An Integrative Review of Enablement in Primary Health Care

Patient enablement and health-related quality of life for patients with chronic back and knee pain: a cross-sectional study in primary care

BACKGROUND

Chronic back and knee pain impairs health- related quality of life (HRQoL) and patient enablement can improve HRQoL.

AIM

To determine whether enablement was a moderator of the effect of chronic back and knee pain on HRQoL.

DESIGN AND SETTING

A cross-sectional study of Chinese patients with chronic back and knee problems in public primary care clinics in Hong Kong.

METHOD

Each participant completed the Chinese Patient Enablement Instrument-2 (PEI-2), the Chinese Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and the Pain Rating Scale (PRS). Multivariable regression examined the effects of PRS score and PEI-2 score on WOMAC total score. A moderation regression model and simple slope analysis were used to evaluate whether the interaction between enablement (PEI-2) and pain (PRS) had a significant effect on HRQoL (WOMAC).

RESULTS

Valid patient-reported outcome data from 1306 participants were analysed. PRS score was associated with WOMAC total score (β = 0.326, P<0.001), whereas PEI-2 score was associated inversely with WOMAC total score (β = -0.260, P<0.001) and PRS score. The effect of the interaction between PRS and PEI-2 (PRS × PEI-2) scores on WOMAC total score was significant (β = -0.191, P<0.001) suggesting PEI-2 was a moderator. Simple slope analyses showed that the relationship between PRS and WOMAC was stronger for participants with a low level of PEI-2 (gradient 3.056) than for those with a high level of PEI-2 (gradient 1.746).

CONCLUSION

Patient enablement moderated the impact of pain on HRQoL. A higher level of enablement can lessen impairment in HRQoL associated with chronic back and knee pain.

The Importance of Patient Empowerment: A Clinical Case of Hereditary Angioedem

Hereditary angioedema (HAE) is a rare condition characterized by recurrent episodes of angioedema without urticaria or pruritus. Untreated angioedema can cause significant work absenteeism and, in rare cases, be lethal due to laryngeal involvement and suffocation. The authors report a case of a patient with laryngeal involvement who was unaware of the severity of their condition. Effective medical training in patient empowerment is essential, and it is an irreplaceable element in healthcare, as it contributes to therapeutic success.

The Impact of a Health Empowerment Program on Self-Care Enablement and Mental Health among Low-Income Families: Evidence from a 5 Year Cohort Study in Hong Kong

Health empowerment can be an effective way to reduce health inequities. This prospective cohort study evaluated the 5 year impact of a health empowerment program (HEP) on health outcomes among adults from low-income families. The Patient Enablement Instrument version 2 (PEI-2), Depression, Anxiety and Stress Scale 21 (DASS-21), and 12 item Short-Form Health Survey version 2 (SF-12v2) were administered at baseline and follow-up for both intervention and comparison groups. A total of 289 participants (n = 162 for intervention group, n = 127 for comparison group) were included in the analysis. Most of the participants were female (72.32%), and aged from 26 to 66 years old (M = 41.63, SD = 6.91). Linear regressions weighted by inverse probability weighting using the propensity score showed that, after follow-up of 5 years, the intervention group demonstrated significantly greater increases in all items and total scores for the PEI-2 (all B > 0.59, p < 0.001), greater decreases in the DASS depression score (B = -1.98 p = 0.001), and greater increases in the Mental Component Summary score of the SF-12v2 (B = 2.99, p = 0.027) than the comparison group. The HEP may be an effective intervention enabling adults from low-income families to manage their health-related issues and improve their mental health, as evidenced by our study.

Enablement and empowerment among patients participating in a supported osteoarthritis self-management programme - a prospective observational study

Background

In Sweden, core treatment for osteoarthritis is offered through a Supported Osteoarthritis Self-Management Programme (SOASP), combining education and exercise to provide patients with coping strategies in self-managing the disease. The aim was to study enablement and empowerment among patients with osteoarthritis in the hip and/or knee participating in a SOASP. An additional aim was to study the relation between the Swedish version of the Patient Enablement Instrument (PEI) and the Swedish Rheumatic Disease Empowerment Scale (SWE-RES-23).

