Patients' experience of a novel interdisciplinary nurse-led self-management intervention (INSELMA)-a qualitative evaluation

BACKGROUND

Despite continuous improvements in anti-rheumatic pharmacological treatment, people with chronic inflammatory arthritis still report substantial disease impact. Based on the framework for complex interventions, we thus developed INSELMA, a novel nurse-coordinated multidisciplinary self-management intervention for patients with rheumatoid arthritis, psoriatic arthritis or axial spondyloarthritis. Based on individual biopsychosocial assessments, a rheumatology nurse facilitated goal setting and coordinated interdisciplinary support. The aim of this study was to explore the patients' experience of participating in the six-months INSELMA intervention.

METHODS

Individual semi-structured interviews were conducted with 15 of the participants after their final follow-up. Thematic analysis was applied.

RESULTS

The analysis derived four overall themes. (1) A new opportunity at the right time. The participants' disease impacted all areas of daily life. Participation in INSELMA was experienced as an opportunity to improve symptoms and together reduce long-held challenges they had fought alone, until now. (2) The importance of person-centred goals. The participants found it meaningful to work with their individual goals, which encompassed physical, psychological, and social factors. Having time between consultations to work with goals at home was important. (3) Empathy, partnership and a little nudging from health professionals are essential. The empathic nurses' continuous support and coaching helped participants become aware of their own resources. The participants highlighted having access to support from a physiotherapist and occupational therapist with rheumatology experience as important. (4) I got more than I could have hoped for. Most of the participants experienced decreased symptom load and improvement in physical strength, mobility, sleep, and mood as well as increased energy, knowledge, and self-management ability. The participants expressed new hope for the future with an improved ability to manage their symptoms and work towards new goals.

CONCLUSION

The participants found the INSELMA intervention meaningful and feasible. They experienced decreased disease impact and increased activity levels, facilitated by empathy and self-management support from health professionals.

A joint venture: patients' experiences with goal setting in rheumatology rehabilitation - a qualitative study

PURPOSE

To explore how patients with rheumatic musculoskeletal diseases (RMDs) perceive participation in the goal setting process prior to interdisciplinary rehabilitation.

METHODS

We conducted semi-structured interviews with 22 participants admitted to an interdisciplinary rehabilitation stay for patients with RMDs at two Danish rehabilitation centres. Qualitative content analysis was applied.

RESULTS

The participants perceived goal setting as a joint venture between two parties: the health professionals and the participant. Three categories were formed, which described both facilitators and barriers in the process. Responsibility for goal setting described the importance of shared responsibility, or health professionals as experts, taking full responsibility for goal setting. Equipped for goal setting included perceptions of being well prepared for the process, or considerations that goal setting was difficult because of a lack of information. An equal member of the team entailed both the feeling of being recognised as one in the team, or feeling like an outsider.

CONCLUSION

Goal setting is perceived as a challenge by some patients. Participation in goal setting depends on both the capacity and the opportunity to participate which are factors linked to patients' level of health literacy.

Characteristics of goal-setting tools in adult rehabilitation: A scoping review

OBJECTIVES

This scoping review aims to map the literature on goal-setting tools in adult rehabilitation, exploring their characteristics, target users and supporting evidence to inform practice and future research in this area.

METHODS

We completed a comprehensive search of four databases to identify relevant articles on tools for goal setting in rehabilitation. We followed Arkey and O'Malley's scoping review process to guide article selection, data extraction and data analysis.

RESULTS

We identified a total of 165 studies that reported on 55 different goal-setting tools, including tools for goal selection and goal documentation (n = 31), goal setting and intervention planning (n = 15), and for measuring the quality of the goal-setting process (n = 9). Over half of the tools were primarily designed for use in rehabilitation of physical disabilities (n = 32). Some tools fell under multiple sub-categories based on their characteristics as follows: 22 framework tools, 12 interview tools, 9 outcome measurement tools for goal achievement, 6 outcome measurement tools for goal quality and 25 documentation tools. The majority of goal-setting instruments targeted goals at the level of activity and participation (n = 51) and aimed to facilitate a client-centred or shared decision-making approach to rehabilitation planning (n = 46).

CONCLUSIONS

This study provides a comprehensive overview of existing goal-setting tools, highlighting their characteristics, target users and identified needs. These findings can enhance practitioners' awareness of the range of goal-setting tools available and can enable more effective utilization of these tools in clinical practice. Further research should investigate how clinicians can combine multiple tools to deliver goal setting.

An umbrella review of the literature on the effectiveness of goal setting interventions in improving health outcomes in chronic conditions

PURPOSE

To identify the contexts in which goal setting has been used in chronic disease management interventions and to estimate the magnitude of its effect on improvement of health outcomes.

METHODS

The strength of evidence and extent of potential bias in the published systematic reviews of goal setting interventions in chronic conditions were summarized using AMSTAR2 quality appraisal tool, number of participants, 95% prediction intervals, and between-study heterogeneity. Components of goal setting interventions were also extracted.

RESULTS

Nine publications and 35 meta-analysis models were identified, investigating 25 health outcomes. Of the 35 meta-analyses, none found strong evidence and three provided some suggestive evidence on symptom reduction and perceived well-being. There was weak evidence for effects on eight health outcomes (HbA1c, self-efficacy, depression, anxiety, distress, medication adherence, health-related quality of life and physical activity), with the rest classified as non-significant. Half of the meta-analyses had high level of heterogeneity.

CONCLUSION

Goal setting by itself affects outcomes of chronic diseases only to a small degree. This is not unexpected finding as changing outcomes in chronic diseases requires a complex and individualized approach. Implementing goal setting in a standardized way in the management of chronic conditions would seem to be a way forward.IMPLICATIONS FOR REHABILITATIONThe link between goal setting and health outcomes seems to be weak.Some levels of positive behavioural change could be of benefits to patients as seen by improved self-efficacy, patients' satisfaction and overall quality of life.Systematic and consistent application of personalized goal-oriented interventions considering patient's readiness to change could better predict improved outcomes.Incorporation of various goal setting components while actively engaging patient and/or their care givers in the process could appraise how goal setting could help with challenges in faced by people living with chronic conditions in different areas.

Development of a complex Interdisciplinary Nurse-coordinated SELf-MAnagement (INSELMA) intervention for patients with inflammatory arthritis

BACKGROUND

Apart from a consistent focus on treating inflammation, patients with inflammatory arthritis (IA) report a range of unmet needs. Many experience not only residual symptoms but also various other physical, psychological, and social effects. Therefore, this study aimed to develop a complex Interdisciplinary Nurse-coordinated self-management (INSELMA) intervention for patients with IA, as an add-on treatment to usual outpatient care for those with substantial disease impact.

METHODS

This study followed the British Medical Research Council's updated framework for developing complex interventions. The process encompassed the following steps: (1) The evidence base was identified; (2) workshops were held, involving 38 relevant stakeholders (managers, physicians, nurses, physiotherapists, occupational therapists, social workers, psychologists from hospitals and municipalities, and two patient research partners), to discuss and further develop the preliminary ideas; (3) relevant theories were identified (i.e., self-efficacy, acceptance and commitment therapy, and health literacy); (4) the intervention was modeled and remodeled and (5) the results, describing the final INSELMA intervention and outcomes.

RESULTS

The INSELMA intervention encompasses an initial biopsychosocial assessment, which is performed by a rheumatology nurse. Then, activities that the participant wishes to improve are identified and goals are set. The nurse refers the participant to a multidisciplinary team and coordinates their support and relevant services in the participant's municipality. In addition, the health professionals have the opportunity to hold two interdisciplinary conferences during the intervention period. The participant and the health professionals work to achieve the set goals during a 6-month period, which ends with a status assessment and a discussion of further needs. The INSELMA intervention aims to increase self-management, reduce the impact of IA (e.g., pain, fatigue, sleep problems, and absenteeism), and increase self-efficacy, quality of life, mental well-being, work ability, and physical activity.

CONCLUSIONS

The development of the INSELMA intervention involved stakeholders from two Danish rheumatology outpatient clinics, patient research partners and municipalities. We believe that we have identified important mechanisms to increase the self-management and quality of life of people with IA and to decrease the disease impact in those who are substantially affected. The health professionals involved have developed competences in delivering the intervention and it is ready to be tested in a feasibility study.

Leisure time activities in adolescents predict problematic technology use

The problematic use of technology of children and adolescents is becoming a growing problem. Research has shown that excessive technology use predicts a variety of psychological and physical health problems. The aim of this study was to analyze the role of leisure time activities (structured and unstructured) in adolescents as a predictor of problematic technology use. Participants were 7723 adolescents, of which 55% were girls, from four Spanish-speaking countries (Chile, Spain, Mexico, and Peru) between the ages of 13 and 18 years. The evaluation instrument applied was the YOURLIFE project self-report questionnaire. Two executive functions were measured: goal setting and inhibitory control. Using structural equation modeling, findings indicated that structured leisure time activities predicted less PTU, whereas unstructured activities predicted more PTU, MLχ2 (69, N = 7723) = 806.60; CFI = 0.929, RMSEA = 0.042, and the model had good predictive capacity for PTU (R2 = 0.46). Structured and unstructured activities also showed indirect effects on PTU through executive functions. As adolescents spent more time in unstructured leisure activities, poorer goal setting, inhibitory control skills, and more PTU were found. The opposite was true for structured leisure time activities. Implications of structured leisure activities to develop executive functioning and to prevent PTU for adolescents are discussed.

