Efficacy of a Transtheoretical Model-Based Expert System For Antihypertensive Adherence

SMS text intervention for uncontrolled hypertension among hypertensive homeless adults in shelter clinics of New York City: protocol for a pragmatic randomised trial study

INTRODUCTION

Uncontrolled hypertension (HTN) is prevalent in persons experiencing homelessness (PEH) and contributes to significant suffering and financial cost. Mobile health approaches such as short messaging service (SMS) texting have led to better control of HTN in the general population. Despite the high utilisation of mobile phones by PEH, SMS texting to support HTN control has not been evaluated among this population. We hypothesise that an SMS testing programme will enhance health communication, information management, outreach and care coordination, and provide behavioural support to address some barriers to HTN management in PEH.

METHODS AND ANALYSIS

This study will use a mixed-methods study design to address two objectives: First, it will evaluate, in a randomised controlled trial, the efficacy of a 6-month SMS texting strategy vs an attention control on blood pressure reduction and adherence to medications and clinical appointments in 120 adults PEH with uncontrolled HTN. Outcomes will be measured at 0, 2, 4 and 6 months. Second, it will assess patients' and providers' acceptability and experience of SMS texting using semistructured interviews with PEH (n=30) and providers (n=10). The study will be conducted in shelter clinics in New York City in collaboration with community organisations. The primary statistical analysis will be on an intention-to-treat basis. The trial results will be reported as comparative summary statistics (difference in response rate or means) with 95% CIs and in accordance with the Consolidated Standards of Reporting Trials (CONSORT). Interviews will be transcribed, coded and analysed using an inductive grounded theory analysis.

ETHICS AND DISSEMINATION

This study has been approved by the Institutional Review Board (IRB) at George Washington University. Written consent will be obtained from participants. The findings will be disseminated in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT05187013.

SMS texting for uncontrolled diabetes among persons experiencing homelessness: Study protocol for a randomized trial

BACKGROUND

Diabetes mellitus (DM) is common among persons experiencing homelessness (PEH), often inadequately managed, and carries significant costs. mHealth strategies including short messaging service (SMS) texting have been feasible and acceptable, and improved control of chronic diseases including DM. SMS strategies for DM have not been tested among PEH despite the accessibility of mobile phones. We propose an SMS strategy could offer better communication, education, and information management; improve outreach; facilitate care coordination; explore barriers to care; and support behavior changes.

METHODS AND ANALYSIS

This mixed-methods (RCT and qualitative) study will be implemented in shelter-clinics in New York City in collaboration with community organizations, allowing for sustainability and scalability. Aim 1 will evaluate the efficacy of a 6-month SMS program for DM management versus an attention control on changes in HbA1c and adherence to DM self-care activities, medications, and appointments at 9 months in adult PEH with uncontrolled DM (n = 100). Outcomes will be measured at 0, 3, 6, &9 months. AIM 2 will assess patients' and providers' attitudes, acceptability, and experience of the program through semi-structured interviews with PEH (n = 20) and providers (n = 10).

DISCUSSION

DM is not well-addressed among PEH. SMS strategies for DM have never been tested in PEH despite evidence of their effectiveness and access to mobile phones among PEH. Results from this study will provide important empirical data to inform evidence-based strategies to avert personal suffering and significant costs. It will have broader policy implications in control of DM and other chronic diseases.

Traditional Heart-Healthy Diet and Medication Adherence in the Norton Sound Region: An 18-Month Telehealth Intervention

INTRODUCTION

Innovations are needed for preventing cardiovascular disease (CVD) and for reaching diverse communities in remote regions. The current study reports on a telemedicine-delivered intervention promoting a traditional heart-healthy diet and medication adherence with Alaska Native men and women residing in the Norton Sound region of Alaska.

METHODS

Participants were 299 men and women with high blood pressure or high cholesterol smoking daily who were randomized to receive telemedicine-delivered counseling and printed materials on diet and medication adherence or on smoking and physical activity. Intervention contacts were at baseline and 3-, 6-, and 12-months follow-up, with a final assessment at 18 months. Nutrition outcomes were the ratio of heart-healthy foods and traditional heart-healthy foods relative to all foods reported on a 34-item food frequency questionnaire. Recent and typical adherence for heart medications were self-reported.

RESULTS

Intervention effects were significant for the heart-healthy foods ratio at 6 months only (p = 0.014) and significant for the traditional heart-healthy foods ratio at 6 months only for those aged 47+ (p = 0.031). For recent and typical medication adherence, there were no significant group differences by time.

DISCUSSION

In a remote region of Alaska, telemedicine proved feasible and acceptable for engaging Alaska Native men and women in counseling on CVD risk behaviors. The findings indicate that more touchpoints may be necessary to impart comprehensive lasting change in heart-healthy eating patterns. Medication adherence group differences were not significant; however, medication adherence was high overall.

Stage-of-change Assessment Predicts Short-term Treatment Engagement for Opioid Use Disorder Patients Initiated on Buprenorphine

Introduction

The emergency department (ED) is an effective setting for initiating medication for opioid use disorder (MOUD); however, predicting who will remain in treatment remains a central challenge. We hypothesize that baseline stage-of-change (SOC) assessment is associated with short-term treatment retention outcomes.

Methods

This is a longitudinal cohort study of all patients enrolled in an ED MOUD program over 12 months. Eligible and willing patients were treated with buprenorphine at baseline and had addiction medicine specialist follow-up arranged. Treatment retention at 30 and 90 days was determined by review of the Prescription Drug Monitoring Program. We used uni- and multivariate logistic regression to evaluate associations between patient variables and treatment retention at 30 and 90 days.

Results

From June 2018–May 2019, 279 patients were enrolled in the ED MOUD program. Of those patients 151 (54.1%) and 120 (43.0%) remained engaged in MOUD treatment at 30 and 90 days, respectively. The odds of treatment adherence at 30 days were significantly higher for those with advanced SOC (preparation/action/maintenance) compared to those presenting with limited SOC (pre-contemplation/contemplation) (60.0% vs 40.8%; odds ratio 2.18; 95% confidence interval 1.15 to 4.1; P <0.05). At 30 days, multivariate logistic regression determined that advanced SOC, age >40, having medical insurance, and being employed were significant predictors of continued treatment adherence. At 90 days, advanced SOC, non-White race, age > 40, and having insurance were all significantly associated with higher likelihood of treatment engagement.

Conclusion

Greater stage-of-change was significantly associated with MOUD treatment retention at 30 and 90 days post index ED visit.

