Adaptation of a wellness intervention for women with chronic disabling conditions

Challenges encountered in the conduct of Optimal Health: A patient-centered comparative effectiveness study of interventions for adults with serious mental illness

BACKGROUND

The aim of patient-centered comparative effectiveness research is to conduct stakeholder-driven investigations that identify which interventions are most effective for which patients under specific circumstances. Conducting this research in real-world settings comes with unique experiences and challenges. We provide the study design, challenges confronted, and the solutions we devised for Optimal Health, a stakeholder-informed patient-centered comparative effectiveness study focused on the needs of seriously mentally ill individuals receiving case management services in community mental health centers across Pennsylvania.

METHODS

Optimal Health, supported by the Patient-Centered Outcomes Research Institute, is a cluster-randomized trial of two evidence-based interventions for improving health and wellness across 11 provider sites. Participants were followed for 18-24 months, with repeated measurements of self-reported health status and activation in care and administrative measurements of primary and specialty health service utilization. Health-related quality of life, engagement in care, and service utilization are to be compared via random effects mixed models. Stakeholders were, and continue to be, engaged via focus groups, interviews, and stakeholder advisory board meetings. A learning collaborative model was used to support shared learning and implementation fidelity across provider sites.

RESULTS

From 1 November 2013 through 15 July 2014, we recruited 1229 adults with serious mental illness, representing 85.1% of those eligible for study participation. Of these, 713 are in the Provider-Supported arm of the study and 516 in Patient Self-Directed Care. Across five data collection time points, we retained 86% and 83% of the participants in the Provider-Supported and Self-Directed arms, respectively.

LESSONS LEARNED

Lessons learned relate to estimation of the size of our study population, the value of multiple data sources, and intervention training and implementation. The use of historical claims data can lead to an overestimation of eligible participants and, subsequently, a reduced study sample and an imbalance between intervention arms. Disruptions in continuity of care in real-world settings can pose challenges to on-site self-report data collection, although the inclusion of multiple data sources in study design can improve data completeness. Geographic dispersion of rural provider sites and staff turnover can lead to training and intervention fidelity challenges that can be overcome with the use of a "train-the-trainer" model, "wellness champions," and the use of a Learning Collaborative approach. Stakeholder engagement in mitigating these challenges proved to be critical to study progress.

CONCLUSION

Conducting real-world patient-centered comparative effectiveness research in healthcare systems that care for seriously mentally ill persons is an important yet challenging undertaking, one which requires flexibility in identifying potential adaptations within all major study phases. Advice from a wide range of stakeholders is critical in development of successful strategies.

Development of a Cognitive Behavioral Group Intervention Programme for Patients with Multiple Sclerosis: An Exploratory Study

A substantial group of patients with multiple sclerosis (MS) has difficulty coping with their disease. Cognitive behavioral group interventions may help these patients cope more effectively with MS. We developed an 8-session group intervention programme for patients recently diagnosed with MS to help them cope more effectively with MS and to overcome negative thoughts and beliefs about the disease to improve health-related quality of life. We tested the feasibility of the group intervention programme and health-related quality of life in a sample of 11 patients recently diagnosed with MS [mean age: 38 (±7.9) yr.; 8 women and 3 men]. All patients were recruited through direct referral by their neurologist or by an MS nurse specialist. The programme was conducted in two small groups of 7 patients each, and each group was led by two psychologists. Cognitive behavioral therapy was an important ingredient in each group session as well as sharing of personal experiences and discussing homework assignments. Each session was formatted the same way but addressed a different MS-specific theme, for example, ‘coping with physical impairments’ or ‘communication with medical staff’. Participants experienced a significant improvement in the health-related quality of life domains of psychological status and vitality, as measured by subscales of Disability and Impact Profile and the Short Form-36 Health Survey. Although further studies are warranted, it appears that a short group intervention programme based on cognitive behavioral techniques for patients with MS might have a positive influence on health-related quality of life.