Methods

Patients with osteoarthritis participating in a SOASP in primary health care were recruited consecutively from 2016 to 2018. The PEI (score range 0–12) was used to measure enablement and the SWE-RES-23 (score range 1–5) to measure empowerment. The instruments were answered before (SWE-RES-23) and after the SOASP (PEI, SWE-RES-23). A patient partner was incorporated in the study. Descriptive statistics, the Wilcoxon’s signed rank test, effect size (r), and the Spearman’s rho (r_s) were used in the analysis.

Results

In total, 143 patients were included in the study, 111 (78%) were women (mean age 66, SD 9.3 years). At baseline the reported median value for the SWE-RES-23 (n = 142) was 3.6 (IQR 3.3–4.0). After the educational part of the SOASP, the reported median value was 6 (IQR 3–6.5) for the PEI (n = 109) and 3.8 (IQR 3.6–4.1) for the SWE-RES-23 (n = 108). At three months follow-up (n = 116), the reported median value was 6 (IQR 4–7) for the PEI and 3.9 (IQR 3.6–4.2) for the SWE-RES-23. The SWE-RES-23 score increased between baseline and three months (p ≤ 0.000). The analysis showed a positive correlation between PEI and SWE-RES-23 after the educational part of the SOASP (r_s = 0.493, p < 0.00, n = 108) and at follow-up at three months (r_s = 0.507, p < 0.00, n = 116).

Conclusions

Patients reported moderate to high enablement and empowerment and an increase in empowerment after participating in a SOASP, which might indicate that the SOASP is useful to enable and empower patients at least in the short term. Since our results showed that the PEI and the SWE-RES-23 are only partly related both instruments can be of use in evaluating interventions such as the SOASP.

Trial registration

ClinicalTrials.gov. NCT02974036. First registration 28/11/2016, retrospectively registered.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-022-05457-9.

Prediction of risk of prolonged post-concussion symptoms: Derivation and validation of the TRICORDRR (Toronto Rehabilitation Institute Concussion Outcome Determination and Rehab Recommendations) score

BACKGROUND

Approximately 10% to 20% of people with concussion experience prolonged post-concussion symptoms (PPCS). There is limited information identifying risk factors for PPCS in adult populations. This study aimed to derive a risk score for PPCS by determining which demographic factors, premorbid health conditions, and healthcare utilization patterns are associated with need for prolonged concussion care among a large cohort of adults with concussion.

METHODS AND FINDINGS

Data from a cohort study (Ontario Concussion Cohort study, 2008 to 2016; n = 1,330,336) including all adults with a concussion diagnosis by either primary care physician (ICD-9 code 850) or in emergency department (ICD-10 code S06) and 2 years of healthcare tracking postinjury (2008 to 2014, n = 587,057) were used in a retrospective analysis. Approximately 42.4% of the cohort was female, and adults between 18 and 30 years was the largest age group (31.0%). PPCS was defined as 2 or more specialist visits for concussion-related symptoms more than 6 months after injury index date. Approximately 13% (73,122) of the cohort had PPCS. Total cohort was divided into Derivation (2009 to 2013, n = 417,335) and Validation cohorts (2009 and 2014, n = 169,722) based upon injury index year. Variables selected a priori such as psychiatric disorders, migraines, sleep disorders, demographic factors, and pre-injury healthcare patterns were entered into multivariable logistic regression and CART modeling in the Derivation Cohort to calculate PPCS estimates and forward selection logistic regression model in the Validation Cohort. Variables with the highest probability of PPCS derived in the Derivation Cohort were: Age >61 years ([Formula: see text] = 0.54), bipolar disorder ([Formula: see text] = 0.52), high pre-injury primary care visits per year ([Formula: see text] = 0.46), personality disorders ([Formula: see text] = 0.45), and anxiety and depression ([Formula: see text] = 0.33). The area under the curve (AUC) was 0.79 for the derivation model, 0.79 for bootstrap internal validation of the Derivation Cohort, and 0.64 for the Validation model. A limitation of this study was ability to track healthcare usage only to healthcare providers that submit to Ontario Health Insurance Plan (OHIP); thus, some patients seeking treatment for prolonged symptoms may not be captured in this analysis.