Individualized behavior-based safety-leadership training: A randomized controlled trial

INTRODUCTION

Construction site managers play a critical role in occupational safety in the construction industry. This study aimed to develop and test a method for training construction site managers in positive feedback and active listening by incorporating the behavioral training components of behavior analysis, goal setting, practice with behavior feedback, homework, and maintenance planning into individualized behavior-based safety-leadership training (IBST), and to assess the effect of IBST on construction site managers' safety-leadership behaviors and performance.

METHOD

In a naturalistic randomized controlled trial, construction site managers were randomly assigned to an experimental group (n = 16) or a control group (n = 19). The experimental-group managers received IBST, while the control-group managers received no training. Paired sample t-tests on pre- to post-training (i.e., six weeks after the final training session) were performed separately for the experimental- and control-group managers.

RESULTS

The safety-leadership behaviors of the experimental-group managers improved in terms of favorable feedback (d = 0.99, p <.01), safety-specific feedback (d = 0.89, p =.02), behavior-specific feedback (d = 0.66, p =.02), antecedent listening (d = 0.68, p =.02), and consequential listening (d = 0.78, p =.01). In addition, safety-leadership performance improved in terms of transformational leadership (d = 0.78, p =.01) and contingent-reward leadership (d = 0.64, p =.02). No significant change was found for the control-group managers.

CONCLUSIONS

The results indicate that behavior analysis, goal setting, practice with behavior feedback, homework, and maintenance planning are effective behavioral training components of safety-leadership training. Positive feedback and active listening were also found to be important behavioral requisites for transformational and contingent-reward leadership.

PRACTICAL APPLICATIONS

IBST can be used to develop occupational safety in the construction industry by improving construction site managers' safety-leadership behaviors and performance.

It Is Smart to Set Treatment Goals, But Are Set Treatment Goals SMART? A Qualitative Assessment of Goals Described in the Assessment of the Burden of COPD Tool

The Assessment of the Burden of COPD (ABC) tool facilitates shared decision-making and goal setting to develop a personalized care plan. In a previous trial (RCT), the ABC tool was found to have a significant effect on patients' Health-related Quality of Life (HRQoL). In this exploratory study we used data from the intervention group of the RCT to investigate if patients with health-related goals had an improved HRQoL compared to those without goals, and if the quality and types of goals differed for those who have a clinically meaningful improvement in HRQoL. We hypothesized that the quality and the type of the goal described in the ABC tool, relates to an improved HRQoL. We assessed the quality of the goals according to the Specificity, Measurability, Achievability, Relevance and Timeliness (SMART) criteria, and coded and counted each type of goal. We found that having a goal or not, did not differ significantly for those who had a clinically meaningful improved HRQoL versus those who had not, nor was the quality or type of goal significantly different. The most common types of goals were exercise more, smoke less, and improve weight. Based on the results, we speculate that when a clinically meaningful improvement in HRQoL is achieved, it is not related to a single component (i.e. goal setting as part of shared decision-making) but that the different components of the ABC tool (visualization of burden, shared decision making, utilization of tailored evidence based interventions, and regular monitoring of progress) may have a synergistic effect on disease cognition and/or behavior change. Noteworthy, the sample size was small while the calculated effect size was moderate, making it unlikely to find a significant effect.

Development of a menu of recovery goals to facilitate goal setting after critical illness

OBJECTIVE

To develop an expert-informed (including end users) recovery goal menu for adults recovering from critical illness applicable to the community/home setting.

RESEARCH METHODOLOGY/DESIGN

Stage 1 Item generation: iterative development of domains, sub-domains, and goals in consultation with former intensive care patients, family members and expert clinicians. Stage 2 Content validity assessment: cognitive interviews and the content validity index.

SETTING

Virtual consultation meetings facilitated by the research team at King's College London and Guy's and St Thomas' NHS Foundation Trust.

MAIN OUTCOME MEASURES

Content validity as assessed by: the Item-Content Validity Index (I-CVI), Scale Level-Content Validity Index/Universal Agreement (S-CVI/UA) score, the Scale Level-Content Validity Index/Average (S-CVI/Ave) score and Average Content Validity Ratio (CVR).

RESULTS

Item generation resulted in a goal menu comprising 4 domains, 22 sub-domains and 95 goals assigned as follows: Self-care: 9 sub-domains with 37 goals, Productivity: 7 sub-domains with 13 goals, Leisure: 3 sub-domains with 25 goals, and Person domain 3 sub-domains with 20 goals. Cognitive interviews resulted in addition of 79 goals and modification of 7, addition of 4 new sub-domains and modification of 4, thus resulting in 4 domains, 26 sub-domains with a total of 174 goals. Twenty-four sub-domains (169 goals) were deemed relevant with Item-Content Validity Index (I-CVI) scores ranging from 0.72 to 1. Two sub-domains (5 goals) did not meet the 0.7 cut-off and were removed. The Scale Level-Content Validity Index/Universal Agreement (S-CVI/UA) score was 0.46; the Scale Level-Content Validity Index/Average (S-CVI/Ave) 0.91. Average Content Validity Ratio (CVR) was 0.93.

CONCLUSION

An expert informed recovery goal menu for former intensive care patients has been developed with excellent content validity. The final goal menu comprises 169 goals within 24 sub-domains grouped under 4 domains.

IMPLICATIONS FOR CLINICAL PRACTICE

This menu will help patients to set goals and increase our understanding of how individuals recover from critical illness.

The RESPECT-tool as a facilitator for person-centered medication reviews for nursing home residents: tool development and pilot study

BACKGROUND

Although support is needed, no method exists to elicit and integrate personal goals into medication optimization interventions for nursing home residents.

AIM

To develop and evaluate a tool to (1) elicit and evaluate residents' personal goals during medication optimization, and (2) elicit involvement preferences regarding medication decision-making.

METHOD

A draft was composed by the research team, on which feedback was collected through four focus groups with healthcare professionals (n = 23) and pilot interviews with residents (n = 6). The tool was then pilot tested in 11 nursing homes as means to facilitate person-centered medication reviews, focusing on feasibility, appropriateness, and meaningfulness. Evaluation was performed through interviews and focus groups with residents and healthcare professionals, and reports for executed medication reviews. Interview summaries and reports were analyzed inductively.

RESULTS

The RESident's Participation in the Evaluation and Customization of Therapy tool (RESPECT-tool) was drafted as a modular approach of five modules. Pilot study results showed that the tool supported the formulation of personal goals. Goals resulted in changes in all aspects of the nursing home stay, indicating the tool's potential to promote person-centered care. The RESPECT-tool showed value in the context of medication optimization as it allowed to determine potential links between residents' personal goals and medication plans, and its use regularly led to medication changes.

CONCLUSION

A person-centered medication review facilitated by the RESPECT-tool holds a promising approach to medication optimization in nursing homes. Further research should assess impact on relevant outcomes like goal attainment, appropriateness of prescribing and quality of life.

Development of a practical guideline for person centred goal setting in geriatric rehabilitation: a participatory action research

PURPOSE

To improve goal setting in Geriatric Rehabilitation (GR), by developing an evidence-based practical guideline for patient-centred goal setting.

METHODS

Participatory action research (PAR) in a cyclical process, with GR professionals as co-researchers. Each cycle consisted of five phases: problem analysis, literature review, development, practical experience, feedback & evaluation. The evaluation was based on video recordings of goal setting conversations, and on oral and written feedback of the GR professionals who tested the guideline.

RESULTS

In two PAR-cycles the guideline was developed, consisting of eight recommendations for setting and using goals, and of practical advices elaborating three of the recommendations, concerning conversational skills specific for goal setting conversations. After the second cycle the research team concluded that the guideline was feasible in daily practice and effective when used consciously.

CONCLUSION

In this study, a practical guideline for setting and using goals in GR was developed. GR teams can improve their patient centred working with goals by discussing the recommendations in their team and choosing the recommendations to work on. This can be supported by the development of an interdisciplinary training. The effect on quality of care should be subject to further investigation.

