Why Some Patients Practice—and Others Don’t Eva van Leer is trying to predict what determines—and how to improve—voice patients’ adherence to home practice. Foundational Questions
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Foundational Questions  |   November 01, 2017
Why Some Patients Practice—and Others Don’t
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Speech, Voice & Prosody / Foundational Questions
Foundational Questions   |   November 01, 2017
Why Some Patients Practice—and Others Don’t
The ASHA Leader, November 2017, Vol. 22, online only. doi:10.1044/leader.FQ.22112017.np
The ASHA Leader, November 2017, Vol. 22, online only. doi:10.1044/leader.FQ.22112017.np
Name: Eva van Leer, PhD, CCC-SLP, assistant professor, Georgia State University
ASHFoundation funding: 2013 Clinical Research Grant
What is the focus of your research?
I’m interested in improving patient outcomes in voice therapy by improving their adherence to practice and generalization. The work is largely guided by social-cognitive theory, examining the beliefs and states that influence adherence. The aim is to develop methods and tools to measure, predict and improve patient adherence. At this time, we are developing and testing mobile tools to support adherence. Mobile devices are ubiquitous and have the potential to assist us in monitoring and supporting behavior change.
How did your award from the ASHFoundation lead to your current work?
The ASH Foundation clinical research award allowed me to complete the first step in testing an iOS app developed in my lab to support extra-clinical practice, and to gather objective patient practice data in the clinical setting. I learned that practice varies tremendously. Some patients don’t practice at all, while others do so multiple times a day, whether or not they receive external mobile support. The accuracy of practice is also highly variable. By having patients use the app, we learned more about their needs—the kind of functionalities that are helpful, for example, and those that are not used. The project also provided insights into understanding feasibility of studying patient behavior outside of the clinic.
What do you hope to demonstrate or have already demonstrated?
I hope to identify the factors in a mobile tool that can be reliably helpful in motivating and improving patients’ practice and incorporation of voice technique into their daily life. So far, it appears that examples (audio and video) help early in treatment, after there has been a delay in practice, and when revisiting an older exercise. Clinician examples and patient-as-model examples are helpful in different ways. Mobile reminders reduce missed practice (that is, going entire days without attending to voice).
In addition, the nature of the exercise may play a role in adherence. Exercises that require a lot of mental effort—such as producing resonant voice in connected speech—are avoided more, whereas exercises that can be done quite mindlessly—like liptrills or other semi-occluded vocal tract exercises—do not present much of an adherence problem.
Last, with regard to app functionality and utility, some aspects are better left flexible so that these can be individualized to the patient’s needs or preferences, but other aspects must be structured very explicitly.
Why did you choose this particular research focus?
Clinicians, myself included, are often surprised when patients are poorly adherent, even though they may have substantial voice complaints and high voice handicap index (VHI) scores. The intuitive assumption is that people who are suffering will be highly motivated to change their behavior, but this is not how things work. We can see this quantitatively as well: In my studies, VHI scores have not correlated with homework completion. So, although voice complaints bring the patient in for evaluation, there’s a disconnect between motivation for evaluation and motivation for behavior change.
Whenever I’m frustrated with my patients, I look at my own exercise goals—for example, my triceps tone—and understand innately how we may wish for change but not implement the behavioral steps to achieve our desired outcome. Research across fields of behavior change has demonstrated that self-efficacy (belief in your own ability to do a certain task) is a strong predictor of adherence. Thus, if we can increase patients’ self-efficacy for adherence, we may improve adherence. There are a variety of ways to do this.
Part of my “growing up” as clinician was learning that two equally stimulable patients could have widely varying outcomes due to differential adherence. Although their potential was similar, improvement would occur only for the patient who actively and thoughtfully engaged in practice and generalization. I became obsessed with identifying predictors of adherence and improving adherence.
The obsession drove me to return to school for my doctorate. It’s a challenging area to study, because you have to follow patients (who drop out at a 50-percent rate) through treatment to study their adherence behavior; they have to be compliant with the study for us to, ironically, study their compliance with treatment. And, in developing tools to help them, we are constantly improving the tools based on patient feedback or making changes in response to iOS upgrades. You have a lot of moving targets that correlate directly with my gray hair development. A bottle of hair color should be sent to the recipients of the ASHFoundation clinical research award.
How has the ASHFoundation funding affected your professional life?
The funding kick-started my postdoctoral research career. I received the funding just as I started my assistant professorship at Georgia State University. This laid the foundation for my current NIH-funded research.
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November 2017
Volume 22, Issue 11