Effectiveness of a Transtheoretical Model-Based Intervention to Improve Blood Pressure Control of Hypertensive Patients in China: A Clustered Randomized Controlled Trial

Background

Hypertension can result in great cardiovascular risk, while medication adherence and blood pressure control of patients were suboptimal. Therefore, we conducted a 12-month clustered randomized controlled trial to evaluate the effectiveness of transtheoretical model (TTM)-based health intervention mode on blood pressure of Chinese newly-diagnosed hypertensive patients.

Methods

This trial was conducted in six primary healthcare centers, Shunyi District, Beijing, China from September 2016 to September 2017. A total of 400 patients were included and randomized, 194 patients in the control group and 206 patients in the intervention group. Patients in the intervention group received TTM-based health intervention and those in the control group received usual care. Multilevel modeling was used to adjust for clustering effect and repeated measurements.

Results

Systolic blood pressure of patient was reduced by 4.534 mm Hg at 3-month follow-up [95% CI (−3.054, −1.403), p = 0.005], 3.982 mm Hg at 6-month follow-up [95% CI (−7.387, −0.577), p = 0.022], and 5.803 mm Hg at 12-month follow-up [95% (−9.716, −1.891), p = 0.004]. Diastolic blood pressure of patient was reduced by 3.383 mm Hg at 3-month follow-up [95% CI (−5.724, −1.042), p = 0.005], 0.330 mm Hg at 6-month follow-up [95% CI (−2.870, 2.210), p = 0.799], and 3.129 mm Hg at 12-month follow-up [95% CI (−6.048, −0.21), p = 0.036]. Medication adherence of patients was improved at all the three time points. For stages of change for taking medication, patients in the intervention group were 8.401-fold more likely to be in a higher stage at 3-month follow-up [95% CI (4.186, 16.862), p < 0.001]. The odds ratio of being in a higher stage was 8.454 at 6-month follow-up [95% CI (3.943, 18.123), p < 0.001] and 19.263 at 12-month follow-up [95% CI (7.979, 46.505), p < 0.001].

Conclusion

Transtheoretical model-based health intervention might be a promising strategy to improve medication adherence of newly-diagnosed hypertensive patients in community.

Use of the transtheoretical model in medication adherence: A systematic review

BACKGROUND

Medication nonadherence is an important public health issue that has individual and system-level implications. Nonadherence can lead to negative health outcomes and illness, which in turn produce increased healthcare costs for both the individual and system. The transtheoretical model of change (TTM) can be a useful basis for interventions, as it can identify patients' current stages of change and guide them from nonadherence to adherence.

OBJECTIVE

The objective of this systematic review was to determine the utilization of the TTM to predict or improve medication adherence in patients with chronic conditions.

METHODS

A systematic review of current literature was conducted to obtain an overview of the use of TTM-informed interventions for medication adherence in chronic conditions. PubMed, Embase, PsycInfo and CINAHL databases were searched in July 2020. The methodological quality of the studies was evaluated using the Downs and Black checklist. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed for data extraction, analysis, and reporting.

RESULTS

Ten studies were included in the final data synthesis of this review. Eight of the reviewed studies supported the utility of TTM to predict or improve medication adherence in patients with chronic conditions, while two studies did not find any significant improvement in medication adherence after using a TTM-based intervention. The Downs and Black checklist revealed the overall methodological quality of the included studies to be fair [mean (SD) = 16.3 (4.5) of a possible maximum score of 28].

CONCLUSION

This systematic review provides an overview of the utility of TTM in predicting and improving medication adherence in patients with chronic conditions. Although TTM-based interventions in patients with low or moderate medication adherence were effective, there were few studies identified, suggesting the need for further research.

Stages of a transtheoretical model as predictors for the decline of estimated glomerular filtration rate: a retrospective cohort study

Background

The transtheoretical model (TTM) is composed of the multiple stages according to patient’s consciousness and is believed to lead people to realize the importance of healthier behaviors. We examined the association of TTM stages with the decline of estimated glomerular filtration rate (eGFR).

Methods

We used the annual health checkup data and health insurance claims data of the Japan Health Insurance Association in Kyoto Prefecture between April 2012 and March 2016. TTM stages of change obtained from questionnaires at the first health checkup and categorized into six groups. The primary outcome was defined as a more than 30% decline in eGFR from the first health checkup. We fitted multivariable Cox proportional-hazards model for time-to-event analyses adjusting for age, sex, eGFR, body mass index, blood pressure, blood sugar, dyslipidemia, uric acid, urinary protein, and existence of kidney diseases at first health checkup.

Results

We analyzed 239,755 employees and the mean follow-up was 2.9 (standard deviation, 1.2) years. As compared with the stage 1 group, the risk of eGFR decline was significantly low in the stage 3 group (hazard ratio [HR] 0.77; 95% confidence interval [CI], 0.65–0.91); stage 4 group (HR 0.80; 95% CI, 0.65–0.98); and stage 5 group (HR 0.79; 95% CI, 0.66–0.95).

Conclusion

Compared with the precontemplation stage (stage 1), the preparation, action and maintenance stages (stages 3, 4, and 5), were associated with a lower risk of eGFR decline.

The use of discrete choice experiments in adherence research: A new solution to an old problem

Theory can play an important role in providing the framework, and underpinning the design and implementation of interventions to improve medication adherence. Interventions that are grounded in a theory are relatively more effective in improving medication adherence than interventions which do not have a theoretical support. However, a large body of adherence research does not appear to be linked to any theory or model, which therefore may have resulted in interventions that are either ineffective or not sustainable. Interventions that are based on theory have mainly employed socio-behavioural models to explain, and design interventions to address, the complex phenomenon of adherence. Yet, the effectiveness of these interventions is inconclusive, supporting the argument that socio-behavioural models alone have limited applicability in explaining behaviour associated with medication-taking. An important reason for this limitation may be the complex and dynamic nature of adherence. There is a need to include a wide variety of factors in a model and examine adherence in the context of its three phases (initiation, implementation, and discontinuation). One possible way forward is to also examine medication-taking behaviour from an economic perspective, for example, by using a discrete choice experiment (DCE), which provides a different approach to understanding human behaviour about medication-taking and the complexities of decision-making in adhering to medication. DCEs can help in understanding how patients decide to initiate, continue or discontinue taking medication, factors that influence their decision, and the relative importance of those factors, which can assist researchers to prioritise interventions to improve medication adherence. Integration of multiple theories is needed to examine adherence from multiple perspectives and design interventions that are effective and sustainable. This commentary focusses on the pros and cons of some of the commonly used socio-behavioural models in adherence research and suggests a way forward by incorporating DCEs in adherence research.

