Intervention planning for the REDUCE maintenance intervention: a digital intervention to reduce reulceration risk among patients with a history of diabetic foot ulcers

Development of a resource-use measure to capture costs of diabetic foot ulcers to the United Kingdom National Health Service, patients and society

Background

Diabetic foot ulcers (DFUs) add a significant burden to the lives of people with diabetes in the United Kingdom. They can have a considerable impact on a patient's daily life, with treatment requiring frequent changes of dressings and clinic attendances. Nurses and other allied health professionals (AHPs) within the community provide most wound care representing the primary cost driver.

Aims

To collaboratively explore key resource use related to the management of DFUs to develop, and pilot, a participant-reported measure to inform economic evaluations.

Methods

A literature search and semi-structured interviews determined health and non-health resource use in management of DFUs. A consensus view of the selected items was established in a modified Delphi study and further tested for acceptability and validity in a pilot study.

Results

Primary care consultations with a podiatrist or orthotist, district nurse visits, out-of-hours and emergency care, scans and investigations, and consumables provided in clinics were rated as the most important resource use items.

Conclusions

This work has informed the development of a measure that captures resource use considered important by the people most affected by DFUs; patients, family members and carers, and the healthcare professionals key to DFU management.

Supporting patients to prepare for total knee replacement: Evidence-, theory- and person-based development of a 'Virtual Knee School' digital intervention

INTRODUCTION

Digital delivery of pre-operative total knee replacement (TKR) education and prehabilitation could improve patient outcomes pre- and post-operatively. Rigorously developing digital interventions is vital to help ensure they achieve their intended outcomes whilst mitigating their potential drawbacks.

OBJECTIVE

To develop a pre-operative TKR education and prehabilitation digital intervention, the 'Virtual Knee School' (VKS).

METHODS

The VKS was developed using an evidence-, theory- and person-based approach. This involved a mixed methods design with four phases. The first three focused on planning the VKS. The final phase involved creating a VKS prototype and iteratively refining it through concurrent think-aloud interviews with nine patients who were awaiting/had undergone TKR. Meta-inferences were generated by integrating findings from all the phases. ISRCTN registration of the overall project was obtained on 24 April 2020 (ISRCTN11759773).

RESULTS

Most participants found the VKS prototype acceptable overall and considered it a valuable resource. Conversely, a minority of participants felt the prototype's digital format or content did not meet their individual needs. Participants' feedback was used to refine the prototype's information architecture, design and content. Two meta-inferences were generated and recommend: 1. Comprehensive pre-operative TKR education and prehabilitation support should be rapidly accessible in digital and non-digital formats. 2. Pre-operative TKR digital interventions should employ computer- and self-tailoring to account for patients' individual needs and preferences.

CONCLUSIONS

Integrating evidence, theory and stakeholders' perspectives enabled the development of a promising VKS digital intervention for patients awaiting TKR. The findings suggest future research evaluating the VKS is warranted and provide recommendations for optimising pre-operative TKR care.

PATIENT OR PUBLIC CONTRIBUTION

Patient and Public Involvement (PPI) was central throughout the project. For example, PPI representatives contributed to the project planning, were valued members of the Project Advisory Group, had key roles in developing the VKS prototype and helped disseminate the project findings.

Experiences of Using Digital Mindfulness-Based Interventions: Rapid Scoping Review and Thematic Synthesis

BACKGROUND

Digital mindfulness-based interventions (MBIs) are a promising approach to deliver accessible and scalable mindfulness training and have been shown to improve a range of health outcomes. However, the success of digital MBIs is reliant on adequate engagement, which remains a crucial challenge. Understanding people's experiences of using digital MBIs and identifying the core factors that facilitate or act as barriers to engagement is essential to inform intervention development and maximize engagement and outcomes.

OBJECTIVE

This study aims to systematically map the literature on people's experiences of using digital MBIs that target psychosocial variables (eg, anxiety, depression, distress, and well-being) and identify key barriers to and facilitators of engagement.