Social incentives as nudges for agricultural knowledge diffusion and willingness to pay for certified seeds: Experimental evidence from Uganda

A transition from low-input subsistence farming in Sub-Saharan Africa will require the use of yield-increasing agricultural technologies. However, in developing countries, most farmers continue to rely heavily on pest-infested and disease-infected recycled seed from own or local sources leading to low yields. This study used a field experiment to examine the effect of a social incentive combined with goal setting on the diffusion of agricultural knowledge and uptake of quality certified seed by farmers. We relaxed the seed access and information/knowledge constraints by introducing improved varieties of sweetpotato in the study villages and providing training to carefully selected progressive farmers who were then linked to co-villagers. We find that social incentives combined with goal setting reduced the likelihood of the trained progressive farmers reaching out to co-villagers to share information and discuss farming. Further, social incentive combined with goal setting had no significant effect on knowledge and experimentation by progressive farmers, and on willingness to pay for improved seed - as elicited through auctions, our proxy for experimentation, by co-villagers. These findings suggest that the combination of goal setting and public recognition acted to crowd-out diffusion effort. We conclude that social incentive combined with goal setting by established progressive farmers already enjoying a certain degree of public recognition is not sufficient to induce effort in learning and experimentation with agricultural innovations. These results have implications for design of policy and extension services to promote adoption of agricultural technologies with proven food and nutrition security benefits in developing countries.

Patients' experiences with goal setting during initial rehabilitation after newly acquired spinal cord injury: A pilot qualitative interview study

OBJECTIVE

To explore patients' experiences with goal setting during initial rehabilitation after newly acquired spinal cord injury/disorder (SCI/D).

DESIGN

Qualitative design with semi-structured interviews and purposively sampled participants. Interviews were transcribed verbatim. Transcripts were analyzed for qualitative content analysis using the Mayring method.

SETTING

Specialized acute care and rehabilitation center for SCI/D-patients.

PARTICIPANTS

Patients in initial rehabilitation after a newly acquired SCI/D.

INTERVENTIONS

n.a.

OUTCOME MEASURES

n.a.

RESULTS

Ten participants were interviewed in the post-acute phase after a newly acquired SCI/D. Participants described individual patient characteristics as well as organizational elements influencing their experience with goal setting. Organizational elements comprised structural elements (e.g. ward rounds, rehabilitation meetings, etc.) and interaction with and among the interprofessional teams. Perspectives from various health care professionals (HCPs) were perceived as increasing adequate goal setting and motivation. Furthermore, the participants described their own involvement and motivation as crucial for goal achievement. The main point of the critique was the standardization of the goal setting process. Interviewees would have preferred individualized goal setting embedded in a clearly foreseeable rehabilitation plan.

CONCLUSION

Organization and collaboration with and among the HCPs should be geared towards identifying specific patient needs during the course of rehabilitation and deriving individually tailored goals from them. Communication plays an important role in the individual goal setting.

Study protocol for The GOAL Trial: comprehensive geriatric assessment for frail older people with chronic kidney disease to increase attainment of patient-identified goals-a cluster randomised controlled trial

BACKGROUND

An increasing number of older people are living with chronic kidney disease (CKD). Many have complex healthcare needs and are at risk of deteriorating health and functional status, which can adversely affect their quality of life. Comprehensive geriatric assessment (CGA) is an effective intervention to improve survival and independence of older people, but its clinical utility and cost-effectiveness in frail older people living with CKD is unknown.

METHODS

The GOAL Trial is a pragmatic, multi-centre, open-label, superiority, cluster randomised controlled trial developed by consumers, clinicians, and researchers. It has a two-arm design, CGA compared with standard care, with 1:1 allocation of a total of 16 clusters. Within each cluster, study participants ≥ 65 years of age (or ≥ 55 years if Aboriginal or Torres Strait Islander (First Nations Australians)) with CKD stage 3-5/5D who are frail, measured by a Frailty Index (FI) of > 0.25, are recruited. Participants in intervention clusters receive a CGA by a geriatrician to identify medical, social, and functional needs, optimise medication prescribing, and arrange multidisciplinary referral if required. Those in standard care clusters receive usual care. The primary outcome is attainment of self-identified goals assessed by standardised Goal Attainment Scaling (GAS) at 3 months. Secondary outcomes include GAS at 6 and 12 months, quality of life (EQ-5D-5L), frailty (Frailty Index - Short Form), transfer to residential aged care facilities, cost-effectiveness, and safety (cause-specific hospitalisations, mortality). A process evaluation will be conducted in parallel with the trial including whether the intervention was delivered as intended, any issue or local barriers to intervention delivery, and perceptions of the intervention by participants. The trial has 90% power to detect a clinically meaningful mean difference in GAS of 10 units.

DISCUSSION

This trial addresses patient-prioritised outcomes. It will be conducted, disseminated and implemented by clinicians and researchers in partnership with consumers. If CGA is found to have clinical and cost-effectiveness for frail older people with CKD, the intervention framework could be embedded into routine clinical practice. The implementation of the trial's findings will be supported by presentations at conferences and forums with clinicians and consumers at specifically convened workshops, to enable rapid adoption into practice and policy for both nephrology and geriatric disciplines. It has potential to materially advance patient-centred care and improve clinical and patient-reported outcomes (including quality of life) for frail older people living with CKD.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04538157. Registered on 3 September 2020.

Exploring Factors Impacting the Implementation of Recovery-Oriented Treatment Planning on Acute Inpatient Mental Health Units

PURPOSE

The current literature on operationalizing and implementing recovery-oriented inpatient care in diverse settings remains limited. The present study systematically examined factors affecting the implementation of one aspect of recovery-oriented care in a large and diverse national sample of Veterans Health Administration (VHA) inpatient mental health units.

METHOD

VHA inpatient mental health units were scored on the Recovery-Oriented Acute Inpatient scale (RAIN). Sites scoring either one standard deviation above (n = 8; i.e., high-scoring sites) or one standard deviation below (n = 5; i.e., low-scoring sites) the mean on the RAIN factor of inpatient treatment planning subscale were included for additional analyses (N = 13). We used a qualitative approach known as emergent thematic analysis to assess the implementation of inpatient treatment planning elements (e.g., goal setting, shared decision-making) from qualitative interviews, observation notes, and chart reviews collected for the 13 sites. The analysis was guided by Normalization Process Theory.

RESULTS

The eleven themes that emerged across the elements of recovery-oriented inpatient treatment planning mostly represented commonalities across sites, such as a shared treatment philosophy of acute care. However, five themes emerged as "differentiators" that distinguished high- and low-scoring sites and included veteran input, elicitation of recovery goals, the value of group programming, and the purpose of family involvement.

CONCLUSION

Findings provide insight into contextual factors and processes that impacted the implementation of recovery-oriented treatment planning at these VHA inpatient mental health units. To further facilitate the implementation of recovery-oriented inpatient treatment planning elements, future research should examine staff's collective understanding of recovery-oriented inpatient care.

Reducing the Individual Carbon Impact of Video Streaming: A Seven-Week Intervention Using Information, Goal Setting, and Feedback

This online intervention study examined whether system- and action-related information alone, together with goal setting, or together with goal setting and feedback helps people change their video streaming activities in a pro-environmental way. The participants (N = 92) documented their video streaming activities for one week prior to the intervention (week 1), three weeks after the onset of the intervention (weeks 2-4), and in a follow-up period two weeks later (week 7). A reduction of greenhouse gas emissions associated with video streaming was observed over the course of the intervention, together with reduced streaming durations and lowered resolution settings across all groups. There were no differences between the groups. It appears that as regards video streaming, information combined with self-monitoring has considerable potential to change individual behaviour and its associated ecological impact.

The use of inpatient goal planning in a regional burns centre: A thematic analysis of staff and patient experiences

BACKGROUND

Rehabilitation from a burn or related injury can be a lengthy and painful process.

OBJECTIVES

The present study explored the experiences of staff and patients of inpatient goal planning used on a rehabilitation ward within a regional burns centre.

DESIGN

A qualitative study using semi-structured interviews.

SETTING

Patients and staff were recruited from The Welsh Centre for Burns and Plastic Surgery, Morriston Hospital, Swansea, South Wales, UK.

PARTICIPANTS

Twelve participants were recruited and interviewed in two phases. Phase one included six staff members who had been involved in delivering goal planning sessions and phase two included six former inpatients who had participated in goal planning during their rehabilitation in hospital.

RESULTS

Three main themes were identified for staff: benefits for patients and families, process and structure and challenges of the process. For patients, the three main themes identified were: role of goal planning in rehabilitation, tailoring the programme around the patient and encountering challenges.

CONCLUSIONS

Findings from the narratives of staff and patients suggest the use of goal planning in inpatient recovery and rehabilitation in a burns centre is very beneficial. Although challenges were reported, this investigation yields potential for goal planning to be a successful rehabilitation strategy.

Goals of older hospitalized patients with multimorbidity

PURPOSE

Patient-centered healthcare, with aligning treatment to a patients' goal, is recognized by experts as essential to improve healthcare for older patients with multimorbidity. Little literature exists on goals of these specific patients. Therefore, we aimed to explore goals of older hospitalized patients with multimorbidity and compare their goals to those of older hospitalized patients without multimorbidity.

