Measurement of stable changes of self-management skills after rehabilitation: a latent state-trait analysis of the Health Education Impact Questionnaire (heiQ™)

Influence of central aspects of pain on self-management in people with chronic low back pain

OBJECTIVE

This observational study investigated whether central aspects of pain are associated with self-management domains in individuals with chronic low back pain (CLBP) undertaking a pain management program.

METHODS

Individuals with CLBP provided pain sensitivity and self-management data at baseline (n = 97) and 3-months (n = 87). Pressure pain detection threshold (PPT) at the forearm, temporal summation (TS) and conditioned pain modulation (CPM), Widespread Pain Index (WPI), and a Central Aspects of Pain factor (CAPf) were considered as central aspects of pain. Self-management was measured using the 8 domains of the Health Education Impact Questionnaire, as well as Pain Self Efficacy and Health Care Utilisation questionnaires.

RESULTS

PPT, CPM, WPI and CAPf predicted worse performance in several self-management domains at 3-months (r = 0.21 to 0.54, p < 0.05 overall). In multivariable regression models (adjusted for baseline scores of self-management, depression, catastrophization, pain and fatigue) low PPT, high TS, and high CAPf at baseline predicted poorer self-management at 3 months (R2 =0.14 to 0.52, β = -0.37 to 0.35, p < 0.05).

CONCLUSIONS

Central aspects of pain are associated with impaired self-management, over and above effects of pain intensity, fatigue, depression and catastrophizing.

PRACTICE IMPLICATIONS

Treatments that target central aspects of pain might help improve self-management in people with CLBP.

The Other 45: Improving Patients' Chronic Disease Self-Management and Medical Students’ Communication Skills

Context

To improve chronic disease self-management among an underserved population and to improve the skills of second-year osteopathic medical students, an educational curriculum, The Other 45, was developed. In addition to a typical 15-minute office visit, this program allows second-year students to provide chronic disease education to patients for 45 minutes in an effort to improve patient disease self-management and associated health outcomes.

Objective

To determine whether patients who participate in The Other 45 report improvements in their ability to manage their chronic disease(s) and their health outcomes and whether second-year osteopathic medical students report changes in patient-centered care, clinical confidence, and medical/teaching knowledge.

Methods

Patients with a previously diagnosed chronic disease participated in 3 visits for The Other 45. Chronic disease self-management and health outcomes were measured using the Health Education Impact Questionnaire, which participants completed at each visit. Students received a formal presentation on teaching skills, and those who participated in The Other 45 completed a pre- and postclinic survey measuring 3 focused domains: patient-centered care, clinical confidence, and medical/teaching knowledge.

Results

A total of 47 patients and 69 students participated in the study. As measured by the Health Education Impact Questionnaire, patients’ skill and technique acquisition (P=.01), constructive attitudes and approaches (P=.01), and health services navigation (P=.03) showed significant improvement at the 3-week follow-up visit, and self-monitoring and insight showed significant improvement (P=.01) at the 3-month follow-up visit. Patients’ positive and active engagement in life (P=.04 and P=.03) and emotional well-being (P=.003 and P=.0007) significantly improved at the 3-week and 3-month follow-up, respectively. The students improved significantly in all 3 domains as a result of participating in the program: patient-centered care (P=.012), clinical confidence (P<.001), and medical/teaching knowledge (P=.002).

Conclusions

The Other 45 was effective in improving patients’ ability to manage their chronic disease(s), as well as improving second-year osteopathic medical students’ ability to educate a patient with chronic disease. Implementing this type of program has the potential to affect patients with chronic disease as well as medical students in a rural underserved setting.

A systematic review of outcome measures utilised to assess self-management in clinical trials in patients with chronic pain

OBJECTIVES

The aim of this review was to identify, appraise and synthesise the outcome measures used to assess self-management in patients with chronic pain.

METHODS

Medline, Embase, CINAHL, PsycINFO, the Cochrane Library and Google Scholar were searched to identify quantitative measures used within randomised or non-randomised clinical trials to assess self-management in adults (≥18 years) with chronic pain.

RESULTS

25 RCTs published between 1998 and 2016 were included in this review. Studies included patients with chronic pain, hip/knee osteoarthritis, rheumatoid arthritis, chronic low back pain, fibromyalgia and chronic fatigue syndrome. Included studies utilised 14 different measures assessing a variety of constructs including self-efficacy (n = 19), coping (n = 4), empowerment (n = 2), pain attitude and management (n = 3), self-care (n = 1), role behaviour (n = 1) and multiple constructs of self-management (n = 1). The Chronic Pain Coping Inventory (CPCI) and Health Education Impact Questionnaire (heiQ) cover different self-management related constructs across the physical, mental and social health domains.