METHODS

We conducted a scoping review to synthesize empirical qualitative research on people's experiences of using digital MBIs. We adopted a streamlined approach to ensure that the evidence could be incorporated into the early stages of intervention development. The search strategy identified articles with at least one keyword related to mindfulness, digital, user experience, and psychosocial variables in their title or abstract. Inclusion criteria specified that articles must have a qualitative component, report on participants' experiences of using a digital MBI designed to improve psychosocial variables, and have a sample age range that at least partially overlapped with 16 to 35 years. Qualitative data on user experience were charted and analyzed using inductive thematic synthesis to generate understandings that go beyond the content of the original studies. We used the Quality of Reporting Tool to critically appraise the included sources of evidence.

RESULTS

The search identified 530 studies, 22 (4.2%) of which met the inclusion criteria. Overall, the samples were approximately 78% female and 79% White; participants were aged between 16 and 69 years; and the most used measures in intervention studies were mindfulness, psychological flexibility, and variables related to mental health (including depression, anxiety, stress, and well-being). All studies were judged to be adequately reported. We identified 3 themes characterizing barriers to and facilitators of engagement: responses to own practice (ie, negative reactions to one's own practice are common and can deplete motivation), making mindfulness a habit (ie, creating a consistent training routine is essential yet challenging), and leaning on others (ie, those engaging depend on someone else for support).

CONCLUSIONS

The themes identified in this review provide crucial insights as to why people frequently stop engaging with digital MBIs. Researchers and developers should consider using person-based coparticipatory methods to improve acceptability of and engagement with digital MBIs, increase their effectiveness, and support their translation to real-world use. Such strategies must be grounded in relevant literature and meet the priorities and needs of the individuals who will use the interventions.

The perceptions of living with diabetic foot ulcers: A systematic review and meta-synthesis of qualitative studies

BACKGROUND

Diabetic foot ulcers are associated with decreased quality of life in patients with diabetes and impose a heavy burden on patients, their families, and the health care system. For health providers, a deeper understanding of the perceptions of patients is significant. They can provide better management and direction to patients with diabetic foot ulcers, thus improving their quality of life.

OBJECTIVES

To synthesize the findings of qualitative studies to explore the perceptions of individuals living with diabetic foot ulcers.

DESIGN

A systematic review and meta-synthesis of qualitative studies.

METHODS

Published qualitative research articles were identified in PubMed, CINAHL, Embase, ISI Web of Science, Ovid, and Scopus from inception to January 2022, and bibliographical reports were reviewed. In addition, combing with the search for unpublished studies in the Google Scholar ProQuest Dissertations and Theses Database, we conducted a meta-synthesis.

RESULTS

Fourteen articles were eligible for inclusion, and the total number of included individuals was 226, with ages ranging from 28 to 84 years. The perceptions of individuals with diabetic foot ulcers synthesized four overarching themes and their subthemes: perceptions of diabetic foot ulcers (Realization, Reasons), living with diabetic foot ulcers (Change in life, Physical burdens, Emotional burdens, Economic burdens), coping with diabetic foot ulcers (Hospital attendance, Attitude toward amputation, Treatment, Management), and expectations (Expectation of health-personnel, Future expectation).

CONCLUSIONS

Individuals with diabetic foot ulcers suffer greatly in their physical, psychological, and social aspects. Comprehensive and individualized patient-centered care and appropriate families and social support for patients with diabetic foot ulcers should be provided.

Planning a digital intervention for adolescents with asthma (BREATHE4T): A theory-, evidence- and Person-Based Approach to identify key behavioural issues

OBJECTIVES

To describe a transparent approach to planning a digital intervention for adolescents to self-manage their asthma using breathing retraining (BRT), based on an existing, effective adult intervention (BREATHE).

METHODS

A theory-, evidence-, and Person-Based Approach was used to maximise the effectiveness and persuasiveness of the intervention. A scoping review and semistructured interviews with target intervention users (N = 18, adolescents aged 12-17 years with asthma and parents) were carried out to explore user perspectives, barriers, and facilitators towards the intended behaviours and potential intervention features. The combined evidence was used alongside and to inform theory-based activities and enabled iterative planning of the intervention.