Using the transtheoretical model's stages of change to predict medication adherence in patients with type 2 diabetes mellitus in a primary health care setting

BACKGROUND

Qatar is currently experiencing a worrying increase in the prevalence of diabetes mellitus (DM). One of the most common reasons for uncontrolled DM is non-adherence to medications. The socio-behavioral intervention has proven effective in some chronic illnesses.

OBJECTIVES

To assess the stages of change (SOC) and medication adherence scores of type 2 diabetes mellitus (T2DM) patients visiting primary healthcare institutions in Qatar, and to evaluate the cause and effect relationship between SOC and adherence to antidiabetic medications.

METHODS

The 8-item Morisky Medication Adherence Scale (MMAS-8) was used to assess medication adherence, and a 2-item SOC questionnaire was utilized to classify the SOC. The analysis to determine if the SOC could predict medication adherence while controlling for demographic characteristics, total number of prescribed medications and disease duration was done using hierarchical multiple regression.

RESULTS

The final analysis included 387 patients. In relation to medication adherence, majority of the patients were in the maintenance stage (76.7%), followed by the preparation stage (14.7%), the action stage (3.9%), the contemplation stage (3.4%) and the precontemplation stage (1.3%). Most of the patients were in high adherence towards antidiabetic medications (50.3%) followed by low level (26.4%) and medium level (23.3%). SOC was significant and positively predicted medication adherence, which accounted for around 58 to 60% (p < 0.001) while controlling for covariates.

CONCLUSIONS

SOC was significant and positively predicted medication adherence. The study recommends that the SOC questionnaire could potentially be used to identify patients at risk for low adherence.

A cluster randomised trial of a classroom communication resource program to change peer attitudes towards children who stutter among grade 7 students

Background

Classroom-based stuttering intervention addressing negative peer attitudes, perceptions, teasing and bullying of children who stutter (CWS) is required as part of holistic stuttering management because of its occurrence in primary school. This study was conducted in 2017, in 10 primary schools in the Western Cape, South Africa within lower (second and third) and higher (fourth and fifth) quintiles.

Objectives

The primary objective of this study was to determine treatment effect at six months after intervention of grade 7 participants (Classroom Communication Resource [CCR] intervention versus no CCR) using global Stuttering Resource Outcomes Measure (SROM) scores in school clusters. The secondary objective was to determine grade 7 participant treatment effect on the SROM subscales including Positive Social Distance (PSD), Social Pressure (SP) and Verbal Interaction (VI). The subgroup objective was to determine any difference in the primary outcome between schools between and across quintile clusters (lower and higher).

Methods

Once schools were stratified into lower and higher quintile (which are defined according to geographical location, fee per school and resources) subgroup clusters, schools were assigned randomly to control and intervention groups consisting of grade 7 participants who were typically aged ≥ 11 years. Teachers received 1 h of training before administering the single-dose CCR intervention over a 60–90-min session. The CCR intervention included a social story, role-play and discussion. All participants viewed a video of a CWS and stuttering was defined at baseline. The SROM measured peer attitudes at six months after intervention. Randomisation was stratified by quintile group using a 1:1 allocation ratio. Full blinding was not possible; however, the outcome assessor was partially blinded and the analyst was also blinded. Generalised estimating equations (GEE) was used assuming an exchangeable correlation structure to analyse the data adopting an intention-to-treat principle. Multiple imputation was used to handle missing data. Criterion for statistical significance was set at alpha = 0.05.

Results

Ten schools were randomly allocated to control (k = 5) and intervention groups (k = 5), with n = 223 participants allocated to intervention and n = 231 to control groups. A total of 454 participants completed the SROMs in control (n = 231) and intervention (n = 223) groups and were analysed at baseline and six months after intervention. There was no statistically significant difference on the global SROM score (mean difference − 0.11; 95% confidence interval [CI] − 1.56–1.34; p = 0.88). There were also no significant differences on SROM subscales: PSD (mean difference 1.04; 95% CI − 1.02–311; p = 0.32), SP (mean difference − 0.45; 95% CI − 1.22–0.26; p = 0.21) and VI (mean difference 0.05; 95% CI − 1.01–1.11; p = 0.93). Additionally, there was no significant subgroup effect on the global SROM score (lower versus higher quintile subgroups) (interaction p value = 0.52). No harms were noted or reported.

Conclusion

No statistically significant differences were noted. It is possible that the time frame was too short to note changes in peer attitudes and that further study is required to confirm the findings of this study.

Trial registration

Clinicaltrials.gov, NCT03111524. Registered on 9 March 2017.

The Healing and Empowering Alaskan Lives Toward Healthy-Hearts (HEALTHH) Project: Study protocol for a randomized controlled trial of an intervention for tobacco use and other cardiovascular risk behaviors for Alaska Native People

BACKGROUND

Tobacco use and tobacco-related diseases disproportionately affect Alaska Native (AN) people. Using telemedicine, this study aims to identify culturally-tailored, theoretically-driven, efficacious interventions for tobacco use and other cardiovascular disease (CVD) risk behaviors among AN people in remote areas.

DESIGN

Randomized clinical trial with two intervention arms: 1) tobacco and physical activity; 2) medication adherence and a heart-healthy AN diet.

PARTICIPANTS

Participants are N = 300 AN men and women current smokers with high blood pressure or high cholesterol.

INTERVENTIONS

All participants receive motivational, stage-tailored, telemedicine-delivered counseling sessions at baseline and 3, 6, and 12 months follow-up; an individualized behavior change plan that is updated at each contact; and a behavior change manual. In Group 1, the focus is on tobacco and physical activity; a pedometer is provided and nicotine replacement therapy is offered. In Group 2, the focus is on medication adherence for treating hypertension and/or hypercholesterolemia; a medication bag and traditional food guide are provided.

MEASUREMENTS

With assessments at baseline, 3, 6, 12, and 18 months, the primary outcome is smoking status, assessed as 7-day point prevalence abstinence, biochemically verified with urine anabasine. Secondary outcomes include physical activity, blood pressure and cholesterol, medication compliance, diet, multiple risk behavior change indices, and cost-effectiveness.

COMMENTS

The current study has the potential to identify novel, feasible, acceptable, and efficacious interventions for treating the co-occurrence of CVD risk factors in AN people. Findings may inform personalized treatment and the development of effective and cost-effective intervention strategies for use in remote indigenous communities more broadly. Clinical Trial Registration # NCT02137902.

Effects of an intervention based on the Transtheoretical Model on back muscle endurance, physical function and pain in rice farmers with chronic low back pain

BACKGROUND

Chronic low back pain (LBP) can be managed by exercises which should be tailored to an individual's readiness to behavioral change.