Living with illness and self-transcendence: the lived experience of patients with spinal muscular atrophy

AIM

The aim of this study was to explore the lived experiences of patients afflicted with spinal muscular atrophy.

BACKGROUND

Existing research studies on spinal muscular atrophy address the physical and psychological effects and complications of the disease; they also provide suggestions for how to improve the current management of this disease. However, information is limited on the disease process and the lived experience of spinal muscular atrophy patients.

DESIGN

A phenomenological approach was conducted.

METHODS

Through 18 in-depth interviews recorded by a pen voice recorder, this study collected data obtained from a purposive sample of nine patients from the, 'Taiwan spinal muscular atrophy Families,' between November 2010-August 2011. The audio recordings were transcribed verbatim and data were analysed using Colaizzi's steps.

FINDINGS

Four themes and eight subthemes were identified: a loss of control (loss of muscular strength and independence), breaking limitations (assistive device use and mobility design), transcending limitations (independence/autonomy and social development) and living with hope (cherishing life and self-control). The results showed that the lived experiences of the spinal muscular atrophy patients involved living with illness, transcending the self and pursuing the meaning of life. Facing a life-threatening illness, these patients made self-adjustments in their lifestyles and exerted themselves to positively cope with hardships and maintain dignity and self-control.

CONCLUSION

These findings could serve as evidence-based practice resources for healthcare professionals in helping individuals and their family members gain an in-depth understanding of spinal muscular atrophy's progression and life course and assist individuals in improving self-integrity to with hope.

A double whammy: health promotion among cancer survivors with preexisting functional limitations

PURPOSE/OBJECTIVES

To explore the experience of living with a preexisting functional disability and a cancer diagnosis and to identify strategies that promote health in the growing population of cancer survivors.

RESEARCH APPROACH

Qualitative, descriptive.

SETTING

Four sites in the United States.

PARTICIPANTS

19 female cancer survivors with preexisting disabling conditions.

METHODOLOGIC APPROACH

Four focus groups were conducted. The group discussions were audio recorded and transcribed and analyzed using content analysis techniques.

FINDINGS

Analytic categories included living with a cancer diagnosis, health-promotion strategies, and wellness program development for survivors with preexisting functional limitations. Participants described many challenges associated with managing a cancer diagnosis on top of living with a chronic disabling functional limitation. They identified strategies to maintain health and topics in health-promotion programs tailored for this unique group of cancer survivors.

CONCLUSIONS

The "double whammy" of a cancer diagnosis for people with preexisting functional limitations requires modification of health-promotion strategies and programs to promote wellness in this group of cancer survivors.

INTERPRETATION

Nurses and other healthcare providers must attend to patients' preexisting conditions as well as the challenges of the physical, emotional, social, and economic sequelae of a cancer diagnosis.

KNOWLEDGE TRANSLATION

Cancer survivors with preexisting functional disabilities had difficulties finding cancer care providers who could manage their unique needs. That may be because some cancer-care providers are inadequately prepared to care for patients with cancer who have complex preexisting conditions. Cancer survivors with preexisting conditions may benefit from health-promotion programs that emphasize self-advocacy strategies, management of the economic impact of multiple diagnoses, and wellness activities adapted to their unique functional limitations.

Health promotion for cancer survivors: adaptation and implementation of an intervention

Randomized control trial of a health promotion intervention was implemented for low-income cancer survivors. The majority of participants were female, older, divorced, educated, and unemployed or on disability leave. Findings indicate the health promotion intervention improved cancer survivors' self-efficacy and increased their use of health-promoting behaviors.

A health and wellness intervention for those with moderate to severe traumatic brain injury: a randomized controlled trial

OBJECTIVES

To assess the efficacy of a standardized 12-week health and wellness group intervention for those with moderate to severe traumatic brain injury (TBI).

STUDY DESIGN

Randomized controlled trial.

PARTICIPANTS

Seventy-four individuals with moderate to severe TBI recruited from the outpatient program at a rehabilitation hospital, a Veterans Affairs Medical Center, and the community.