RESULTS

The scoping review identified themes relating to user-specific self-management issues, content, education, training needs, and features for a digital intervention. Interviews elicited potential barriers to intended behaviours such as the anticipated embarrassment of using BRT and concerns around remaining calm. Facilitators included BRT delivered by adolescents who share experiences of asthma and information for performing exercises discreetly. Relevant theoretical frameworks ensured that appropriate psychological constructs were targeted. A behavioural analysis identified six intervention functions and thirty behaviour change techniques. Logic modelling mapped the programme theory and mechanisms, which aims to improve adolescent asthma-related quality of life.

CONCLUSIONS

This study gives a transparent insight into the approach followed to plan a self-guided BRT intervention for adolescents and has led to identification of key behavioural issues, enabling relevant intervention content to be chosen. Insight has been given into adolescent perceptions of BRT, which facilitated development of the prototype intervention.

How is the NHS Low-Calorie Diet Programme expected to produce behavioural change to support diabetes remission: An examination of underpinning theory

Background

In 2020, the National Health Service Low-Calorie Diet Programme (NHS-LCD) was launched, piloting a total diet (TDR) replacement intervention with behaviour change support for people living with Type 2 Diabetes (T2D) and excess weight. Four independent service providers were commissioned to design and deliver theoretically grounded programmes in localities across England.

Aims

1) to develop a logic model detailing how the NHS-LCD programme is expected to produce changes in health behaviour, and (2) to analyse and evaluate the use of behaviour change theory in providers' NHS-LCD Programme designs.

Methods

A documentary review was conducted. Information was extracted from the NHS-LCD service specification documents on how the programme expected to produce outcomes. The Theory Coding Scheme (TCS) was used to analyse theory use in providers' programme design documents.

Results

The NHS-LCD logic model included techniques aimed at enhancing positive outcome expectations of programme participation and beliefs about social approval of behaviour change, to facilitate programme uptake and behaviour change intentions. This was followed by techniques aimed at shaping knowledge and enhancing the ability of participants to self-regulate their health behaviours, alongside a supportive social environment and person-centred approach.Application and type of behaviour change theory within service providers' programme designs varied. One provider explicitly linked theory to programme content; two providers linked 63% and 70% of intervention techniques to theory; and there was limited underpinning theory identified in the programme design documents for one of the providers.

Conclusion

The nature and extent of theory use underpinning the NHS-LCD varied greatly amongst service providers, with some but not all intervention techniques explicitly linked to theory. How this relates to outcomes across providers should be evaluated. It is recommended that explicit theory use in programme design and evidence of its implementation becomes a requirement of future NHS commissioning processes.

Eczema Care Online: development and qualitative optimisation of an online behavioural intervention to support self-management in young people with eczema

OBJECTIVES

To describe the development of Eczema Care Online (ECO), an online behaviour change intervention for young people with eczema (phase I); and explore and optimise the acceptability of ECO among this target group using think-aloud interviews (phase II).

METHODS

Theory-based, evidence-based and person-based approaches to intervention development were used. In phase I, a qualitative systematic review and qualitative interviews developed an in-depth understanding of the needs and challenges of young people with eczema. Guiding principles highlighted key intervention design objectives and features to address the needs of this target group to maximise user engagement. Behavioural analysis and logic modelling developed ECO's hypothesised programme theory. In phase II, qualitative think-aloud interviews were carried out with 28 young people with eczema and the intervention was optimised based on their feedback.

RESULTS

The final intervention aimed to reduce eczema severity by supporting treatment use (emollients, topical corticosteroids/topical calcineurin inhibitors), management of irritants/triggers, emotional management and reducing scratching. Generally, young people expressed positive views of intervention content and design in think-aloud interviews. Quotes and stories from other young people with eczema and ECO's focus on living with eczema (not just topical treatments) were valuable for normalising eczema. Young people believed ECO addressed knowledge gaps they had from childhood and the safety information about topical corticosteroids was reassuring. Negative feedback was used to modify ECO.