OBJECTIVE

To evaluate the effects of an intervention program based on the Transtheoretical Model of behavioral change (TTM) on back muscle endurance, physical function and pain in rice farmers with chronic LBP.

METHODS

In a 32-week study, 126 rice farmers were allocated to the TTM (n= 62) and non-TTM (n= 64) groups. Modified Biering-Sorensen test, Oswestry Disability Questionnaire and visual analogue scale were used for evaluating back muscle endurance, physical function and severity of pain, respectively. The evaluations were performed at baseline and at weeks 8, 20 and 32 of the study. Data were analyzed using repeated measure ANOVA.

RESULTS

The back muscle endurance was significantly greater in the TTM group than in the non-TTM group at week 32 (p= 0.025). Physical function and severity of pain were significantly improved in the TTM group when compared with the non-TTM group at weeks 20 and 32 (p< 0.01).

CONCLUSIONS

A TTM-based intervention could improve back muscle endurance and physical function, and reduce the pain in rice farmers with LBP. Further studies should be considered to explore the long-term effects of this intervention.

Subgroups Among Smokers in Preparation: A Cluster Analysis Using the I-Change Model

BACKGROUND

Investigating potential sub-stages of change could provide important information that could be used to improve the tailoring of smoking cessation interventions to individual smokers' profiles. Smokers in the preparation stage may be most interesting, as they are most likely to participate in smoking cessation interventions.

OBJECTIVE

To examine whether Dutch adult smokers in the preparation stage of change, i.e. motivated to quit smoking within one month, can be organized into subgroups.

METHODS

Data from 753 smokers who participated in an effectiveness trial of a web-based, computer-tailored smoking cessation programme were subjected to secondary analysis. Cluster analyses were based on respondents' baseline responses to items on pros and cons of quitting and quitting self-efficacy. Chi-squared tests and ANOVA were used to compare the baseline characteristics of the resulting clusters. Logistic and multinomial regression were used for longitudinal comparisons of clusters with respect to smoking abstinence and stage transition at six-week and six-month follow-ups.

RESULTS

Four clusters were identified; Classic, Unprepared, Progressing and Disengaged Preparers. Cross-sectional and longitudinal analyses validated these clusters: they differed with respect to the clustering variables, gender, cigarette dependence and educational level. Disengaged Preparers were less likely than Progressing Preparers to report smoking abstinence at six months (OR = 0.28; p < .05).

CONCLUSIONS

These results suggest that smoking cessation interventions tailored to the preparation stage of change, i.e. the set of cognitions usually present in preparers, are only appropriate for the subgroup we defined as Classic Preparers. The other clusters might need different interventions as they display different cognition sets.

Intention for Car Use Reduction: Applying a Stage-Based Model

This study investigates which variables drive intention to reduce car use by modelling a stage of change construct with mechanisms in the Theory of Planned Behavior (TPB) and Norm Activation Model (NAM). Web questionnaires (n = 794) were collected via 11 workplaces. The socio-demographics, work commute, stage of change, attitudes to sustainable travel modes, social norms, perceived behavioral control, and personal norm were assessed. An initial descriptive analysis revealed that 19% of the employees saw no reason to reduce their car use; 35% would like to reduce their car use but felt it was impossible; 12% were thinking about reducing their car use but were unsure of how or when to do this; 12% had an aim to reduce current car use, and knew which journeys to replace and which modes to use; and 23% try to use modes other than a car for most journeys, and will maintain or reduce their already low car use in the coming months. A series of Ordered Logit Models showed that socio-demographic variables did not explain the stage of change. Instead, personal norms, instrumental and affective attitudes, and perceived behavioral control toward sustainable travel modes were all significant and explained 43% of the variance in stage of change. Furthermore, it was found that the significant relationships were not linear in nature. The analysis also showed an indirect effect of social norms on the stage of change through personal norms. Implications are discussed regarding the design of interventions aimed at influencing a sustainable work commute.

The Classroom Communication Resource (CCR) intervention to change peer's attitudes towards children who stutter (CWS): study protocol for a randomised controlled trial

BACKGROUND

Children who stutter (CWS) are at a high-risk of being teased and bullied in primary school because of negative peer attitudes and perceptions towards stuttering. There is little evidence to determine if classroom-based interventions are effective in changing peer attitudes towards stuttering. The primary objective is to determine the effect of the Classroom Communication Resource (CCR) intervention versus usual practice, measured using the Stuttering Resource Outcomes Measure (SROM) 6-months post-intervention among grade 7 students. The secondary objective is to investigate attitude changes towards stuttering among grade participants on the SROM subscales.

METHODS

A cluster randomised controlled trial (RCT) will be conducted with schools as the unit of randomization. Schools will be stratified into quintile groups, and then randomized to receive the CCR intervention or usual practice. Quintile stratification will be conducted in accordance to the Western Cape Department of Education classification of schools according to geographical location, fee per school and allocation of resources and funding. Participants will include primary schools in the lower (second and third) and higher (fourth and fifth) quintiles and children aged 11 years or older in grade 7 will be included. The study will consist of the CCR intervention program or usual practice as a no-CCR control. The CCR is a classroom-based, teacher led intervention tool including a story, role-play and discussion. The grade 7 teachers allocated to the CCR intervention, will be trained and will administer the intervention. The analysis will follow intention-to-treat (ITT) principle and generalized estimating equations (GEE) to compare groups on the global SROM and its subscales to account for possible clustering within schools. The subgroup hypothesis will be tested by adding an interaction term of quintile group x intervention.

DISCUSSION

This study is designed to assess whether the CCR intervention versus usual practice in schools will lead to positive shift in attitudes about stuttering at 6-months post-intervention among grade 7 participants.

TRIAL REGISTRATION

The trial number is NCT03111524 . It was registered with clinical trials.gov Protocol registration and results system (PRS) retrospectively on 9 March 2017.

Stage-Based Mobile Intervention for Substance Use Disorders in Primary Care: Development and Test of Acceptability

Background

In 2016, 21 million Americans aged 12 years and older needed treatment for a substance use disorder (SUD). However, only 10% to 11% of individuals requiring SUD treatment received it. Given their access to patients, primary care providers are in a unique position to perform universal Screening, Brief Intervention, and Referral to Treatment (SBIRT) to identify individuals at risk, fill gaps in services, and make referrals to specialty treatment when indicated. Major barriers to SBIRT include limited time among providers and low motivation to change among many patients.