CONCLUSIONS

In this study, we observed that premorbid psychiatric conditions, pre-injury health system usage, and older age were associated with increased risk of a prolonged recovery from concussion. This risk score allows clinicians to calculate an individual's risk of requiring treatment more than 6 months post-concussion.

The validity and reliability of the patient enablement instrument (PEI) after GP appointments in Finnish health care centres

BACKGROUND

The aim of this study was to assess the validity and reliability of the Patient Enablement Instrument (PEI) in Finnish health care centre patients. A pilot study was conducted to assess the content validity of the PEI. A questionnaire study in three health care centres in Western Finland was performed in order to assess acceptability, construct validity, internal consistency, and measurement error of the instrument. A telephone interview 2 weeks after the appointment was performed to evaluate reproducibility.

RESULTS

The pilot study with 17 participants indicated good content validity of the PEI. In the questionnaire study, altogether 483 with a completed PEI score were included in the analyses. Factor analysis and item-scale correlations suggested high structural validity. The internal consistency of the instrument was high (Cronbach's α = 0.93). The PEI score diminished strongly over the two-week period.

CONCLUSIONS

The PEI has good content validity and acceptability, good construct validity, high internal consistency but low reproducibility. Thus, the PEI seems to be an applicable tool to measure patient enablement in Finnish primary health care.

Patients’ and healthcare professionals’ perspectives towards technology-assisted diabetes self-management education. A qualitative systematic review

Introduction

Diabetes self-management education is a key aspect in the long-term management of type 2 diabetes. The patient and healthcare professional (HCP) perspective on the use of technology-assisted DSME has yet to be studied. Hence, the objective of this study was to better understand the factors that facilitate or hinder the adoptions of such education by adults with type 2 diabetes and their HCPs.

Methods

We systematically searched five databases (Medline, Embase, CINAHL, Web of Science Core Collection, and PsycINFO) until August 2019. The search included qualitative and mixed-method studies that reported the views of patients and HCPs regarding features, uses, and implementations of technology-assisted DSME. Data were synthesized through an inductive thematic analysis.

Results

A total of 13 articles were included, involving 242 patients, ranging from 18 to 81 years and included web-based, mobile application, digital versatile disc (DVD), virtual reality or telehealth interventions. Patients and HCPs had mixed views towards features of the technology-assisted interventions, with patients’ personal qualities and HCPs’ concerns affecting uses of the interventions. Patients generally preferred technologies that were easy to access, use, and apply and that had reliable information. Patients’ ambitions motivated them, and personal attributes such as poor competence with technology, poor literacy, and language barriers acted as barriers. Patients especially liked the peer support that they received but did not like it when there was no regulation of advice on these platforms. HCPs believed that while the interventions were useful to patients, they faced difficulties with integration into their clinical workflows.

Conclusion

This review explored the features of technology-assisted diabetes self-management education interventions that enhanced positive patient engagements and the negative aspects of both the platforms and the target groups. Technical support and training will be effective in managing these concerns and ensuring meaningful use of these platforms.

Examining the Moderating Role of Patient Enablement on the Relationship Between Health Anxiety and Psychosomatic Distress: A Cross-Sectional Study at a Traditional Chinese Medicine Outpatient Clinic in Hong Kong

Background

Little research effort has been devoted to examining the role of patient enablement in alleviating health anxiety in primary care. In this study, we examined the role of patient enablement as a moderator in the relationship between health anxiety, psychological distress, and treatment seeking in traditional Chinese medicine (TCM).

Methods

The participants were 634 patients of a government-subsidized Chinese medicine outpatient clinic in Hong Kong. They were asked to complete a series of questionnaires on patient enablement, health anxiety, anxiety, depression, physical distress, annual clinic visits, and service satisfaction and provided various demographic details. Descriptive statistics, correlations, and general linear models were used to analyze the data.