CONCLUSION

The review identified 14 measures used as proxy measure to assess self-management in patients with chronic pain. These measures have good content and construct validity, and internal consistency. However additional research is required to develop their reliability, responsiveness and interpretability.

PRACTICE IMPLICATIONS

Multi-constructs measures (CPCI, heiQ) are suitable for assessing self-management.

Does improvement in self-management skills predict improvement in quality of life and depressive symptoms? A prospective study in patients with heart failure up to one year after self-management education

Background

Heart failure (HF) patient education aims to foster patients’ self-management skills. These are assumed to bring about, in turn, improvements in distal outcomes such as quality of life. The purpose of this study was to test the hypothesis that change in self-reported self-management skills observed after participation in self-management education predicts changes in physical and mental quality of life and depressive symptoms up to one year thereafter.

Methods

The sample comprised 342 patients with chronic heart failure, treated in inpatient rehabilitation clinics, who received a heart failure self-management education program. Latent change modelling was used to analyze relationships between both short-term (during inpatient rehabilitation) and intermediate-term (after six months) changes in self-reported self-management skills and both intermediate-term and long-term (after twelve months) changes in physical and mental quality of life and depressive symptoms.

Results

Short-term changes in self-reported self-management skills predicted intermediate-term changes in mental quality of life and long-term changes in physical quality of life. Intermediate-term changes in self-reported self-management skills predicted long-term changes in all outcomes.

Conclusions

These findings support the assumption that improvements in self-management skills may foster improvements in distal outcomes.

Patient empowerment: a systematic review of questionnaires measuring empowerment in cancer patients

BACKGROUND

There is an increased attention to and demand for patient empowerment in cancer treatment and follow-up programs. Patient empowerment has been defined as feeling in control of or having mastery in relation to cancer and cancer care. This calls for properly developed questionnaires assessing empowerment from the user perspective. The aim of this review was to identify questionnaires and subscales measuring empowerment and manifestations of empowerment among cancer patients.

MATERIALS AND METHODS

We conducted a systematic search of the PubMed, PsycINFO and CINAHL databases. Empowerment and multiple search terms associated with empowerment were included. We included peer-reviewed articles published in English, which described questionnaires measuring empowerment or manifestations of empowerment in a cancer setting. In addition, the questionnaire had to be a patient-reported outcome measure for adult cancer patients.

RESULTS

Database searches identified 831 records. Title and abstract screening resulted in 482 records being excluded. The remaining 349 full text articles were retrieved and assessed for eligibility. This led to the inclusion of 33 individual instruments measuring empowerment and manifestations of empowerment. Of these, only four were specifically developed to measure empowerment, and two were originally developed for the cancer setting, whereas the remaining two were developed elsewhere, but adapted to the cancer setting. The other 29 questionnaires were not intended to measure the concept of empowerment, but focused on patient-centered care, patient competence, self-efficacy, etc. However, they were included because part of the instrument (at least five items) was considered to measure empowerment or manifestations of empowerment.

CONCLUSION

Our study provides an overview of the available questionnaires, which can be used by researchers and practitioners who wish to measure the concept of empowerment among cancer patients. Very few questionnaires were explicitly developed to explore empowerment, and the review brings to light a significant lack of questionnaires that measure patient empowerment comprehensively.

Making robust decisions about the impact of health education programs: Psychometric evaluation of the Health Education Impact Questionnaire (heiQ) in diverse patient groups in Norway

OBJECTIVE

To undertake a rigorous psychometric evaluation of the widely used eight-scale heiQ version 2.0 (evaluating immediate effects of self-management interventions) in diverse patient groups in Norway.

METHODS

Cross-sectional survey data were collected from 1019 Norwegians. Data were extracted from studies among people with musculoskeletal disorders (n=516), psoriasis (n=254), heart disease (n=97), and Type 2 diabetes (n=152). To investigate the factorial validity of the Norwegian heiQ, confirmatory factor analyses (CFA) were carried out using Mplus.

RESULTS

One-factor model fit, without modifications, was acceptable for the Emotional distress scale. Only one correlated residual was required to be fitted in each of the other scales to achieve satisfactory model fit. The postulated highly restricted full eight-factor model (no cross-loadings, no correlated residuals) showed good fit to the data. Internal consistency was acceptable for most scales (0.72-0.90) but low for Self-monitoring and insight.

CONCLUSION

This study of the Norwegian heiQ replicates the factor structure of the original Australian heiQ, using robust and highly restricted CFA procedures, demonstrating a clean independent clusters model structure.

PRACTICE IMPLICATIONS

Researchers, program implementers and policymakers could use the Norwegian heiQ with confidence to generate reliable information on program outcomes and support quality improvement activities.