Objective

The objective of this study was to develop and test the acceptability of a prototype of a mobile-delivered substance use risk intervention (SURI) for primary care patients and a clinical dashboard for providers that can address major barriers to SBIRT for risky drug use. The SURI delivers screening and feedback on SUD risk via mobile tools to patients at home or in the waiting room; for patients at risk, it also delivers a brief intervention based on the transtheoretical model of behavior change (TTM) to facilitate progress through the stages of change for quitting the most problematic drug and for seeking treatment if indicated. The prototype also delivers 30 days of stage-matched text messages and 4 Web-based activities addressing key topics. For providers, the clinical dashboard summarizes the patient’s SUD risk scores and stage of change data, and provides stage-matched scripts to guide in-person sessions.

Methods

A total of 4 providers from 2 federally qualified health centers (FQHCs) were recruited for the pilot test, and they in turn recruited 5 patients with a known SUD. Furthermore, 3 providers delivered dashboard-guided SBIRT sessions and completed a brief acceptability survey. A total of 4 patients completed a Web-based SURI session and in-person SBIRT session, accessed other program components, and completed 3 acceptability surveys over 30 days. Questions in the surveys were adapted from the National Cancer Institute’s Education Materials Review Form. Response options ranged from 1=strongly disagree to 5=strongly agree. The criterion for establishing acceptability was an overall rating of 4.0 or higher across items.

Results

For providers, the overall mean acceptability rating was 4.4 (standard deviation [SD] 0.4). Notably, all providers gave a rating of 5.0 for the item, “The program can give me helpful information about my patient.” For patients, the overall mean acceptability rating was 4.5 (SD 0.3) for the mobile- and provider-delivered SBIRT sessions and 4.0 (SD 0.4) for the text messages and Web-based activities. One highly rated item was “The program could help me make some positive changes” (4.5).

Conclusions

The SURI program and clinical dashboard, developed to reduce barriers to SBIRT in primary care, were well received by providers and patients.

Putting evidence into practice: evidence-based interventions for oral agents for cancer

BACKGROUND

The limited evidence available suggests that adherence to oral agents for cancer is a significant clinical problem and may have a substantial impact on treatment success or failure. Adherence is a difficult issue among patients who are very sick with a life-threatening disease who often must adhere to complex treatment protocols independently at home.

OBJECTIVES

This article aims to identify effective interventions for the promotion, treatment, and management of adherence to oral agents for cancer and to synthesize the literature for use in clinical practice.

METHODS

As part of the Oncology Nursing Society (ONS) Putting Evidence Into Practice (PEP) initiative, a comprehensive examination of the current literature was conducted to identify effective interventions for patients prescribed oral agents for cancer. The ONS PEP weight-of-evidence classification schema levels of evidence were used to categorize interventions to assist nurses in identifying strategies that are effective at improving adherence.

FINDINGS

The majority of evidence found was conducted in conditions other than cancer; therefore, research is needed to identify whether these interventions are effective at promoting adherence in patients with cancer.

Identifying configurations of behavior change techniques in effective medication adherence interventions: a qualitative comparative analysis

BACKGROUND

Interventions to improve medication adherence are diverse and complex. Consequently, synthesizing this evidence is challenging. We aimed to extend the results from an existing systematic review of interventions to improve medication adherence by using qualitative comparative analysis (QCA) to identify necessary or sufficient configurations of behavior change techniques among effective interventions.

METHODS

We used data from 60 studies in a completed systematic review to examine the combinations of nine behavior change techniques (increasing knowledge, increasing awareness, changing attitude, increasing self-efficacy, increasing intention formation, increasing action control, facilitation, increasing maintenance support, and motivational interviewing) among studies demonstrating improvements in adherence.

RESULTS

Among the 60 studies, 34 demonstrated improved medication adherence. Among effective studies, increasing patient knowledge was a necessary but not sufficient technique. We identified seven configurations of behavior change techniques sufficient for improving adherence, which together accounted for 26 (76 %) of the effective studies. The intervention configuration that included increasing knowledge and self-efficacy was the most empirically relevant, accounting for 17 studies (50 %) and uniquely accounting for 15 (44 %).

CONCLUSIONS

This analysis extends the completed review findings by identifying multiple combinations of behavior change techniques that improve adherence. Our findings offer direction for policy makers, practitioners, and future comparative effectiveness research on improving adherence.

Development of Personalized Health Messages to Promote Engagement in Advance Care Planning

OBJECTIVES

To develop and test the acceptability of personalized intervention materials to promote advance care planning (ACP) based on the Transtheoretical Model (TTM), in which readiness to change is a critical organizing construct.

DESIGN

Development study creating an expert system delivering TTM-personalized feedback reports and stage-matched brochures with more-general information on ACP and modifications based on participant reviews.

SETTING

Senior centers.

PARTICIPANTS

Community-living persons aged 65 and older (N = 77).

MEASUREMENTS

Participant ratings of length, attractiveness, and trustworthiness of and reactions to reports and brochures.

RESULTS

The expert system assessed participants' readiness to engage in each of four ACP behaviors: completion of a living will, naming a health care proxy, communication with loved ones about quality vs quantity of life, and communication with clinicians about quality vs quantity of life. The system also assessed pros and cons of engagement and values and beliefs that influence engagement. The system provided individualized feedback based on the assessment, with brochures providing additional general information. Initial participant review indicating unacceptable length led to revision of feedback reports from full-sentence paragraph format to bulleted format. After review, the majority of participants rated the materials as easy to read, trustworthy, providing new information, making them more comfortable reading about ACP, and increasing interest in participating in ACP.

CONCLUSION

Older adults found an expert system individualized feedback report and accompanying brochure to promote ACP engagement to highly acceptable and engaging. Additional research is necessary to examine the effects of these materials on behavior change.

The impact of tailored text messages on health beliefs and medication adherence in adults with diabetes: A randomized pilot study

BACKGROUND

Inadequate medication adherence reduces optimal health outcomes and can lead to increased costs, particularly in patients with diabetes. Efforts to improve adherence have resulted in limited effects; approaches leveraging mobile technology have emerged, but their focus has mainly been limited to simple reminder messages.

OBJECTIVE

The purpose of this pilot study was to test the effectiveness of tailored text messages focusing on improving medication adherence and health beliefs in adults with diabetes.

METHODS

Adults aged 21-64, with uncontrolled diabetes, and taking at least one anti-diabetic medication were recruited and randomized into 2 study arms: daily tailored text messaging for 90 days or standard care. Comparing baseline and endpoint survey responses, changes in theory-driven health beliefs and attitudes were assessed. The impact on medication adherence was evaluated using pharmacy claims by calculating the percent of days covered (PDC).