METHODS

Older hospitalized patients (aged ≥ 70 years) were included in a prospective mixed-methods cohort study at the University Medical Centre Groningen, the Netherlands. Goals were assessed by a standardized interview, whereafter they were categorized and analyzed descriptively.

RESULTS

Four hundred and ninety-three older hospitalized patients (median age 75 (IQR 72-80), 64% male) were included, of which 223 patients presented with multimorbidity (45%). Goals mentioned most often were 'controlling disease' and 'alleviating complaints'. No differences were found in goals mentioned by patients with and without multimorbidity. Forty-one percent of both patients with and without multimorbidity mentioned goals that were disease-unrelated.

CONCLUSION

No major differences were found in goals of older hospitalized patients with and without multimorbidity. However, the large proportion of patients mentioning disease-unrelated goals emphasizes the importance of goal elicitation by healthcare professionals within hospital care to provide optimally integrated care.

Efficacy of mindfulness and goal setting interventions for increasing resilience and reducing smoking in lower socio-economic groups: randomised controlled trial protocol

BACKGROUND

Smoking and resulting health problems disproportionately impact low socioeconomic status (SES) individuals. Building resilience presents an approach to 'closing the gap'. Mindfulness-based interventions and setting realistic goals are preferred in low socioeconomic communities. We aim to test if these interventions, delivered online and consolidated with peer support offered via ex-smokers, are successful in promoting smoking cessation and resilience. Our conceptualisation of resilience encompasses the inner capacity/skills and external resources (e.g., social support) which smokers utilise to bounce back from adversity. We include a process evaluation of barriers/facilitators to interventions and cost-effectiveness analysis (from health system perspective).

METHODS

We plan a four-arm parallel 12-month RCT with a 6-month follow-up to test the efficacy of three group-based interventions each followed by peer support. Arm 1: mindfulness-integrated cognitive behavioural therapy; Arm 2: mindfulness training; Arm 3: setting realistic goals; Arm 4: active control group directed to quit services. All interventions will be administered online. Participants are adult smokers in Australia (N = 812) who have an average weekly household income less than $457AUD or receive welfare benefits. Group-based interventions will occur over 6 months, followed by 6 months of forum-based peer support.

PRIMARY OUTCOME

self-reported 14-day period prevalence of smoking abstinence at 6 months, with remote biochemical verification of saliva cotinine (< 30 ng/mL). Secondary outcomes include: internal resilience (Connor-Davidson Resilience Scale-25); external resilience (ENRICHD social support tool); quality adjusted life years (EQ-5D-5L); self-efficacy for smoking abstinence (Smoking-Abstinence Self-Efficacy Questionnaire); motivation to quit smoking (Biener and Abrams Contemplation Ladder); nicotine dependence (Fagerstrom Test for Nicotine Dependency); equanimity (Equanimity Scale-16); stress (Perceived Stress Scale-10); goal assessment/attainment (Problems and Goals Assessment Scale).

DISCUSSION

This study is the first to compare resilience interventions for low SES smokers which have been identified by them as acceptable. Our various repeated measures and process evaluation will facilitate exploration of mechanisms of impact. We intervene within the novel framework of the Psychosocial Model of Resilience, applying a promising paradigm to address a critical and inequitable public health problem. Trial registration Australian New Zealand Clinical Trials Registry ID: ACTRN12621000445875, registered 19 April 2021 ( https://anzctr.org.au/Trial/Registration/TrialReview.aspx?id=381007&isReview=true ). The Universal Trial Number is U1111-1261-8951.

Engaging children and adolescents with acquired brain injury and their families in goal setting: The family perspective

This study explored the experiences of goal setting in paediatric rehabilitation from the perspectives of children and adolescents with acquired brain injury (ABI) and their parents in paediatric rehabilitation. Using a qualitative research design, 15 semi-structured interviews were conducted with 13 parents and 8 young people with ABI aged between 9 and 18 years who were engaged in outpatient rehabilitation. Interview transcripts were analysed using constructivist grounded theory methods. Two main themes and several sub-themes emerged: Experiences of goal setting: The role of professionals; The role of the young person; and The role of the parents. Working as a team: Understanding each other and building trust; Communicating, sharing knowledge and different perspectives; and Being flexible. These themes reflect parent's and young people's experience of goal setting during paediatric rehabilitation for ABI and suggest clinicians play an important role in educating young people and their families about goal setting in the outpatient rehabilitation context. Young people and their parents also perceive the focus of outpatient rehabilitation as working collaboratively with clinicians to gain knowledge to manage the consequences of ABI. Our findings emphasize the importance of the therapeutic consumer-clinician relationship and the need to actively engage young people in goal setting.

Effectiveness of a personalized health profile on specificity of self-management goals among people living with HIV in Canada: findings from a blinded pragmatic randomized controlled trial

PURPOSE

To estimate among people living with chronic HIV, to what extent providing feedback on their health outcomes will affect the number and specificity of patient-formulated self-management goals.

METHODS

A personalized feedback profile was produced for individuals enrolled in a Canadian HIV Brain Health Now study. Goal specificity was measured by total number of specific words (matched to a domain-specific developed lexicon) per person-words using text mining techniques.

RESULTS

Of 176 participants enrolled and randomly assigned to feedback and control groups, 110 responses were received. The average number of goals was similar for both groups (3.7 vs 3.9). The number of specific words used in the goals formulated by the feedback and control group were 642 and 739, respectively. Specific nouns and actionable verbs were present to some extent and "measurable" and "time-bound" words were mainly missing. Negative binomial regression showed no difference in goal specificity among groups (RR = 0.93, 95% CI 0.78-1.10). Goals set by both groups overlapped in 8 areas and had little difference in rank.

CONCLUSION

Personalized feedback profile did not help with formulation of high-quality goals. Text mining has the potential to help with difficulties of goal evaluation outside of the face-to-face setting. With more data and use of learning models automated answers could be generated to provide a more dynamic platform.

First-year medical students' perceptions of a self-regulated learning-informed intervention: an exploratory study

BACKGROUND

Students with developed self-regulated learning (SRL) skills demonstrate an ability to set individualized educational goals, select optimal learning strategies for reaching these goals, and reflect on overall progress. The primary aims of this study were to investigate first-year medical students' perceived utility of a self-regulated learning-informed intervention and to assess the impact of its implementation on students' intended use of SRL throughout medical school.

METHODS

A two-part educational intervention focused on SRL skill development was carried out at Harvard Medical School during the start of the 2021 academic year. For the first component of the intervention, 169 first-year medical students engaged in an interactive class session structured around SRL concept videos, a brief lecture, small group discussions and individual reflection. Students completed pre- and post-intervention surveys which inquired about learners' current and anticipated application of SRL skills. During the second component of the intervention, 15 first-year medical students participated in a set of one-on-one academic SRL coaching sessions. All coaching participants completed follow-up semi-structured interviews.

RESULTS

A statistically significant increase was observed between students' use of skills in all domains of self-regulated learning prior to the intervention and their anticipated use of these skills following the intervention. Prior to the intervention, 60.1% (n = 92) of students reported utilizing evidence-based learning strategies, compared to 92.8% (n = 142) of students (p < 0.001) who anticipated applying this SRL skills at the completion of the classroom session. Six core themes emerged from qualitative analysis of the post-intervention survey including learning plan development, accountability and progress tracking, goals for growth, engagement through active learning, routine reflection, and adapting to the curriculum.

CONCLUSIONS

Both classroom-based learning sessions and one-on-one academic coaching programs are feasible approaches for encouraging the use of self-regulated learning techniques in the preclinical setting.

Study protocol for the description and evaluation of the "Habit Coach" - a longitudinal multicenter mHealth intervention for healthy habit formation in health care professionals

BACKGROUND

The adoption of a healthy lifestyle plays a crucial role for the health and well-being of health care professionals. Previous e- and mHealth interventions relied on deliberative psychological processes (e.g., intention, planning) to target lifestyle changes, while revealing mixed efficacy. The additional potential of non-deliberative, automatic processes (i.e., habits) for behavior change has been understudied in interventions so far. The Habit Coach mHealth intervention combines deliberative and non-deliberative processes to support health care professionals in forming healthy physical activity, nutrition and mindfulness habits in daily life. The aim of this paper is to outline the study protocol including a detailed description of the mHealth intervention, evaluation plan, and study design. The purpose of this trial is to understand healthy habit formation in health care professionals over time.

METHODS

A one-arm, multicenter mHealth intervention study will be conducted. Behavioral and psychosocial predictors will be collected via within-app questionnaires across a 100-day period at baseline, post, as well as at weekly assessments. To understand habit formation across time, linear mixed models will be used.

DISCUSSION

This trial aims to unravel the role of motivational and volitional determinants for healthy habit formation across multiple health behaviors in health care professionals embedded in a mHealth intervention.

TRIAL REGISTRATION

This trial is registered in the German Clinical Trials Register, DRKS-ID DRKS00027156. Date of registration 17 November 2021.