Improved self-management skills predict improvements in quality of life and depression in patients with chronic disorders

OBJECTIVE

Self-management programs aim to improve patients' skills to manage their chronic condition in everyday life. Improvement in self-management is assumed to bring about improvements in more distal outcomes, such as quality of life. This study aimed to test the hypothesis that changes in self-reported self-management skills observed after participation in self-management programs predict changes in both quality of life and depressive symptoms three months later.

METHODS

Using latent change modeling, the relationship between changes in latent variables over three time points (start and end of rehabilitation, after three months) was analysed. The sample comprised 580 patients with different chronic conditions treated in inpatient rehabilitation clinics. The influence of additional predictor variables (age, sex, perceived social support) and type of disorder as a moderator variable was also tested.

RESULTS

Changes in self-reported self-management skills after rehabilitation predicted changes in both quality of life and depressive symptoms at the end of rehabilitation and the 3 months follow-up. These relationships remained significant after the inclusion of other predictor variables and were similar across disorders.

CONCLUSION

The findings provide support for the hypothesis that improvements in proximal outcomes of self-management programs may foster improvements in distal outcomes. Further studies should investigate treatment mechanisms.

Leventhal's common-sense model and asthma control: Do illness representations predict success of an asthma rehabilitation?

This study investigates whether illness representations predict changes in asthma control or vice versa. Illness perceptions and asthma control were assessed in N = 113 asthma patients at the begin/end of an inpatient rehabilitation. Bivariate cross-lagged panel analyses showed that the illness representation dimensions Personal control, Consequences, Coherence, and Emotional representation predicted the change in asthma control, but asthma control did not predict illness representations. In multiple regression analyses with covariates, Personal control still predicted the change in asthma control. Illness beliefs assessed at the beginning of an intervention might help to identify patients with lower probability of treatment success.

Asthma Control Test and Asthma Control Questionnaire: factorial validity, reliability and correspondence in assessing status and change in asthma control

OBJECTIVE

This study examined the factor structures and reliabilities of the Asthma Control Test (ACT) and the Asthma Control Questionnaire (ACQ-7; ACQ-6) and the correspondence between them in assessing both level and change in asthma control.

METHODS

Lung function and questionnaire data for ACT and ACQ were assessed in 113 asthma patients at the beginning (T1) and the end (T2) of inpatient rehabilitation. Confirmatory factor analyses, composite reliability coefficients, Pearson correlations, Cohen's Kappa and positive/negative agreements were computed.

RESULTS

Unidimensional factor structure was confirmed for ACT. For ACQ configural invariance (i.e. same factor structure) over time could not be established. Furthermore, in ACQ-7, FEV1 showed no relation to the latent factor. Reliability estimates were 0.86-0.88 (ACT), 0.88-0.92(ACQ-6) and 0.81-0.86 (ACQ-7). Pearson correlations between ACT and ACQ were between 0.75 and 0.90 and tended to be higher at T2. If the aim is to identify patients with either not well-controlled asthma or change in asthma control, concordance was at least moderate (Kappa = 0.52-0.72). Correspondence tended to be lower in identifying patients with well-controlled asthma (Kappa = 0.30-0.79). In some circumstances, ACQ-6 showed higher agreement with ACT than did ACQ-7.

CONCLUSIONS

ACT is a unidimensional measure, but factor structure of ACQ remains unclear. Correspondence between ACT and ACQ depends on the aim of the assessment. Including FEV1 in the assessment of asthma control level even lowers reliability of ACQ and concordance with ACT. Our results support GINA (2014) in conceptualizing FEV1 as a risk factor for poor asthma outcome instead of an indicator of level of asthma control.

Individual prevention courses for occupational skin diseases: changes in and relationships between proximal and distal outcomes

BACKGROUND

To treat people with occupational contact dermatitis, the German Accident Prevention and Insurance Association in the Health and Welfare Services offers 2-day individual prevention (IP) seminars.

OBJECTIVES

We investigated whether there are short-term and medium-term changes in proximal (e.g. behaviour) and distal (e.g. symptoms) outcomes after an IP seminar, whether changes in proximal outcomes are associated with changes in distal outcomes, and whether subgroups can be identified that benefit in particular.

PATIENTS/MATERIALS/METHODS

In a prospective study, 502 participants of 85 IP courses completed the health education impact questionnaire (heiQ™) and skin symptom questionnaire (Skindex-29) at the start of the course, immediately thereafter, and after 6 months. Change was assessed according to standardized effect size. Regression techniques were used to analyse associations between proximal and distal outcomes.

RESULTS

After 6 months, participants showed improved self-management skills and preventive behaviour, and less fear of job loss, disease-related symptoms, and emotional distress. Significant associations between proximal and distal outcomes were found. Participants who felt more limited by their skin disease showed greater effects.

CONCLUSIONS

The results are consistent with the assumption that IP courses provide a range of benefits for people with occupational contact dermatitis. Changes in distal outcomes may be influenced by changes in proximal outcomes.