We’ve come a long way in our treatment of people with swallowing disorders. The evidence base for the exercises, compensatory strategies, and dietary modifications we prescribe grows every year.
But poor client adherence is still a frequent issue for clinicians who work with clients with dysphagia—and, in fact, for clinicians across disciplines who work with any number of client problems.1 Simply stated, our interventions don’t work if our clients can’t or won’t use them!
The World Health Organization recently published a report that concluded that increasing adherence interventions could have a greater impact on health than any other improvement in specific treatment strategies.
Let’s face it: the activities we recommend aren’t always easy or pleasurable. So what can we do to build client participation and engagement?
3 Strategies for Improved Adherence
1. Take small steps.
Clinicians sometimes take an “everything but the kitchen sink approach” to therapy. We provide a list of compensatory strategies (slow down, take small bites, swallow hard, tuck your chin, and so forth), another list of exercises (Effortful Swallow, Masako Maneuver, Tongue Press, etc.), and add in a number of rules about foods our clients should and shouldn’t eat or drink (no thin liquids, no hard to chew foods).
It’s no wonder that our clients and their family members can feel completely overwhelmed!
Consider breaking your plan down into smaller, more manageable pieces. What’s the most important thing your client needs to do?
Start with the one or two things that are going to have the biggest impact on your client’s safety and quality of life. Once these pieces are in place, you can gradually add to the plan.
2. Encourage self-assessment.
Resist the urge to ask your client, “So… how is the exercise program going?” You are likely to hear an answer of “Fine,” which may or may not be the case. If you are assigning exercises through MedBridge, the Home Exercise Program builder also tracks client adherence when they access their program online or through the MedBridge GO app, so you can directly check on how your client is doing.
Encourage your client to perform a meaningful evaluation of the prescribed exercises or strategies. Use open-ended questions like:
- What challenges did you run into as you tried to do this at home?
- Why do you think you’ve been most successful in getting this done?
- Which strategies seem to help the most or the least?
These questions encourage self-assessment and help you identify and address barriers to adherence as well as promote the factors that facilitate participation. Asking specific questions like, “What would be the best time for you to complete your exercises?” and “Where do you prepare your food?” can help your clients visualize themselves implementing the plan, assisting both them and you in identifying potential problems.
3. Consider health literacy.
Health literacy has been defined as the degree to which people are able to access, understand, appraise, and communicate information to engage with the demands of different health contexts.2 Your client’s ability to understand health-related information is related to, but not exactly the same as, his or her general literacy skill level and may impact their ability to use strategies, modify their diet appropriately, or complete exercises consistently.
It’s helpful for clients to have a variety of materials to choose from.3 While some clients like a written schedule for their exercises, others may do better with an electronic reminder. For instance, the MedBridge GO app sends push notifications to remind your client that it’s time to practice their exercises. Some clients may do well with written instructions for their strategies, while others prefer videos. If you’re a MedBridge subscriber, you have access to both, making it easier to customize according to your clients’ needs. When it comes to client education, one size definitely does not fit all!
Our responsibility as clinicians is not to force clients to do what we think they should do. Instead, we should work toward shaping each intervention plan so that it better fits into the client’s lifestyle. The ideal plan takes into account the many demands on the client and family and makes sense to our clients given their understanding of their swallow impairment.
- Krekeler, B. N., Broadfoot, C. K., Johnson, S., Connor, N. P., & Rogus-Pulia, N. (2017). Patient adherence to dysphagia recommendations: a systematic review. Dysphagia, 33(2): 173-184.
- Geboers, B., Brainard, J. S., Loke, Y. K., Jansen, C. J. M., Salter, C., Reijneveld, S. A., & de Winter, A. F. (2015). The association of health literacy with adherence in older adults, and its role in interventions: a systematic meta-review. BMC Public Health, 15: 903.
- Lloyd, J., Thomas, L., Powell-Davies, G., Osten, R., & Harris, M. (2018). How can communities and organisations improve their health literacy? Public Health Research & Practice, 28(2): 2821809.