Results

We found that patient enablement correlated positively with service satisfaction. Patient enablement also interacted significantly with health anxiety in affecting indices of psychological distress (depression, anxiety) and treatment seeking (annual visits). Among highly enabled patients, the positive association between health anxiety and indices of psychological distress was weakened, and they also showed more health anxiety-driven treatment seeking as measured by annual clinic visits.

Conclusion

These findings suggest a moderating mechanism by which patient enablement weakens the relationship between health anxiety on psychological well-being and increases treatment-seeking behavior in TCM. Practitioners are encouraged to provide sufficient information to patients to foster self-care and disease self-management using complementary and alternative medicine (CAM).

Improving primary care management of asthma: do we know what really works?

Asthma imposes a substantial burden on individuals and societies. Patients with asthma need high-quality primary care management; however, evidence suggests the quality of this care can be highly variable. Here we identify and report factors contributing to high-quality management. Twelve primary care global asthma experts, representing nine countries, identified key factors. A literature review (past 10 years) was performed to validate or refute the expert viewpoint. Key driving factors identified were: policy, clinical guidelines, rewards for performance, practice organisation and workforce. Further analysis established the relevant factor components. Review evidence supported the validity of each driver; however, impact on patient outcomes was uncertain. Single interventions (e.g. healthcare practitioner education) showed little effect; interventions driven by national policy (e.g. incentive schemes and teamworking) were more effective. The panel's opinion, supported by literature review, concluded that multiple primary care interventions offer greater benefit than any single intervention in asthma management.

Competencies for a Healthy Physically Active Lifestyle-Reflections on the Model of Physical Activity-Related Health Competence

BACKGROUND

The World Health Organization's Global Action Plan on Physical Activity 2018-2030 states that physical activity interventions should strengthen peoples' competencies for health. Yet, frameworks that bundle pivotal competencies for a healthy and physically active lifestyle have not been extensively discussed in the past.

RESULTS

In the present article, the authors therefore present the model of Physical Activity-related Health Competence (PAHCO), an integrative structure model including the 3 areas of movement competence, control competence, and self-regulation competence. After providing a rationale for the use of the competence concept, the authors focus on implications from the PAHCO model to guide interventions for the promotion of a healthy and physically active lifestyle. The authors argue that the PAHCO model is located at the interface between health literacy and physical literacy, research areas that have gained increasing scholarly attention in recent years. In addition, PAHCO appears to be compatible with the concept of health capability because it can represent the important aspect of agency.

CONCLUSIONS

The article concludes with a scientific positioning of model components and some empirical results that have been accumulated so far.

PEN-13: A New Generic 13-Item Questionnaire for Measuring Patient Enablement (German Version)

Background: The purpose of our study was to develop and psychometrically test a German-language survey instrument that measures patient enablement generically and in greater detail than previous instruments. Methods: A multidisciplinary team developed 13 items to capture individual aspects of patient enablement (PEN-13). A pre-test with 26 subjects was followed by a random sample survey of N = 1168 subjects. An exploratory factor analysis was conducted in a random split-half sample of the data to explore PEN-13's factor structure; a confirmatory factor analysis was conducted in the validation sample. The internal consistency of the factors was evaluated using Cronbach's alpha, PEN-13's construct validity was checked by means of additional hypothesis testing. Results: The two factors self-management and patient-practitioner interaction, detected in the exploratory analysis, were confirmed with a few modifications in the confirmatory factor analysis, with the comparative fit index (CFI) amounting to 0.903. The Cronbach's alpha values of those two factors amounted to α = 0.90 and α = 0.82, respectively. The correlations of the PEN-13 score with the 'general self-efficacy' and 'health literacy' (HLS-EU-Q16) scores further confirmed its construct validity; the respective correlation coefficients amounted to 0.57 and 0.60. Conclusion: The German version of the survey instrument Patient Enablement Scale-13 items (PEN-13) shows acceptable psychometric properties. Practical implications: PEN-13 seems particularly suitable for health services research purposes. We recommend checking the results in another sample as well as evaluating its responsiveness to enablement-enhancing interventions.