CONCLUSIONS

A prototype of the ECO intervention was developed using rigorous and complementary intervention development approaches. Subsequent think-aloud interviews helped optimise the intervention, demonstrated ECO is likely to be acceptable to this target group, and provided support for our guiding principles including key design objectives and features to consider when developing interventions for this population. A randomised controlled trial and process evaluation of the intervention is underway to assess effectiveness and explore user engagement with the intervention's behavioural goals.

Intervention Planning for the Tinnitus E-Programme 2.0, an Internet-Based Cognitive Behavioral Intervention for Tinnitus

Purpose The purpose of this study is to comprehensively describe the intervention planning process for the Tinnitus E-Programme 2.0, an Internet-based cognitive behavioral intervention for tinnitus. Method Theory-, evidence-, and person-based approaches to intervention development were used. In Phase 1, quantitative systematic reviews were used to identify potentially effective intervention techniques and design features. Primary mixed-methods research involving adults with tinnitus explored the acceptability of the first version of the intervention. In Phase 2, person-based guiding principles highlighted key intervention design objectives and features to address needs of the intervention's target group (identified in Phase 1) to maximize its acceptability, feasibility of delivery, and effectiveness. Theory-based "behavioral analysis" and "logic modeling" comprehensively described intervention content and potential mechanisms of action. From this planning work, a prototype intervention was developed. Results The intervention design objectives outlined in the guiding principles were to (a) normalize tinnitus, (b) support users to maintain a regular relaxation practice, (c) minimize the worsening of users' tinnitus sensation, and (d) ensure the intervention is accessible to those with hearing loss. Behavioral analysis and logic modeling identified intervention processes (e.g., illness perceptions, beliefs about consequences, skills, goals) and purported mediators (acceptance of tinnitus, negative thinking, use of the cognitive skills tools for managing negative thoughts, and practicing regular relaxation) hypothesized to facilitate reductions in tinnitus symptom severity. Conclusions The guiding principles highlight key design objectives and features to consider when developing interventions for tinnitus. The logic model offers hypothesized mechanisms of action that can be tested in future process analyses.

How patients interpret early signs of foot problems and reasons for delays in care: Findings from interviews with patients who have undergone toe amputations

Aims

To describe how patients respond to early signs of foot problems and the factors that result in delays in care.

Methods

Semi-structured interviews were conducted with a large sample of Veterans from across the United States with diabetes mellitus who had undergone a toe amputation. Data were analyzed using inductive content analysis.

Results

We interviewed 61 male patients. Mean age was 66 years, 41% were married, and 37% had a high school education or less. The patient-level factors related to delayed care included: 1) not knowing something was wrong, 2) misinterpreting symptoms, 3) “sudden” and “unexpected” illness progression, and 4) competing priorities getting in the way of care-seeking. The system-level factors included: 5) asking patients to watch it, 6) difficulty getting the right type of care when needed, and 7) distance to care and other transportation barriers.

Conclusion

A confluence of patient factors (e.g., not examining their feet regularly or thoroughly and/or not acting quickly when they noticed something was wrong) and system factors (e.g., absence of a mechanism to support patient’s appraisal of symptoms, lack of access to timely and convenient-located appointments) delayed care. Identifying patient- and system-level interventions that can shorten or eliminate care delays could help reduce rates of limb loss.

Knowledge, Attitude and Practice on Diabetic Wound Care Management among Healthcare Professionals and Impact from A Short Course Training in Sabah, Borneo

Objective

Healthcare professionals with an advanced level of knowledge and skills on diabetic wound care management are needed to effectively manage complex wounds. This study aimed to determine the effects of an educational intervention to enhance the management of wound care among healthcare professionals.

Method

This study was part of a quasi-experimental pre-post research design where 82 healthcare professionals were recruited and assigned to intervention and control groups. The participants in the intervention group attended two days of educational intervention training on diabetic wound care management, while there was no intervention in the control group. A questionnaire on knowledge, attitude, and practice was applied before and one-month post-intervention to both groups.