RESULTS

A total of 75 subjects were consented, and 48 were randomized. Mean PDC at baseline were comparable between cohorts (84.4% and 87.1%, respectively). Declines in adherence were observed in both groups over time but no significant differences were observed between groups or from baseline to the end of the active study period. Unadjusted tests suggested that perceived benefits and competence might have improved in the intervention arm.

CONCLUSIONS

Tailoring mobile phone text messages is a novel way to address medication nonadherence and health beliefs; further investigation to this combined technique is needed to better understand its impact on behavior change in adults with diabetes.

'Engage me in taking care of my heart': a grounded theory study on patient-cardiologist relationship in the hospital management of heart failure

OBJECTIVE

In approaching the study and practice of heart failure (HF) management, authors recognise that the patient-doctor relationship has a central role in engaging patients in their care. This study aims at identifying the features and the levers of HF patient engagement and suggestions for orienting clinical encounters.

DESIGN

Using a grounded theory approach, we conducted 22 in-depth interviews (13 patients with HF, 5 physicians and 4 caregivers). Data were collected and analysed using open, axial and selective coding procedures according to the grounded theory principles.

SETTINGS

All interviews were conducted in an office in a university hospital located in a metropolitan area of Milan, Italy.

PARTICIPANTS

The data comprised a total of 22 patient, hospital cardiologist and caregiver interviews. Patients aged ≥18 years with New York Heart Association (NYHA) Functional Class of II or III were eligible to take part. Patients were recruited primarily through their referral cardiologist.

RESULTS

The HF patient engagement process develops in four main phases that are characterised by different patients' emotional, cognitive and behavioural dynamics that contribute to shape the process of a patient's meaning making towards health and illness regarding their care. The emerging model illustrates that HF patient engagement entails a meaning-making process enacted by the patient after the critical event. This implies patients' ability to give sense to their care experience and to their disease, symptomatology and treatments, and their changes along their illness course. Doctors are recognised as crucial in fostering patients' engagement along all the phases of the process as they contribute to providing patients with self-continuity and give new meaning to their illness experience.

CONCLUSIONS

This study identifies the core experiential domains and the main levers involved in driving patients with HF to effectively engage in their disease management. The model emerging from this study may help clinicians think in a fresh way about encounters with patients and their role in fostering their patients' health engagement.

Adherence to antihypertensive medications: is prescribing the right pill enough?

Significant progress has been made in the management of hypertension (HTN) in the last 60 years. A large number of antihypertensive drugs (AHD) is available for effective control of elevated blood pressure (BP) that were also shown to be beneficial in improving all-cause mortality and cardiovascular morbidity in hypertensive individuals. Despite these successes, rates of BP control and outcomes in hypertensive patients remain suboptimal. Therefore, the availability of effective drug therapy itself appears to be insufficient to guarantee desirable results. Adherence to antihypertensive medications is a crucial mediator of favorable outcomes in treating HTN, and non-adherence, in turn, halts BP control. In this review, we will summarize the available evidence on health-related impacts of adherence to AHD, methods for the evaluation of adherence and potential interventions aimed to improve adherence in hypertensive individuals.

Characterizing workers participating in a worksite wellness health screening program using blood pressure control, self-monitoring, medication adherence, depression, and exercise

Blood pressure control remains a serious public health issue because hypertension is the most common risk factor for cardiovascular disease. Effective management of hypertension often requires lifestyle modification and medication adherence. The objective of this study was to identify the prevalence of blood pressure control, medication adherence, self-monitoring of blood pressure, depression, and exercise among workers with access to health resources. Faculty and staff (N = 484) from a university and health care institution in the southeastern United States participated in biometric and questionnaire screening. The researchers used initial screening data from this worksite wellness program to describe baseline blood pressure control (< 140/90 mm Hg), self-monitoring of blood pressure, medication adherence, depression, and exercise. Overall, 63% of the workers' blood pressure was controlled; however, 23% of the sample had been prescribed antihypertensive medication to control their blood pressure. Thirty percent of the sample reported practicing blood pressure self-monitoring, 72.2% reported that they exercised, and 22% reported feeling down and depressed. More than half (64.9%) who used prescribed antihypertensive medication reported adherence to these medications.

Do patient-perceived pros and cons of opioids predict sustained higher-dose use?

OBJECTIVES

Chronic opioid therapy (COT) is associated with various adverse outcomes, especially at higher doses, yet little is known about predictors of sustained higher-dose COT. This study aimed to ascertain, among higher-dose COT patients, the association of patient-perceived pros and cons of opioids with continued higher-dose use 1 year later.

METHODS

Patients (N=1229) in 2 large health plans prescribed ≥50 mg morphine-equivalent dose (MED) per day for chronic noncancer pain completed a survey assessing opioid benefits and harms. The Prescribed Opioid Difficulties Scale questionnaire assessed psychosocial problems, concerns, benefits, and side effects related to opioid use. Logistic regression models estimated the associations of the reported benefits and problems with higher-dose continuation (≥50 mg MED/d) versus dose reduction (<50 mg MED/d) 1 year later.

RESULTS

Over 80% of participants continued higher-dose opioid use at 1 year, regardless of reported problems, concerns, side effects, pain reduction, or perceived helpfulness. Higher scores on the Prescribed Opioid Difficulties Scale Problems subscale (odds ratio=0.79, 95% confidence interval, 0.68-0.92) and Concerns subscale (odds ratio=0.76, 95% confidence interval, 0.65-0.90) were negatively associated with higher-dose use 1 year later. Other baseline measures (opioid helpfulness, reduction in pain, number of side effects, and side effect bothersomeness) were not significantly associated with continued higher-dose use.

DISCUSSION

The large majority of patients continued using higher-dose opioids regardless of baseline characteristics. These findings suggest the difficulty of reducing opioid dose among chronic higher-dose opioid users.

Stage of change and motivation to healthier lifestyle in non-alcoholic fatty liver disease

BACKGROUNDS & AIMS

Healthy diet and physical activity are the treatment cornerstones of non-alcoholic fatty liver disease (NAFLD); their effectiveness is however limited by difficulties in implementing lifestyle changes. We aimed at determining the stage of change and associated psychological factors as a prerequisite to refine strategies to implement behavior changes.

METHODS

We studied 138 consecutive NAFLD patients (73% male, age 19-73 years). The diagnosis was confirmed by liver biopsy in 64 cases (steatohepatitis, 47%). All cases completed the validated EMME-3 questionnaire, consisting of two parallel sets of instruments (for diet and physical activity, respectively) and providing stages of change according to transtheoretical model. Logistic regression analysis was used to identify factors associated with stages making behavioral changes more demanding.