Comparison of the Patient Enablement Instrument (PEI) with two single-item measures among Finnish Health care centre patients

Background

The Patient Enablement Instrument (PEI) is an established patient-reported outcome measure (PROM) that reflects the quality of appointments with general practitioners (GPs). It is a six-item questionnaire administered to the patient immediately after a consultation. The aim of this study was to evaluate whether a single-item measure could replace the PEI when measuring patient enablement among Finnish health care centre patients.

Methods

Two single-item measures, Q1 and Q2, were chosen for comparison with the PEI. Firstly, a pilot study with questionnaire testing and brief interviews with the respondents were performed in order to assess the content validity of the PEI and the single-item measures. Secondly, a questionnaire study after a single appointment with a GP was carried out in three health care centres in Western Finland in order to evaluate the construct and criterion validity of the single-item measures. A telephone interview was performed 2 weeks after the appointment in order to assess the test-retest reliability of the single-item measures. The sensitivity, specificity, and both positive and negative predictive values of Q1 and Q2 were calculated with different PEI score cut-off points.

Results

Altogether 483 patients with a completed PEI were included in the questionnaire study analyses. Altogether 149 and 175 patients had completed Q1 and Q2, respectively, both in the questionnaire and the telephone interview. The correlations between the PEI and Q1 and Q2 were 0.48 and 0.84, respectively. Both the single-item measures had a high sensitivity and a negative predictive value in relation to patients with lower PEI scores. The reliability coefficients were 0.24 for Q1 and 0.76 for Q2. The test-retest values of Q1, Q2, and the PEI were low.

Conclusions

Q2 seems to be a valid and reliable measure of patient enablement. Q1 seems to be less correlated with the PEI, but it also has a high negative predictive value in relation to low enablement scores.

Nurse practitioner consultations in primary health care: a case study-based survey of patients' pre-consultation expectations, and post-consultation satisfaction and enablement

Background

Research has not yet fully investigated links to consultation duration, patient expectations, satisfaction, and enablement in nurse practitioner consultations. This study was developed to address some of these research gaps in nurse practitioner consultations, particularly with a focus on expectations, satisfaction, and enablement.

Aim

To explore the influence of pre-consultation expectations, and consultation time length durations on patient satisfaction and enablement in nurse practitioner consultations in primary health care.

Design

Survey component of a larger convergent parallel mixed methods case study designed to conjointly investigate the communication processes, social interactions, and measured outcomes of nurse practitioner consultations. The survey element of the case study focusses on investigating patients’ pre-consultation expectations and post-consultation patient satisfaction and enablement.

Methods

A questionnaire measuring pre-consultation expectations, and post-consultation satisfaction and enablement, completed by a convenience sample of 71 adults consulting with nurse practitioners at a general practice clinic. Initial fieldwork took place in September 2011 to November 2012, with subsequent follow-up fieldwork in October 2016.

Results

Respondents were highly satisfied with their consultations and expressed significantly higher levels of enablement than have been seen in previous studies of enablement with other types of clinicians (P=0.003). A significant, small to moderate, positive correlation of 0.427 (P=0.005) between general satisfaction and enablement was noted. No significant correlation was seen between consultation time lengths and satisfaction or enablement.

Conclusion

Higher levels of patient enablement and satisfaction are not necessarily determined by the time lengths of consultations, and how consultations are conducted may be more important than their time lengths for optimising patient satisfaction and enablement.

Nurse practitioner consultations in primary health care: an observational interaction analysis of social interactions and consultation outcomes

OBJECTIVE

To determine the discrete nature of social interactions occurring in nurse practitioner consultations and investigate the relationship between consultation social interaction styles (biomedical and patient-centred) and the outcomes of patient satisfaction, patient enablement, and consultation time lengths.

METHODS

A case study-based observational interaction analysis of verbal social interactions, arising from 30 primary health care nurse practitioner consultations, linked with questionnaire measures of patient satisfaction and enablement.