METHOD

Eligible participants were randomized to treatment (health and wellness therapy group) or wait-list control (treatment, n = 37; wait-list, n = 37). The primary outcome was the Health Promoting Lifestyle Profile-II.

RESULTS

The results of the mixed-model repeated-measures analysis indicated no differences between treatment and control groups engaging in activities to increase their health and well-being.

CONCLUSIONS

Findings did not support the efficacy of the intervention. Results may have been impacted by the wide variability of individualized health and wellness goals selected by group members, the structure and/or content of the group, and/or the outcome measures selected.

Using an e-health intervention to promote the health of cancer survivors with preexisting disabling conditions

Although there has been research on the use of e-health for cancer patients and those living with disabilities, no interventions focus on cancer survivors who had a disabling condition prior to their cancer. Therefore, we developed and piloted the feasibility of the online health-promotion program LiveAble. Based on a theoretically driven health-promotion program previously shown to be effective among people with various chronic conditions, LiveAble was adapted to be an e-heath intervention for cancer survivors with preexisting disabilities. Eleven cancer survivors reviewed LiveAble and provided feedback. The participants' average age was 54 years. Most had neuromuscular impairments prior to their cancer; about half were breast cancer survivors. Average scores on the Self-efficacy for Health Practices Scale increased. Participants rated LiveAble useful, attractively presented, and relevant to people with disabilities. Their feedback also suggested areas for change, such as a system that was easier to navigate and more individualized. Only 51% of these participants agreed that LiveAble motivated them to take action to improve their health. To turn information into action, participants may need additional assistance and encouragement. Although preliminary results were promising, future efforts should determine the efficacy of LiveAble with larger and more diverse groups of survivors.

Self-efficacy and health status improve after a wellness program in persons with multiple sclerosis

PURPOSE

To determine if an intensive wellness program for persons with MS results in improved self-efficacy, quality of life (QOL), or physical activity outcomes.

METHODS

129 subjects participated in one of seven 4-day interdisciplinary educational wellness programs throughout the United States. This intervention was based on the philosophy that health management is important to disease management. The program consisted of psychological and physiological evaluations, lectures and workshops. Before the intervention and after at 1, 3 and 6 months, self-efficacy (MS Self-Efficacy Scale, MSSE, control), health related QOL (SF-36) and physical activity (Physical Activity Scale for Persons with Physical Disabilities, PASAID) was assessed.

RESULTS

Improvements were noted at 1, 3 and 6 months post-intervention. Those present at 6 months included, MSSE, role physical, vitality and mental health scales of the SF-36. PASAID did not change. Improvements were independent of disability (EDSS).

CONCLUSION

A 4-day multidisciplinary educational wellness program can result in improvement in self-efficacy and health-related QOL in persons with MS and can be stable up to at least 6 months. Improvements do not depend on degree of disability.

Psychosocial health status of persons seeking treatment for exposure to libby amphibole asbestos

A cross-sectional exploratory study was conducted to describe the psychosocial health status of persons seeking health care for exposure to Libby amphibole asbestos (LAA). Health indicators including depression, stress, acceptance of illness, and satisfaction with access and financial aspects of care were obtained via electronic and paper-pencil survey. The exposure pathway and demographic data were gleaned from the health record. Of the 386 participants, more than one-third (34.5%) demonstrated significant levels of psychological distress. The oldest group of women had the lowest levels of depression and stress and the highest acceptance of illness. Gender, age, and satisfaction with financial resources were significantly related to depression, stress, and acceptance of illness. Satisfaction with access to care was significant only for stress. No differences in depression, stress, and acceptance of illness were found based on residence, exposure pathway, or insurance status.

The relevance of depressive symptoms and social support to disability in women with multiple sclerosis or fibromyalgia

Multiple sclerosis and fibromyalgia syndrome may spur substantial disability for those affected. Using structural equation modeling, this secondary analysis examined predictors of disability in women with multiple sclerosis (n = 118) and fibromyalgia syndrome (n = 197) recruited for separate wellness studies. Greater functional limitations, lower economic adequacy, less social support, and higher depressive symptoms predicted greater disability in both groups. The final multigroup model showed good fit chi [(111, n = 315) = 135.92, comparative fit index = 0.99, root mean square error of approximation = 0.03] and identified similarities and differences across groups.