RESULTS

The individual profiles were variable; for diet, no cases had precontemplation as prevalent stage of change (highest score in individual profiles); 36% had contemplation. For physical activity, 50% were classified in either precontemplation or contemplation. Minor differences were recorded in relation to associated metabolic complications or steatohepatitis. Logistic regression identified male sex (odds ratio, 4.51; 95% confidence interval, 1.69-12.08) and age (1.70; 1.20-2.43 per decade) as the independent parameters predicting precontemplation or contemplation for diet. No predictors were identified for physical activity.

CONCLUSIONS

NAFLD cases have scarce readiness to lifestyle changes, particularly with regard to physical activity. Defining stages of change and motivation offers the opportunity to improve clinical care of NAFLD people through individual programs exploiting the powerful potential of behavioral counseling, an issue to be tested in longitudinal studies.

Relationship of blood pressure self-monitoring, medication adherence, self-efficacy, stage of change, and blood pressure control among municipal workers with hypertension

Uncontrolled blood pressure remains a major public health issue. Medication adherence is a key factor in blood pressure management; however, adherence behavior is not clearly understood and the most significant factors contributing to poor medication adherence and blood pressure control are unknown. The purpose of this study was to determine the relationship of self-monitoring of blood pressure, medication adherence, self-efficacy, stage of change, and blood pressure control among municipal workers with access to health insurance. Stage of change was a significant independent predictor of self-monitoring of blood pressure, but not blood pressure control. A strong relationship was found between medication adherence and medication adherence self-efficacy (r = .549, p < .05).

Relationship of blood pressure self-monitoring, medication adherence, self-efficacy, stage of change, and blood pressure control among municipal workers with hypertension

Uncontrolled blood pressure remains a major public health issue. Medication adherence is a key factor in blood pressure management; however, adherence behavior is not clearly understood and the most significant factors contributing to poor medication adherence and blood pressure control are unknown. The purpose of this study was to determine the relationship of self-monitoring of blood pressure, medication adherence, self-efficacy, stage of change, and blood pressure control among municipal workers with access to health insurance. Stage of change was a significant independent predictor of self-monitoring of blood pressure, but not blood pressure control. A strong relationship was found between medication adherence and medication adherence self-efficacy (r = .549, p < .05).

Likelihood of dermatology patients to inquire about sun protection measures during a regular clinic visit

BACKGROUND

Health information-seeking behavior refers to ways individuals acquire health information. Few studies demonstrate its association with skin cancer.

OBJECTIVES

To determine the likelihood of patients to inquire about sun protection methods from dermatologists and whether such knowledge will affect their preventive behaviors.

METHODS

Over a 2-month period, 396 dermatology patients completed a survey assessing their sun awareness knowledge and inquiry about sun protection measures. Features associated with increased skin cancer risk were correlated with patients' inquiry about sun protection information and their future intentions to practice safe sun behavior.

RESULTS

One in seven patients (13.8%) inquired about sun protection measures. Patients with features known to be associated with increased skin cancer risk infrequently inquired about sun protection methods (4.5-23.8%). Post-physician counseling, patients with previous sun awareness education had a greater intention to use sunscreen routinely (41.4% vs 28.3%, p  =  .01), avoid the sun (31.2% vs 18.2%, p  =  .004), and wear sun-protective clothing (32.5% vs 23.2%., p  =  .05).

CONCLUSION

Patients' desire for medical information from physicians does not translate efficiently into seeking sun awareness information from dermatologists. Dermatologists should play a greater proactive role in skin cancer prevention through initiation of regular personalized discussions on sun awareness issues.

Randomized Trial of a Computer-Tailored Intervention for Patients with Depression

Purpose.

Examine the efficacy of a computer-tailored intervention (CTI) based on the transtheoretical model (TTM) for reducing depression, an increasingly important component of health promotion programs.

Design.

Pretest-posttest randomized trial.

Setting.

Participants were recruited and treated at home after being identified in two primary care clinics in Eastern Massachusetts and Chicago, Illinois.

Subjects.

A total of 350 adults experiencing at least mild symptoms of depression but not involved in or planning to seek treatment for depression.

Intervention.

A print manual and three CTI reports tailored to stage of change for using effective methods to prevent or reduce depression, other TTM variables, level of depression, and behavior.

Measures.

Pre-post changes and reliable and clinically significant change on the Beck Depression scale II and pre-post changes on the 20-item Medical Outcomes Study Short Form survey–based measure of physical functioning at 9 months' follow-up.

Analysis.

t-tests and χ2 tests. Complete-case analysis and two intention-to-treat analyses—assumption of no change and multiple imputation (MI)—are reported. Exploratory analyses examined whether the effects of the intervention on depression were moderated by five subject characteristics: baseline level of depression, baseline level of physical functioning, baseline stage of change for preventing or managing depression, age, and education.

Results.

Complete-case and intention-to-treat analyses showed that the intervention group experienced significantly greater improvements in depression (d = .220–.355); results for physical functioning were weaker (d = .150–.309) and did not reach statistical significance in the MI analysis. The effects of the intervention on reliable and clinically significant change in depression were largest among participants who were experiencing moderate depression (d = .363–.519) or severe depression (d = .603–.718) or who were in the precontemplation or contemplation stage (d = .573–.856) at baseline.

A Family History Intervention

This article describes the effect of individualized counseling using family history data and objective cardiovascular risk factors on intent to change and actual exercise behavior in a diverse sample of working adults. Using a longitudinal, quasi-Bxperimental, crossover design, objective data (blood lipids, glucose, blood pressure, and body mass index) and subjective data (awareness of heart disease risk, depression, spirituality, and knowledge of family history) were collected from 91 (mostly female and with a mean age of 45 years) primary and secondary teachers in a southwestern city. The Transtheoretical Model of Change guided the study and measured intent to exercise. Objective risks in this sample mirrored national indices of risk for obesity and abnormal lipids. Although some participants increased their exercise, no significant differences were found between the groups in exercise behavior at 6 and 12 months. Using knowledge of family history to raise awareness and encourage lifestyle changes related to cardiovascular risk warrants further study.

Predicting oral contraceptive continuation using the transtheoretical model of health behavior change

CONTEXT

Improved continuation of oral contraceptive use may decrease the incidence of unintended pregnancy. Therefore, identifying predictors of continuation is important to informing targeted interventions.

METHODS

A survey conducted in 2003-2005 collected data from young women who sought oral contraceptives at three family planning clinics in New York, Dallas and Atlanta. Cluster analysis of data from 1,245 women was used to identify three distinct groups on the basis of baseline responses to items measuring constructs from the transtheoretical model of health behavior change: perceived advantages of pill use, perceived disadvantages and self-confidence in ability to sustain use. Logistic regression was used to assess the likelihood of continuation among the clusters.