RESULTS

A significant majority of observed social interactions used patient-centred communication styles (P=0.005), with neither nurse practitioners nor patients or carers being significantly more verbally dominant. Nurse practitioners guided the sequence of consultation interaction sequences, but patients actively participated through interactions such as asking questions. Usage of either patient-centred or biomedical interaction styles were not significantly associated with increased levels of patient satisfaction or patient enablement. The median consultation time length of 10.1 min (quartiles 8.2, 13.7) was not significantly extended by high levels of patient-centred interactions being used in the observed consultations.

CONCLUSION

High usage levels of patient-centred interaction styles are not necessarily contingent upon having longer consultation times available, and clinicians can encourage patients to use participatory interactions, whilst still then retaining overall guidance of the phased sequences of consultations, and not concurrently extending consultation time lengths. This study adds to the body of nurse practitioner consultation communication research by providing a more detailed understanding of the nature of social interactions occurring in nurse practitioner consultations, linked to the outcomes of patient satisfaction and enablement.

Coping better with health problems after a visit to the family physician: associations with patients and physicians characteristics

BACKGROUND

Good patient experience is recognized as an important component of a strong primary care system. Among the dimensions related to experience in family medicine, the ability to cope better with health problems is considered to be a measure of the quality of a consultation with a family physician (FP). The objective is to identify factors related to patients, physicians and practice, associated with patients' ability to cope better with their health problems after a family medicine consultation.

METHODS

The data stemmed from the Swiss part of the Quality and Costs of Primary Care (QUALICOPC) study, an international cross sectional survey aiming to compare quality, cost and equity in primary care. In Switzerland, a random sample of 199 FPs and 1791 patients participated. The negative answer to the question: "After this visit, I feel I can cope better with my health problems" was modeled using multilevel logistic regressions.

RESULTS

Difficulty to cope better with health problems was positively associated with the following: younger age (OR: 1.58, 95% CI [1.03-2.41]), cultural aspects related to the Swiss area of language (French speaking people declared higher inability than German and Italian ones), presence of chronic disease (OR: 1.54 95% CI [1.00-2.39]). Conversely an intermediate number (1-4) of visits during the last 6 months (OR: 0.37 95% CI [0.23-0.62]) and the satisfaction with the physician (OR: 0.18 95% CI [0.08-0.44]) are negative predictors of the patient inability to cope better with his health problems. A self-reported effort-reward imbalance at work (OR: 0.64 95% CI [0.41-1.00]) was the only predictive FP characteristic (negatively associated).

CONCLUSIONS

Although the design of the study does not allow causal inference, this study showed that the predictors of patient difficulties to cope better with health problem are mainly centered on the patients' characteristics. The patient-physician relationship both in terms of quality and frequency of visits is probably also important. Organizational practice characteristics do not seem to play a major role but stress at work among physicians should be further investigated.

Patient Enablement After a Single Appointment With a GP: Analysis of Finnish QUALICOPC Data

Background: Patient enablement is described as patient’s ability to understand and cope with illness after a consultation. The purpose of this study was to analyze factors associated with enablement in Finnish primary health care. An additional aim was to evaluate whether a single question could be used to measure enablement. Methods: A questionnaire survey was addressed to Finnish general practitioners (GPs) within the Quality and Costs of Primary Care in Europe (QUALICOPC) study framework. A trained fieldworker contacted nine patients for every participating GP. Two to 9 patients per GP (median 9 patients) completed the questionnaire. Patient enablement was measured by a single question based on the Patient Enablement Instrument questionnaire. Multivariate and multilevel analyses were performed to find variables that have an independent association with patient enablement. Results: A total of 1196 patients completed the QUALICOPC questionnaire. A total of 898 patients (75.1%) agreed that they felt better able to cope with their health problem or illness after an appointment with a GP, reflecting patient enablement. In the theme group analyses, 11 factors were found to have a statistically significant (P < .05) association with enablement. In the final multivariable model, positive perceptions of doctor-patient communication and patient satisfaction were positively associated with enablement. Conclusions: The results, using a single question to measure enablement, are comparable to previous findings on factors associated with enablement. Further research is needed and these results should be regarded as preliminary.