Goal setting with young people for anxiety and depression: What works for whom in therapeutic relationships? A literature review and insight analysis

Background

Goal setting and goal-focused work is widely used in young people’s mental health settings. However, little is known about how, why or for whom this is helpful. This study aims to explore the mechanisms of collaborative goal setting as part of therapeutic relationships: is it helpful for young people experiencing anxiety and/or depression, how and why/not, for whom, and under what circumstances?

Methods

Online database searches generated 10,907 records. Seven unique studies are included, combined with insight analysis from directed discussions with international advisors with lived experience of anxiety and/or depression and therapy (N = 8; mean age = 20.8), and mental health academics/clinicians (N = 6).

Results

Findings are presented as a narrative synthesis and suggest that goal setting is helpful to young people experiencing anxiety and/or depression because it helps build good therapeutic relationships through open communication and building trust. Goal setting helps make things more manageable, enabling young people to feel supported and have ownership of their care. Individual preferences, or high levels of distress, trauma, low confidence, hopelessness, negative past experiences of goal setting, perfectionism, and rumination are considered limiting factors to goal setting. Additionally, contextual factors including country and long-term therapy are explored.

Conclusion

Whilst the resultant sample is small, emphasis on the voices of young people in the research is both prominent and of paramount importance. Several key literature gaps are identified, including evidenced links to the reduction in symptoms. Priority must be given to researching unhelpful mechanisms of goal setting for young people experiencing anxiety and/or depression, to avoid any potential iatrogenic effects.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40359-022-00879-5.

Does the Weekly Practice of Recalling and Elaborating Episodes Raise Well-Being in University Students?

Increasing well-being is a prominent worldwide goal that can be achieved primarily through social support and environmental factors. However, in times of social distancing or isolation, it is important to also rely on self-managed activities. This study aimed to (a) test the effectiveness of a seven-week well-being intervention, in increasing need satisfaction, self-compassion, emotion regulation, and grateful disposition by curbing need frustration, self-derogation, and emotional suppression, and (b) examine the maintenance and long-term effects of the practices based on recall, elaboration, and writing. One hundred and twenty university students weekly recalled and elaborated for seven consecutive weeks on three recent episodes of gratitude, self-affirmation, goal setting, or meaningful things, according to the group to which they were assigned. Before the intervention, immediately after and one month later, they filled in questionnaires to assess need satisfaction/frustration, self-compassion/derogation, emotion regulation and grateful disposition. The results confirmed an increase in well-being and a decrease in ill-being for all groups (Cohen d for the significant differences ranging from 0.18 to 0.53). The effects were maintained one month later and even increased for self-compassion, self-derogation, need frustration, and emotional reappraisal. A follow-up assessment revealed that a third of the participants continued with the well-being practices. Implications and suggestions for future well-being interventions are discussed.

Goal Setting with Latinx Families of Children with Intellectual and Developmental Disabilities: Case Studies

Behavioral community psychology focuses on studying issues that matter to communities, unpacking contextual factors that impact people's behaviors, and identifying strategies to address such issues. Goal setting is one such strategy often used by behavioral psychologists. Grounded in the values of behavioral community psychology and a behavior analysis paradigm, this study illustrated two case studies of Latinx parents of children with disabilities where goal-setting strategies were implemented to promote behavior change. The first case study focused on the promotion of healthy lifestyle behaviors and routines among Latinx families of children with disabilities in the United States. The second case study examined goal setting related to youth development by parents of adolescents with disabilities in Colombia. In both cases, participants received training on goal setting and had opportunities to discuss progress toward achieving their goals, share action steps taken, and discuss the contextual challenges or barriers that they experienced. The results indicate that behavioral goal-setting procedures can be effective in helping parents attain their goals and brainstorm strategies for addressing behavioral and contextual challenges. Implications for future research advancing behavioral community psychology are discussed.

The utility of short-term goal achievement as an early indicator of discharge destination in people admitted to neurological rehabilitation with severe functional deficits

PURPOSE

This study investigates whether short-term goal achievement in the early phase of neurological rehabilitation is an accurate indicator of discharge destination in patients with severe disability in comparison to change in scores in the motor domain of the Functional Independence Measure (FIM motor).

METHOD

A prospective observational cohort study.

PARTICIPANTS

A consecutive sample of 53 patients admitted to rehabilitation with a neurological diagnosis and FIM motor score below 47.Measures: Short-term goal achievement and FIM motor change in the first 2 weeks following admission and discharge destination.

RESULTS

Short-term goal achievement showed good prognostic utility [area under the curve (AUC) of 0.75; 95% confidence intervals (CI) 0.6, 0.89] for discharge destination, dichotomized as home or semi-independent living versus nursing home care, similar to that demonstrated by change in FIM motor scores (AUC of 0.69; 95% CI 0.55, 0.84), p = 0.55. A cut-off was established for short-term goal achievement at more than half of goals achieved, with an AUC of 0.73 (95% CI 0.58, 0.87); sensitivity 71.4% and specificity 74.4%.

CONCLUSIONS

Short-term goal achievement in the early phase post-admission is a good indicator of the person's potential to return home.Implications for RehabilitationShort-term goal setting should be a key practice feature of neurological rehabilitation.Goal achievement is an indicator of a person's potential to return home or to semi-independent living in people with severe neurological deficits.Evaluation of short-term goal achievement may inform the ongoing rehabilitation program and discharge planning.

Measuring the Master Adaptive Learner: Development and Internal Structure Validity Evidence for a New Instrument

BACKGROUND

The master adaptive learner (MAL) uses self-regulated learning skills to develop adaptive, efficient, and accurate skills in practice. Given rapid changes in healthcare, it is essential that medical students develop into MALs. There is a need for an instrument that can capture MAL behaviors and characteristics. The objective of this study was to develop an instrument for measuring the MAL process in medical students and evaluate its psychometric properties.

METHODS

As part of curriculum evaluation, 818 students completed previously developed instruments with validity evidence including the Self-Regulated Learning Perception Scale, Brief Resilience Scale, Goal Orientation Scale, and Jefferson Scale of Physician Lifelong Learning. The authors performed exploratory factor analysis to examine underlying relationships between items. Items with high factor loadings were retained. Cronbach's alpha was computed. In parallel, the multi-institutional research team rated the same items to provide content validity evidence of the items to MAL model.

RESULTS

The original 67 items were reduced to 28 items loading onto four factors: Planning, Learning, Resilience, and Motivation. Each subscale included the following number of items and Cronbach's alpha: Planning (10 items, alpha = 0.88), Learning (6 items, alpha = 0.81), Resilience (6 items, alpha = 0.89), and Motivation (6 items, alpha = 0.81). The findings from the factor analyses aligned with the research team ratings of linkage to the components of MAL.

CONCLUSION

These findings serve as a starting point for future work measuring master adaptive learning to identify and support learners. To fully measure the MAL construct, additional items may need to be developed.

Adaptation of the Patient Benefit Assessment Scale for Hospitalised Older Patients: development, reliability and validity of the P-BAS picture version

Background

The Patient Benefit Assessment Scale for Hospitalised Older Patients (P-BAS HOP) is a tool developed to both identify the priorities of the individual patient and to measure the outcomes relevant to him/her, resulting in a Patient Benefit Index (PBI), indicating how much benefit the patient had experienced from the hospitalisation. The reliability and the validity of the P-BAS HOP appeared to be not yet satisfactory and therefore the aims of this study were to adapt the P-BAS HOP and transform it into a picture version, resulting in the P-BAS-P, and to evaluate its feasibility, reliability, validity, responsiveness and interpretability.

Methods

Process of instrument development and evaluation performed among hospitalised older patients including pilot tests using Three-Step Test-Interviews (TSTI), test-retest reliability on baseline and follow-up, comparing the PBI with Intraclass Correlation Coefficient (ICC), and hypothesis testing to evaluate the construct validity. Responsiveness of individual P-BAS-P scores and the PBI with two different weighing schemes were evaluated using anchor questions. Interpretability of the PBI was evaluated with the visual anchor-based minimal important change (MIC) distribution method and computation of smallest detectable change (SDC) based on ICC.

Results

Fourteen hospitalised older patients participated in TSTIs at baseline and 13 at follow-up after discharge. After several adaptations, the P-BAS-P appeared feasible with good interviewer’s instructions. The pictures were considered relevant and helpful by the participants. Reliability was tested with 41 participants at baseline and 50 at follow-up. ICC between PBI₁ and PBI₂ of baseline test and retest was 0.76, respectively 0.73. At follow-up 0.86, respectively 0.85.

For the construct validity, tested in 169 participants, hypotheses regarding importance of goals were confirmed. Regarding status of goals, only the follow-up status was confirmed, baseline and change were not. The responsiveness of the individual scores and PBI were weak, resulting in poor interpretability with many misclassifications. The SDC was larger than the MIC.

Conclusions

The P-BAS-P appeared to be a feasible instrument, but there were methodological barriers for the evaluation of the reliability, validity, and responsiveness. We therefore recommend further research into the P-BAS-P.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-021-02708-7.