A randomized controlled trial of a wellness intervention for women with fibromyalgia syndrome

OBJECTIVE

To examine the effects of a wellness intervention, Lifestyle Counts, for women with fibromyalgia syndrome on the level of self-efficacy for health-promoting behaviours, health-promoting activity and perceived quality of life.

DESIGN

A randomized controlled single-blinded trial with treatment and attention-control groups.

SETTING

Community in the southwestern United States.

SUBJECTS

Convenience sample of 187 women (98 treatment, 89 attention control) with fibromyalgia syndrome (mean age = 53.08 years, SD 9.86).

INTERVENTION

The two-phase Lifestyle Counts intervention programme included lifestyle change classes for eight weeks, with goal-setting and telephone follow-up for three months. Participants in the attention-control group were offered an equivalent amount of contact in classes on general disease-related information and health education topics and unstructured follow-up phone calls. Participants were followed for a total of eight months after baseline.

OUTCOME MEASURES

Self-report instruments measuring self-efficacy for health behaviours, health-promotion behaviours and health-related quality of life (SF-36 and the Fibromyalgia Impact Questionnaire) were completed at baseline, two months (after the classes), five months (after telephone follow-up) and at eight months.

RESULTS

Both groups improved significantly (P<0.05) over time on the measures of self-efficacy, health behaviours, fibromyalgia impact and quality of life. There were significant group x time interactions for scores on the Health Promoting Lifestyle II subscales of physical activity and stress management.

CONCLUSIONS

The Lifestyle Counts wellness intervention holds promise for improving health-promoting behaviours and quality of life of women with fibromyalgia syndrome.

The use of goal attainment scaling to facilitate and assess individualized change in a wellness intervention for women with fibromyalgia syndrome

PURPOSE

The authors examined goal achievement over an 8-month period in women with fibromyalgia participating in a holistic health promotion intervention using Goal Attainment Scaling.

DESIGN

Descriptive.

METHODS

Goal attainment was assessed by interviews at five points: baseline (retrospectively), immediately after the 8-week classes, at the middle and end of the telephone support period, and 3 months later.

FINDINGS

The percentage of women who attained or exceeded their goals in the four health promotion areas of Lifestyle Adjustment, Physical Activity, Nutrition, and Stress Management increased from between 15% and 26% at the end of the classes to between 58% and 76% at the end of the telephone support period. Although scores declined somewhat in the following 3 months, at least 60% of the women continued to report behaviors at or above their goal level in all areas except Physical Activity.

CONCLUSIONS

Goal Attainment Scaling, an individually determined measure of change, can effectively capture behavioral changes associated with a holistic health promotion intervention. A nurse facilitator, who not only understood the need for specific, measurable GAS but was also able to encourage and support women's identification of goals that were meaningful to them, was key to the positive findings observed here.

Development of the Activity Effort Scale for women aging with paralytic polio

The purpose of this study was to develop and psychometrically test the Activity Effort Scale among women aging with the affects of paralytic polio. On the basis of prior qualitative research, six items were generated. Two researchers with expertise in disability were consulted for examination of the items, which led to the addition of two more items to the scale. Next, a survey was sent to 500 women with a history of paralytic polio. Data from participants were subjected to psychometric testing: factor analysis, reliability testing, and correlation with existing measures. Useable surveys were returned by 299 women aged 49 to 75 years. Mean age of infection with polio was 7.6 years, and 54% had spinal polio. Principal component analysis of the 8-item scale resulted in one component with an eigenvalue above 1, explaining 74% of the variance. The Cronbach's alpha was .92. Correlations between variables supported content validity. Data suggest that the Activity Effort Scale is a valid and reliable tool consisting of one component measuring frequency of effort exerted beyond levels of discomfort, pain, and fatigue among women aging with paralytic polio.