Results

Pre-test resulted in a low level of knowledge 72.1% and 74.4%, negative level of attitude 67.4% and 66.7%, and a moderate level of practice 79.1% and 76.9% in both intervention and control groups respectively. Post-test resulted in increasing levels of knowledge (76.7%), positive attitude (100%), and practice (76.7%) in the intervention group. At the same time, there was no significant change in the control group. Repeated Measure ANOVA for within-subject and between-subject effects resulted in a statistically significant p-value of 0.001 for knowledge, attitude, and practice after the educational intervention.

Conclusion

Health professionals have only a moderate level of knowledge on diabetic wound care management. It is important to improve this level by specific trainings and by using a good training module.

Developing a behavioural intervention package to identify and amend incorrect penicillin allergy records in UK general practice and subsequently change antibiotic use

OBJECTIVES

To develop a behavioural intervention package to support clinicians and patients to amend incorrect penicillin allergy records in general practice. The intervention aimed to: (1) support clinicians to refer patients for penicillin allergy testing (PAT), (2) support patients to attend for PAT and (3) support clinicians and patients to prescribe or consume penicillin, when indicated, following a negative PAT result.

METHODS

Theory-based, evidence-based and person-based approaches were used in the intervention development. We used evidence from a rapid review, two qualitative studies, and expert consultations with the clinical research team to identify the intervention 'guiding principles' and develop an intervention plan. Barriers and facilitators to the target behaviours were mapped to behaviour change theory in order to describe the proposed mechanisms of change. In the final stage, think-aloud interviews were conducted to optimise intervention materials.

RESULTS

The collated evidence showed that the key barriers to referral of patients by clinicians were limited experience of referral and limited knowledge of referral criteria and PAT. Barriers for patients attending PAT were lack of knowledge of the benefits of testing and lack of motivation to get tested. The key barriers to the prescription and consumption of first-line penicillin following a negative test result were patient and clinician beliefs about the accuracy of PAT and whether taking penicillin was safe. Intervention materials were designed and developed to address these barriers.

CONCLUSIONS

We present a novel behavioural intervention package designed to address the multiple barriers to uptake of PAT in general practice by clinicians and patients. The intervention development details how behaviour change techniques have been incorporated to hypothesise how the intervention is likely to work to help amend incorrect penicillin allergy records. The intervention will go on to be tested in a feasibility trial and randomised controlled trial in England.

Prevention of foot ulcers in the at-risk patient with diabetes: a systematic review

Prevention of foot ulcers in patients with diabetes is important to help reduce the substantial burden on both patient and health resources. A comprehensive analysis of reported interventions is needed to better inform healthcare professionals about effective prevention. The aim of this systematic review is to investigate the effectiveness of interventions to help prevent both first and recurrent foot ulcers in persons with diabetes who are at risk for this complication. We searched the available medical scientific literature in PubMed, EMBASE, CINAHL, and the Cochrane databases for original research studies on preventative interventions. We screened trial registries for additional studies not found in our search and unpublished trials. Two independent reviewers assessed data from controlled studies for methodological quality, and extracted and presented this in evidence and risk of bias tables. From the 13,490 records screened, 35 controlled studies and 46 non-controlled studies were included. Few controlled studies, which were of generally low to moderate quality, were identified on the prevention of a first foot ulcer. For the prevention of recurrent plantar foot ulcers, there is benefit for the use of daily foot skin temperature measurements, and for therapeutic footwear with demonstrated plantar pressure relief, provided it is consistently worn by the patient. For prevention of ulcer recurrence, there is some evidence for providing integrated foot care, and no evidence for a single session of education.Surgical interventions have been shown effective in selected patients, but the evidence base is small. Foot-related exercises do not appear to prevent a first foot ulcer. A small increase in the level of weight-bearing daily activities does not seem to increase the risk for foot ulceration. The evidence base to support the use of specific self-management and footwear interventions for the prevention of recurrent plantar foot ulcers is quite strong. The evidence is weak for the use of other, sometimes widely applied, interventions, and is practically non-existent for the prevention of a first foot ulcer and non-plantar foot ulcer.