RESULTS

Participants who were confident in their ability to use the pill and who considered both its advantages and its disadvantages important were more likely to continue use for six months than were those who gave low scores to the method's advantages and their ability to use it (odds ratio, 1.4). The same appeared to be true for those who gave high scores to the pill's advantages and their ability to use it, but a low score to the method's disadvantages (1.3); however, this finding was only marginally significant. Demographic variables were not significant after adjustment for cluster membership.

CONCLUSIONS

Cluster membership based on transtheoretical model constructs helps predict oral contraceptive continuation. Women who undervalue the advantages of pill use and have low confidence in their ability to use the method represent a target for interventions and future research.

A meta-analysis of computer-tailored interventions for health behavior change

OBJECTIVE

Computer-tailored interventions have become increasingly common for facilitating improvement in behaviors related to chronic disease and health promotion. A sufficient number of outcome studies from these interventions are now available to facilitate the quantitative analysis of effect sizes, permitting moderator analyses that were not possible with previous systematic reviews.

METHOD

The present study employs meta-analytic techniques to assess the mean effect for 88 computer-tailored interventions published between 1988 and 2009 focusing on four health behaviors: smoking cessation, physical activity, eating a healthy diet, and receiving regular mammography screening. Effect sizes were calculated using Hedges g. Study, tailoring, and demographic moderators were examined by analyzing between-group variance and meta-regression.

RESULTS

Clinically and statistically significant overall effect sizes were found across each of the four behaviors. While effect sizes decreased after intervention completion, dynamically tailored interventions were found to have increased efficacy over time as compared with tailored interventions based on one assessment only. Study effects did not differ across communication channels nor decline when up to three behaviors were identified for intervention simultaneously.

CONCLUSION

This study demonstrates that computer-tailored interventions have the potential to improve health behaviors and suggests strategies that may lead to greater effectiveness of these techniques.

Does a typical contemplator exist? Three clusters of smokers in contemplation

The aim of this study is to test whether subtypes exist among smokers in contemplation. Data from 194 adult smokers that participated in a randomized controlled trial testing the effectiveness of a computer-tailored smoking cessation program in Dutch general practices were used for secondary analysis. Cluster analysis was conducted based on baseline scores on pros and cons of quitting and self-efficacy to quit. Clusters were cross-sectionally compared for demographic variables and smoking characteristics with analyses of variance (ANOVA) and Chi-square tests. Logistic and multinomial regression analyses were used for longitudinal comparison for smoking behavior and stage of change at 6 months follow-up. Three clusters were identified: Early, Progressing and Disengaged Contemplators. Clusters differed significantly on all clustering variables (P < 0.001). Disengaged smokers were significantly less addicted than Early Contemplators. Cluster membership was not predictive of outcome measures. No subtype was identified representing the Classic Contemplator, scoring high on both pros and cons of quitting and low on self-efficacy, as found in previous studies among US samples. The predictive validity of the clusters found was limited.

Challenges and recommendations for blinding in behavioral interventions illustrated using a case study of a behavioral intervention to lower blood pressure

OBJECTIVE

To describe the challenges to blinding in behavioral interventions, specifically those for asymptomatic medical conditions, where the intervention is through counseling, and to provide recommendations for achieving blinding in behavioral randomized controlled trials (RCTs).

METHODS

This paper reviews the challenges of preserving blinding in behavioral RCTs with a focus on interventions for asymptomatic medical conditions. This is illustrated using a case study of an ongoing behavioral intervention to improve hypertension control.

RESULTS

In contrast to easily keeping study investigators and participants masked to treatment assignment through the use of identical pills or sham treatments, the need to have differing levels of blinding among study personnel and participants in randomized behavioral intervention trials is presented. Recommendations for achieving this are provided.

CONCLUSIONS

Despite the challenges inherent in behavioral interventions, it is possible to achieve differing levels of blinding across study personnel and participants to minimize bias and generate valid data in RCTs that test interventions for asymptomatic medical conditions such as hypertension. Modifications may be needed for RCTs in symptomatic medical conditions.

PRACTICE IMPLICATIONS

Researchers designing behavioral RCTs should be aware of the challenges to blinding all staff and study participants, and plan to have procedures in place to standardize outcome data collection and intervention delivery without compromising the varying levels of blinding. The challenges and recommendations described may need modifications in behavioral intervention studies for symptomatic conditions.

Computer-mediated patient education: opportunities and challenges for supporting women with ovarian cancer

A majority of women with ovarian cancer will face recurrent disease despite receiving aggressive chemotherapy at the time of diagnosis. Given the complex medical and psychosocial needs of women with ovarian cancer and the time constraints within busy clinical settings, providing women with the necessary education related to their disease and treatments can be challenging. The advent of computers and web-based technologies has created new opportunities for educating cancer patients and supporting them to better cope with their disease. This article reviews prior studies of computer-based patient education interventions to identify key intervention components and other factors associated with improved patient outcomes. Opportunities for using computer-based technologies to support women with ovarian cancer are discussed and WRITE Symptoms (a Written Representational Intervention To Ease Symptoms), a web-based, symptom management intervention for women with recurrent ovarian cancer, is introduced.

Optimising long-term participation in physical activities after stroke: exploring new ways of working for physiotherapists

There is now good empirical evidence of physical and functional benefits for individuals with stroke from long-term engagement in a range of physical activities. However, long-term participation of stroke survivors in physical activity after rehabilitation is low, and maximum benefits are not being achieved. This article reviews relevant literature and evidence, and suggests that physiotherapists are ideally placed to support patients in long-term participation in activity as they prepare patients for the end of physical rehabilitation. However, this requires the development, testing and application of stroke-specific evidence-based behavioural and motivational interventions that are feasible in clinical practice, take account of the role of carers, and seek to address the barriers to activity faced by stroke survivors at the end of rehabilitation. It also requires physiotherapists to take a leading role in developing appropriate policies and strategies with other exercise professionals and services to address the transition from rehabilitation to an active lifestyle following stroke.

Decision making in the transtheoretical model of behavior change

Decision making is an integral part of the transtheoretical model of behavior change. Stage of change represents a temporal dimension for behavior change and has been the key dimension for integrating principles and processes of change from across leading theories of psychotherapy and behavior change. The decision-making variables representing the pros and cons of changing have been found to have systematic relationships across the stages of change for 50 health-related behaviors. Implications of these patterns of relationships are discussed in the context of helping patients make more effective decisions to decrease health risk behaviors and increase health-enhancing behaviors.