Exploring behavior change techniques for reablement: A scoping review

BACKGROUND

Reablement is a team-based person-centered health and social care model, most commonly available for community-dwelling older adults. Understanding the components of reablement and how it is delivered, received, and enacted facilitates best evidence and practice. Determining behavior change techniques (BCTs) or strategies is an important step to operationalize implementation of reablement.

OBJECTIVE

We conducted a scoping review of peer-reviewed literature to identify BCTs used within reablement studies.

METHODS

We registered our study with the Joanna Briggs Institute and conducted five database searches. Inclusion criteria were peer-reviewed studies focused on adults and older adults without significant cognitive impairment or dementia receiving reablement, and all study designs, years, and languages. We excluded studies focused on reablement for people with dementia or reablement training programs. The last search was on April 8, 2021. Two authors screened independently at Level 1 (title and abstract) and 2 (full text). Two authors adjudicated BCTs for each study, and a third author confirmed the final list.

RESULTS

We identified 567 studies (591 publications) and included 21 studies (44 publications) from six global locations. We identified 27 different BCTs across all studies. The three most common BCTs for reablement were goal setting (behavior), social support (unspecified), and instruction on how to perform a behavior.

CONCLUSIONS

We highlight some behavioral components of reablement and encourage detailed reporting to increase transparency and replication of the intervention. Future research should explore effective BCTs (or combinations of) to include within reablement to support health behavior adoption and maintenance.

Quality improvement project to improve providers' goal-setting activity for chronic disease self-management

BACKGROUND

Patient-centered medical home (PCMH) places patients at the center of care and actively considers patients' goals, preferences and skill levels in caring for their disease while developing a care plan. We implemented a quality improvement (QI) project to improve internal medicine resident goal-setting activity with patients for chronic disease self-management.

METHODS

The plan-do-study-act (PDSA) model was used and a root cause analysis was conducted with internal medicine residents (n=20) and faculty (n=7) to identify barriers to patient goal setting. Two main causes were identified - lack of awareness and lack of knowledge about where and how to set patient goals in the electronic medical record (EMR). Reminders during daily morning huddles, discussions with faculty, educational video presentation and organizational policy change interventions were implemented in four serial PDSA cycles.

RESULTS

The goal setting activity documentation rate by resident providers increased to 14% following inclusion of patient goal setting reminders during daily morning huddles. There was notable increase in the goal setting documentation rate to 29% following discussion in faculty meeting. The goal setting documentation rate remained the same (29%) despite educational video and policy change intervention. However, goal setting documentation rate increased to 33% by the end of the study.

CONCLUSION

Our QI project resulted in a measurable increase in the use of methods of healthcare delivery associated with improved outcomes. This model worked well in our setting, and sharing our success may benefit others seeking to achieve similar goals.

Development of an assessment guide to evaluate meaningful outcomes for people living with dementia who are engaged in reablement programs

PURPOSE

Clinical practice guidelines for dementia recommend the provision of rehabilitative or reablement interventions that support functioning. This project sought to develop an assessment guide, centring on goal attainment scaling (GAS), for practitioners to measure attainment of meaningful outcomes for people living with dementia participating in reablement programs.

MATERIALS AND METHODS

To assist in guide development, two focus groups (people impacted by dementia [n = 10]) explored priority reablement goals. Two further focus groups (allied health practitioners [n = 11]) explored understanding and experience using GAS, opinions on what goals would be realistic, and how an assessment guide could best support practice.

RESULTS

The key focus group themes that emerged and which underpinned guide development were: 'what is possible'; 'who sets the goals'; 'practitioner perspectives on using GAS'. Leisure was a key goal priority for people impacted by dementia, and echoed by practitioners. The assessment guide is structured around three steps: choosing goals (using focus group derived Reablement Goal Lists); defining goals (using a new Dementia-specific SMART Framework); scoring goals (using GAS-Light).

CONCLUSIONS

Providing a structured approach to evaluation of reablement programs for people living with dementia could lead to more consistent service provision, improved outcomes and opportunities for benchmarking.Implications for RehabilitationDementia is a leading cause of disability in older people.Rehabilitative interventions such as reablement are recommended to support functioning in people living with dementia, but there is currently no consistent method of selecting and evaluating attainment of meaningful outcomes.This study describes the reablement goals identified by people impacted by dementia as being most important, along with allied health practitioner views on goal-setting and the use of Goal Attainment Scaling (GAS).Study findings were used to develop a structured assessment guide employing three steps: choosing reablement goals; defining those goals using a new dementia-specific SMART Framework; and scoring goals using GAS-Light.A consistent approach to goal selection and evaluation of attainment for people impacted by dementia participating in reablement programs may lead to more effective rehabilitative interventions in this group.

Integrating river restoration goals with urban planning practices: the case of Kebena river, Addis Ababa

In the urban environment, rivers are most affected by development mismanagement to the extent that some of the essential services such as habitat for biodiversity conservation, recreation and domestic uses to communities are critically impaired. Consequently, river restoration is presented as practical solution to address urban river degradation issues and to revitalize urban rivers and river buffers. Goal setting along with clear and measurable goals in urban river restoration processes is one of the critical tools to guide restoration activities. This study aims to assess the qualitative effects of clearly defined river restoration goals and analyze their tangible effects on river restoration efforts in Kebena river watershed, Addis Ababa. Qualitative data from expert interviews, stakeholders’ consultation, document review and institutional analysis are used to inform this research. The results show that the Environmental Protection Authority and Structural plan of the city have vaguely defined river restoration goal in the planning and implementation phases of river restoration projects. On the other hand, the goals of different institutions varied in context, while others were redundant and lacked synergy. As a result, urban rivers and river buffers accommodate various land uses that are negatively affecting the potential of rivers and river buffers in benefiting communities. Finally, the study forwarded critical methodological steps to guide the formulation of a well-defined goal and setting priorities for concrete actions to restore the river.

Occupational therapy addressing the ability to perform activities of daily living among persons living with chronic conditions: a randomised controlled pilot study of ABLE 2.0

BACKGROUND

The ABLE intervention was developed to enhance the ability to perform activities of daily living (ADL) tasks among persons living with chronic conditions. ABLE is a generic, home-based, individualised, 8-week occupational therapy intervention program, developed to be delivered in Danish municipalities. In a previous study, the feasibility of ABLE was evaluated in terms of content and delivery. In this pilot study, the remaining feasibility aspects of a randomised controlled trial including (i) trial procedures (recruitment and retention), (ii) randomisation, (iii) adherence to program, (iv) feasibility of additional outcome measurements, and (iv) access to information on usual occupational therapy were evaluated.

METHODS

The study was conducted in a Danish municipality, using a two-armed parallel randomised controlled design, planning a recruitment strategy including 20 persons living with one/more chronic conditions and experiencing problems performing ADL. The following progression criteria were used to determine if a future full-scale randomised controlled trial was feasible: (i) recruitment (50% met the eligibility criteria) and retention (80%), (ii) randomisation (80% accepted randomisation, procedure was executed as planned), (iii) adherence to program (100% followed the treatment protocol), (iv) outcome measurements (80% of the participants delivered relevantly and fully answered questionnaires), and (v) usual occupational therapy (extraction of needed information was successful).

RESULTS

Due to the COVID-19 pandemic, the study was truncated resulting in limited but sufficient data to answer most of the study questions. (i) Eighteen of 37 eligible persons (48.6%) were recruited; of those treated (n = 6), all remained (100%); (ii) 18 accepted randomisation (100%), and procedure was effective; (iii) ABLE was delivered with adherence (100%); (iv) 92.3-100% of the participants gave relevant and complete answers in two of three questionnaires; and (v) needed information on usual occupational therapy was extractable in seven of nine aspects.

CONCLUSIONS

Proceeding to full-scale trial is recommendable; however, a few adjustments on outcome measurements, inclusion criteria and extraction of information on usual occupational therapy are needed.

TRIAL REGISTRATION

The study was registered at ClinicalTrials.gov (Identifier: NCT04295837 ) on December 5th, 2019. Retrospectively registered.

