - Memory aids (phone reminders, alarms) - Involvement in therapeutic alliancePhysician-related - Provide information on common side effects and strategies to address - Use of "patient-centered" approach - Address patients attitudes and beliefs about medicationsSocial/Environment-related - Involve and educate family - Improve access to mental health services (case management, home visits, convenient clinic hours and locations) - More attractive clinic environment - Improved coordination between service providersTreatment-related - Minimize complexity of medication regimen - Titration to optimum dose - Provide clear instructions on medication use - Minimize impact of side effects - Select medication with fewer side effectsTable 6. Barrier and Strategies for Condition-Related Dimension 4) Therapy-Related Dimension
  18. 18. Barriers StrategiesComplexity of medication - Identify and discontinue unnecessary medicationsregimen (number of daily doses; - Reduce dose frequency for medications wherenumber of concurrent possible; use long-acting dosage forms wheremedications) possible - Identify combination medications that can replace two separate prescriptions - Identify opportunities to use one drug to treat more than one medical condition - Identify medications prescribed to treat the side effects of other medications - Introduce reminder strategies tailored to the individual, such as pill organizers, calendars, phone reminder systems, etc. - Provide updated written list of medicationsLack of immediate benefit of - Educate about what to expect from treatment (e.g., how medication works, time to onset of effect,therapy expected goals of therapy, how to monitor for effectiveness)Chronic or long-term therapy - Simplify regimen - Refer to support group - Use reminder strategies - Involve family members - Cue medication taking to daily tasks or routineActual or perceived unpleasant - Educate about what to expect from treatment andside effects risks vs. benefits (e.g., tolerance might develop to certain side effects) - Suggest ways to manage minor side effects - Identify alternative medications with less side effect potentialGeneral treatment regimen - Explore preferences and issues with treatmentconcerns regimen: - Does person believe treatment is needed or effective?
  19. 19. - Does person want to use medicine to treat condition? - Does person have concerns about long-term treatment? - Involve person in determining goals of therapy - Address medication-related issues that make adherence difficult, such as the need to master specific administration techniques (e.g., injections, inhalers)Table 7. Barrier and Strategies for Therapy-Related Dimension 5) Patient-Related Dimension Poor medication adherence is sometimes attributed to lack of knowledge about thedisease and lack of motivation, and low self-efficacy. A persons perception of the dangerposed by their disease may influence on medication adherence. Barriers StrategiesKnowledge - Identify "knowledge gaps" - Provide information where gaps exist - Confirm understanding; have person repeat the information - Demonstrate any special techniques for use of devices for administering medication - Ask about any concerns the person has about using the medicine - Provide appropriate written information - Follow up for reinforcement of the information providedMotivation - Use motivational interviewing techniques for people in the precontemplation and contemplation stages of change - "Roll" with resistance
  20. 20. - Involve person in problem solving - Provide information and alternatives - Express empathy - Avoid argumentation - Develop discrepancy between the persons behavior and important personal goals - Involve family members - Refer to support groupSelf-Efficacy - Use motivational interviewing techniques to enhance the persons confidence in their ability to overcome barriers and succeed in change - Recognize small positive steps the person is taking - Use supportive statements - Help person set reasonable and reachable goals - Express belief that person can achieve goalsTable 8. Barrier and Strategies for Patient-Related Dimension
  21. 21. Conclusion The current knowledge and evidence regarding treatment or medication adherencesuggest that healthcare providers should understand the patients experience and expectationsto build partnerships. The effort to help patients understand their status enables theindividuals to make a reasonable decision to achieve timely treatment or medication.Building a relationship on trust and timely intervention and education for patients are the bestcourse of helping people to stick to their routines.
  22. 22. Reference Steven Baroletti et al., Medication Adherence in Cardiovascular Disease, Circulation.2010-Vol 121: 1455-1458 Barry Berman, Developing an Effective Customer Loyalty Program, CaliforniaManagement Review. 2000 Fall Vol 49: 143-148 Russel L. et al., Influence of Patient Literacy on the Effectiveness of a Primary Care–Based Diabetes Disease Management Program, JAMA. October 13, 2004—Vol 292, No. 14 Molassiotis A. et al., A pilot study of the effects of a behavioural intervention ontreatment adherence in HIV-infected patients, AIDS Care. 2003 Feb;15(1):125-35 Weingarten SR et al., Interventions used in disease management programs forpatients with chronic illness which ones work? Meta-analysis of published reports, BMJ 325 :925 doi: 10.1136/bmj.325.7370.925 (Published 26 October 2002) Cutler et al., Perspective Thinking Outside the Pillbox: Medication Adherence as aPriority Care Reform, The New England Journal of Medicine,2010; 362:1553-155 Power et al., Obesity, cardiovascular fitness, and physically active adolescents’motivations for activity: A self-determination theory approach, Psychology of Sport andExercise Volume 12, Issue 6, November 2011 R.M. Ryan and E.L. Deci, Self-determination theory and the facilitation of intrinsicmotivation, social development, and well-being. American Psychologist, 55 (2000), pp. 68–78. Lewis SD et al., Using success stories to share knowledge and lessons learned inhealth promotion. Womens Health (Larchmt). 2004 Jun;13(5):616-24.Web ResourcesCustomer Loyalty Program That Works http://hbswk.hbs.edu/item/6733.htmlAdult MEDUCATION (2006 American Society on Aging and American Society ofConsultant Pharmacists Foundation) http://www.adultmeducation.com/index.html

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