Structural equation modeling of disability in women with fibromyalgia or multiple sclerosis

Structural equation modeling (SEM), a popular statistical technique for analysis of multivariate data in the social sciences, is increasingly being used in the behavioral and clinical sciences. SEM is appropriate for posing complex models that evaluate the direct and indirect influence of several variables on one or more outcome variables. A biosocial model of disability, the Disablement Process Model, lends itself to evaluation by SEM. Using SEM, this study examined predictors of disability (Age, Education, Duration of Illness, and Economic Adequacy Functional Limitations, Depressive Symptoms, and Social Support) separately in women with multiple sclerosis (MS) and women with fibromyalgia syndrome (FMS) and compared the respective models across groups. Data were analyzed with Analysis of Moment Structures (Amos) 7.0. Problems identified in initial confirmatory model testing included collateral correlated errors, a negative error variance, and poor performance of the disability indicators. After specifying well-fitting confirmatory models for each group, a structural model for the larger FMS group was estimated. Model refinement resulted in the reversal of the path between Depressive Symptoms and Social Support. Further model revisions were based on comparative fit statistics and theoretical logic. The structural model developed from the FMS sample required minimal changes to fit the MS sample. The multisample model explained greater variance in disability in women with FMS than in women with MS. Social support and depressive symptoms mediated the effect of functional limitations on disability. Interventions that target modifiable characteristics, such as depression and social support, may improve outcomes such as disability.

Improving the health and wellness of persons with disabilities: A call to action too important for nursing to ignore

In 2005, the US Surgeon General issued a Call to Action to Improve the Health and Wellness of Persons with Disabilities, with the goal being the improvement of the health status of men, women, and children with disabilities. Despite federal legislation to address inequities in health care for the 54-60 million people in the US with disabilities, many have reported negative experiences in their interactions with health care providers from all health professions. Collectively, the nursing profession has been silent in its response to this call. This article describes the current status of health care of individuals with disabilities in the US, and suggests appropriate responses by the nursing profession to the Surgeon General's Call to Action. Specific suggestions are identified for nursing practice, education, research, nursing leaderships, and the profession of nursing as a whole.

Improving the health and health behaviors of women aging with physical disabilities: A peer-led health promotion program

OBJECTIVE

To examine the efficacy of a health promotion program for women aging with physical disabilities.

METHOD

A sample of 137 middle-aged and older women with physical disabilities was randomly assigned to either an 8-week health promotion program or to a wait-list control group. Both groups completed questionnaires before, immediately after, and 3 months after the intervention.

RESULTS

Relative to women in the control group, women in the health-promotion program demonstrated improvements in health behaviors, most of which were maintained at follow-up. The intervention group showed some improvements on measures of physical health, but there was little evidence of improvement in psychological health outcomes. Testing our theoretical model, self-efficacy was supported as a mediator of the effect of the intervention on health behaviors, and health behaviors combined with self-efficacy were supported as mediators of the effect of the intervention on physical health outcomes. Contrary to our hypotheses, our measures of social support and social connectedness were not affected by the intervention.

CONCLUSIONS

A brief, peer-led, group health promotion program resulted in improved scores on measures of self-efficacy, increased health behavior, and physical health. Self-efficacy, which was supported as a mediator in the effect of the intervention on behaviors and health outcomes, should remain an important focus of future interventions with this population.

Building health promotion interventions for persons with chronic disabling conditions

There is a growing number of persons with chronic disabling conditions and a concurrent interest and need for health-promotion interventions to prevent disability and promote quality of life within the context of chronic conditions. Most often researchers/clinicians build their own intervention focusing on selected dimensions of health promotion for a specific population. This article recommends an alternative process of building health-promotion interventions for specific groups through the adaptation of content and processes of well-developed intervention frameworks with sound theoretical and empirical support. This efficient approach enhances the likelihood that new interventions will prove to be effective and enhance the quality of life for persons with chronic disabling conditions.