Using Realistic Evaluation to understand how interventions work on dairy farms

Interventions that aim to help farmers change on-farm practices recommend that advisors communicate effectively with farmers, work collaboratively to set goals and provide farmers with resources that are applicable to the farm context. We developed an intervention that aimed to help farmers modify and use a standard operating procedure (SOP) for colostrum management; failure of passive transfer of immunoglobulins is common on dairy farms and SOPs for colostrum management are increasingly required by farm animal welfare assurance programs. We used Realistic Evaluation to evaluate whether, how and why our intervention to help farmers modify and use SOPs for colostrum management facilitated change and provide recommendations based on our approach that can improve the design and implementation of future interventions. We used a multiple case study on five farms over 8 months, collecting data through interviews, participant observation, document analysis and field notes. We identified three mechanisms that influenced whether participants modified and used their SOP. The purpose mechanism distinguished between participants who thought the aim of the SOP was for farm staff to learn and understand how to complete a task versus those who thought that the SOP was only useful for compliance with assurance programs. The utility mechanism distinguished between participants who thought that the SOP would be helpful for daily use on their farm, versus those who did not. The physical text mechanism distinguished between participants who used the templates we provided to modify and use their SOP, versus those who did not. A key contextual factor on all farms was participant belief of having capable and engaged staff on their farm; modification and use of the SOP did not occur unless this was the case. To facilitate change, intervention developers should actively participate in the intervention to develop an understanding of farmer needs, understand the purpose behind different goals set by farmers and integrate tools, advice and resource demonstrations when possible. We conclude that Realistic Evaluation is a useful framework for evaluating how contexts and mechanisms generate outcomes on farms, and to understand how, and in which contexts, complex interventions facilitate change. We suggest that this approach can improve the success of interventions and help direct the approaches used on different farms.

From Reflection to Action: Combining Machine Learning with Expert Knowledge for Nutrition Goal Recommendations

Self-tracking can help personalize self-management interventions for chronic conditions like type 2 diabetes (T2D), but reflecting on personal data requires motivation and literacy. Machine learning (ML) methods can identify patterns, but a key challenge is making actionable suggestions based on personal health data. We introduce GlucoGoalie, which combines ML with an expert system to translate ML output into personalized nutrition goal suggestions for individuals with T2D. In a controlled experiment, participants with T2D found that goal suggestions were understandable and actionable. A 4-week in-the-wild deployment study showed that receiving goal suggestions augmented participants' self-discovery, choosing goals highlighted the multifaceted nature of personal preferences, and the experience of following goals demonstrated the importance of feedback and context. However, we identified tensions between abstract goals and concrete eating experiences and found static text too ambiguous for complex concepts. We discuss implications for ML-based interventions and the need for systems that offer more interactivity, feedback, and negotiation.

Do Mandated Weight Loss Goals Prior to Bariatric Surgery Improve Postoperative Outcomes?

BACKGROUND

Most patients pursuing bariatric surgery undergo mandated preoperative weight management programs. The purpose of this study was to assess whether preoperative mandated weight loss goals lead to improved perioperative morbidity, postoperative weight loss, and resolution of comorbidities.

METHODS

Data from patients who underwent primary laparoscopic Roux-en-Y gastric bypass (LRYGB), and laparoscopic sleeve gastrectomy (LSG) between October 2012 and October of 2015 was reviewed. Patients were divided in two groups: those with BMI of 35-45 were not required to achieve a weight loss goal prior to surgery (no-WLG group) while those with BMI > 45 were given a weight loss goal proportionate to their weight (WLG group). Body mass index (BMI), history of diabetes mellitus type-II (DM-II), hypertension (HTN), hyperlipidemia (HLD), and obstructive sleep apnea (OSA) were recorded at baseline and 4 years postoperatively. Length of hospital stay (LOS) and reinterventions were considered proxies for postoperative morbidity.

RESULTS

A total of 776 patients, 81.4% LRYGB, were included in the study (age 45.1 ± 11.9). There was no difference in %ΔBMI, DM-II, HDL, HTN, LOS, or reinterventions among the two groups at 4 years postoperatively in both LRNY and LSG patients. This lack of difference persisted even when patients with similar BMI (43-45 vs 45.01-47) were compared.

CONCLUSION

WLG group did not have decreased perioperative morbidity, nor improved weight loss and comorbidity resolution 4 years after surgery. While these findings should also be confirmed by multicenter trials, they question the value of mandated WLG prior to bariatric surgery as they seem ineffective and may limit patient access to surgery.

Reliability and validity of the Patient Benefit Assessment Scale for Hospitalised Older Patients (P-BAS HOP)

BACKGROUND

The Patient Benefit Assessment Scale for Hospitalised Older Patients (P-BAS HOP) is a tool which is capable of both identifying the priorities of the individual patient and measuring the outcomes relevant to him/her, resulting in a Patient Benefit Index (PBI) with range 0-3, indicating how much benefit the patient had experienced from the admission. The aim of this study was to evaluate the reliability, validity, responsiveness and interpretability of the P-BAS HOP.

METHODS

A longitudinal study among hospitalised older patients with a baseline interview during hospitalisation and a follow-up by telephone 3 months after discharge. Test-retest reliability of the baseline and follow-up questionnaire were tested. Percentage of agreement, Cohen's kappa with quadratic weighting and maximum attainable kappa were calculated per item. The PBI was calculated for both test and retest of baseline and follow-up and compared with Intraclass Correlation Coefficient (ICC). Construct validity was tested by evaluating pre-defined hypotheses comparing the priority of goals with experienced symptoms or limitations at admission and the achievement of goals with progression or deterioration of other constructs. Responsiveness was evaluated by correlating the PBI with the anchor question 'How much did you benefit from the admission?'. This question was also used to evaluate the interpretability of the PBI with the visual anchor-based minimal important change distribution method.

RESULTS

Reliability was tested with 53 participants at baseline and 72 at follow-up. Mean weighted kappa of the baseline items was 0.38. ICC between PBI of the test and retest was 0.77. Mean weighted kappa of the follow-up items was 0.51. ICC between PBI of the test and retest was 0.62. For the construct validity, tested in 451 participants, all baseline hypotheses were confirmed. From the follow-up hypotheses, tested in 344 participants, five of seven were confirmed. The Spearman's correlation coefficient between the PBI and the anchor question was 0.51. The optimal cut-off point was 0.7 for 'no important benefit' and 1.4 points for 'important benefit' on the PBI.

CONCLUSIONS

Although the concept seems promising, the reliability and validity of the P-BAS HOP appeared to be not yet satisfactory. We therefore recommend adapting the P-BAS HOP.

An evaluation of goal setting in the NHS England diabetes prevention programme

OBJECTIVE

We know little about how goal setting is actually delivered in routine practice. The National Health Service Diabetes Prevention Programme (NHS-DPP) is a behavioural intervention aiming to prevent progression to Type 2 diabetes in those at risk. It has been delivered across England by four commercial providers. This study aimed to establish whether goal setting in the NHS-DPP was delivered in line with the current evidence base. Design: Observational study and document review. One-hundred-and-eighteen NHS-DPP sessions with 419 people were observed at eight sites (two sites per provider). Main outcome measures: Multiple characteristics of goal setting were reliably coded from each providers' programme plans (intended goal setting) and from audio-recorded NHS-DPP sessions (actual goal setting). Results: Providers intended to deliver goal setting in 88.3% of sessions, though goal setting was delivered in only 52.5% of sessions. During delivery, the observed goals set across providers were generally specific (62.5%), set privately (53.1%), with goal difficulty rarely mentioned (3.1%). Conclusions: Goal setting in the NHS-DPP is being under-delivered, and not in line with the evidence base for promoting behavioural change. Goal setting in national behaviour change programmes should be optimised and training provided specifically for goal setting.

Focusing on recovery goals improves motivation in first-episode psychosis

INTRODUCTION

Diminished motivation (e.g., low drive, curiosity, and engagement in activities) is associated with robust impairment in psychosocial functioning in schizophrenia, yet even the most effective evidence-based interventions rarely effect meaningful change in motivation. Individual Resiliency Training (IRT) is a psychosocial treatment for individuals following a first episode of psychosis, supporting motivation through recovery goal setting and pursuit. The extent to which such an approach might improve motivation over time is unknown.

METHOD

We tested the impact of exposure to IRT modules focused on goal setting and attainment on motivation and functional outcomes among participants in the Recovery After an Initial Schizophrenia Episode-Early Treatment Program (RAISE-ETP). In the sample of 404 individuals with a first episode of psychosis receiving treatment across 34 community sites, we ran mixed-effect models with group (exposed to four or more goal-focused IRT sessions vs. Community Care (CC)), time (baseline, six- and 12-month follow-up), and the group-by-time interaction as predictors of motivation, role and social functioning. We also ran these analyses with those exposed to three or fewer goal-focused IRT sessions compared to CC.

RESULTS

Controlling for gender, ethnicity, baseline cognition, and total number of outpatient mental health visits, exposure to four or more goal-focused IRT sessions was associated with greater improvements in motivation and role functioning compared to CC; effects were not observed for social functioning. Participants receiving three or fewer goal-focused IRT sessions did not differ from those in CC in these outcomes. Further, sensitivity analysis showed that general exposure to IRT was not associated with differential outcomes.

CONCLUSIONS

Findings suggest that sufficient focus on recovery goal setting and support in psychosocial intervention for first-episode psychosis may have specific impact on motivation.

Feasibility and outcomes of a goal-directed physical therapy program for patients with metastatic breast cancer

PURPOSE

To evaluate the feasibility and outcomes of a tailored, goal-directed, and exercise-based physical therapy program for patients with metastatic breast cancer (MBC).

METHODS

This was an observational, uncontrolled feasibility study. The physical therapy intervention was highly tailored to the individual patient's goals, abilities, and preferences and could include functional, strength, aerobic, and relaxation exercises. Feasibility outcomes were participation rate (expected: 25%), safety, and adherence (percentage of attended sessions relative to scheduled sessions). Additional outcomes were goal attainment, self-reported physical functioning, fatigue, health-related quality of life, and patient and physical therapist satisfaction with the program.

RESULTS

Fifty-five patients (estimated participation rate: 34%) were enrolled. Three patients did not start the intervention due to early disease progression. An additional 22 patients discontinued the program prematurely, mainly due to disease progression. Median intervention adherence was 90% and no major intervention-related adverse events occurred. A goal attainment score was available for 42 patients (of whom 29 had completed the program and 13 had prematurely dropped out). Twenty-two (52%) of these patients achieved their main goal fully or largely and an additional 15 patients (36%) partially. Eighty-five percent would "definitely recommend" the program to other patients with MBC. We observed a modest improvement in patient satisfaction with physical activities (Cohen's d_z 0.33).

CONCLUSION

The tailored intervention program was feasible in terms of uptake, safety, and outcomes and was highly valued by patients and physical therapists. However, disease progression interfered with the program, leading to substantial dropout.

TRIAL REGISTRATION

NTR register: NTR6475.

Facilitators and "deal breakers": a mixed methods study investigating implementation of the Goal setting and action planning (G-AP) framework in community rehabilitation teams

BACKGROUND

High quality goal setting in stroke rehabilitation is vital, but challenging to deliver. The G-AP framework (including staff training and a stroke survivor held G-AP record) guides patient centred goal setting with stroke survivors in community rehabilitation teams. We found G-AP was acceptable, feasible to deliver and clinically useful in one team. The aim of this study was to conduct a mixed methods investigation of G-AP implementation in diverse community teams prior to a large-scale evaluation.

METHODS

We approached Scottish community rehabilitation teams to take part. Following training, G-AP was delivered to stroke survivors within participating teams for 6 months. We investigated staff experiences of G-AP training and its implementation using focus groups and a training questionnaire. We investigated fidelity of G-AP delivery through case note review. Focus group data were analysed using a Framework approach; identified themes were mapped into Normalisation Process Theory constructs. Questionnaire and case note data were analysed descriptively.

RESULTS

We recruited three teams comprising 55 rehabilitation staff. Almost all staff (93%, 51/55) participated in G-AP training; of those, 80% (n = 41/51) completed the training questionnaire. Training was rated as 'good' or 'very good' by almost all staff (92%, n = 37/41). G-AP was broadly implemented as intended in two teams. Implementation facilitators included - G-AP 'made sense'; repetitive use of G-AP in practice; flexible G-AP delivery and positive staff appraisals of G-AP impact. G-AP failed to gain traction in the third team. Implementation barriers included - delays between G-AP training and implementation; limited leadership engagement; a poor 'fit' between G-AP and the team organisational structure and simultaneous delivery of other goal setting methods. Staff recommended (i) development of training to include implementation planning; (ii) ongoing local implementation review and tailoring, and (iii) development of electronic and aphasia friendly G-AP records.

CONCLUSIONS

The interaction between G-AP and the practice setting is critical to implementation success or failure. Whilst facilitators support implementation success, barriers can collectively act as implementation "deal breakers". Local G-AP implementation efforts should be planned, monitored and tailored. These insights can inform implementation of other complex interventions in community rehabilitation settings.

Engaging children and adolescents with acquired brain injury and their families in goal setting: The clinician perspective

This paper explored clinicians' experiences of the goal setting process with children and adolescents with acquired brain injuries (ABI) and their families in paediatric neurorehabilitation. Semi-structured interviews were conducted with 13 clinicians, all members of an interdisciplinary paediatric rehabilitation service, who work with children and adolescents with ABI and their families. Interview transcripts and additional data were analysed using constructivist grounded theory methods. Three main themes and sub-themes were developed: (1) Seeing the bigger picture: Goals change over time; Families set bigger picture goals; Need-to-dos: Goals that the child/adolescent needs to achieve; and Want-to-dos: Goals that the child/adolescent wants to achieve; (2) Collaborating as a team: Everyone needs to be on the same page; Hearing the child's/adolescent's voice; and Parents as advocates; and (3) Recognizing and navigating challenges: Child-/adolescent- and family-related challenges and Time as a service-related challenge. Participants perceived the clinician's role during goal setting as that of an active collaborator, enabling children and adolescents with ABI and their families to generate meaningful goals. These findings demonstrate insights into goal setting in paediatric ABI neurorehabilitation from clinicians' perspectives, and highlight the importance of collaboration, flexibility and anticipation of challenges in facilitating children's, adolescents' and families' involvement in this process.

Goal-setting program improves nutrition and physical activity among Supplemental Nutrition Assistance Program eligible adults

OBJECTIVE

To examine the impact of Nutrition for Life (NFL), a goal-setting nutrition education program, on the knowledge, self-efficacy and behaviour of adults eligible for Supplemental Nutrition Assistance Program-Education.

DESIGN

NFL was developed using a 4-week goal-setting behavioural strategy focused on nutrition, physical activity and meal planning techniques. A quantitative repeated-measures design using self-reported data was collected at pre- and post-interventions and at 1-week and 1-month follow-ups.

SETTING

Two Federally Qualified Health Centers in Philadelphia, PA, USA.

PARTICIPANTS

A total of ninety-eight participants enrolled in the intervention; the majority were women (80·2 %), Black/Non-Hispanic (75·0 %) and 45-54 year old (39·6 %).

RESULTS

Participants showed significant improvement in knowledge, self-efficacy and behaviour. Specifically, mean daily intake for vegetables increased by 0·31 cup (P < 0·05) and for fruits by 0·39 cup (P < 0·01) at 1-week follow-up. Participants also showed healthier behaviour at 1-month follow-up. Planning at least seven meals per week increased from 14·8 to 50 % (P < 0·01), completing at least 30 min of physical activity every day in the last week increased from 16·7 to 36 % (P < 0·01) and consuming water with all meals increased from 39 to 70·6 % (P < 0·01).

CONCLUSIONS

The implementation of a goal-oriented nutrition education program offers a promising approach at achieving positive behaviour change among SNAP-eligible adults.

Setting performance and learning goals is useful for active and inactive individuals, if goals are personalized and flexible: commentary on Swann et al. (2020)

This commentary expands on the recent critical review by Swann et al. (2020) which aimed to update the applications of Goal-Setting Theory (Locke & Latham, 2019) in physical activity promotion. Drawing from other work on goal striving and behaviour change, we make four key points to further elaborate on Swann et al.'s review. First, goals are more likely to be enacted if they are specific, personally relevant and pursued for autonomous motives; performance goals can be useful for inactive individuals if set appropriately and self-endorsed. Second, goal striving needs to be flexible and adjustable, and to consider goal priorities and time factors relevant to goal engagement and disengagement. Goal-Setting Theory would therefore benefit from being expanded to add the factors of goal priority, context, and time. Third, research on goal setting in physical activity could benefit from embracing idiographic designs and interventions. Fourth, other theoretical approaches to goal striving should be considered when discussing goal setting in physical activity promotion.

Medical Updates in Management of Hypertonia

Identifying the subtypes of hypertonia is becoming increasingly important. Treatment strategies, including tone-modulating surgical interventions, medication type and dosing, and chemodenervation, may differ depending on the type of hypertonia present. It is important to delineate how hypertonia interferes with function and quality of life so that the appropriate intervention can be selected at the right time. Outcomes of treatment depend heavily on clear communication of goals. Botulinum toxin should not be used in isolation but as an adjunct to rehabilitation modalities.

Enhanced care planning and clinical-community linkages versus usual care to address basic needs of patients with multiple chronic conditions: a clinician-level randomized controlled trial

Background

Many patients with poorly controlled multiple chronic conditions (MCC) also have unhealthy behaviors, mental health challenges, and unmet social needs. Medical management of MCC may have limited benefit if patients are struggling to address their basic life needs. Health systems and communities increasingly recognize the need to address these issues and are experimenting with and investing in new models for connecting patients with needed services. Yet primary care clinicians, whose regular contact with patients makes them more familiar with patients’ needs, are often not included in these systems.

Methods

We are starting a clinician-level cluster-randomized controlled trial to evaluate how primary care clinicians can participate in these community and hospital solutions and whether doing so is effective in controlling MCC. Sixty clinicians in the Virginia Ambulatory Care Outcomes Research Network will be matched by age and sex and randomized to usual care (control condition) or enhanced care planning with clinical-community linkage support (intervention). From the electronic health record we will identify all patients with MCC, including cardiovascular disease or risks, diabetes, obesity, or depression. A baseline assessment will be mailed to up to 50 randomly selected patients for each clinician (3000 total). Ten respondents per clinician (600 patients total) with uncontrolled MCC will be randomly selected for study inclusion, with oversampling of minorities. The intervention includes two components. First, we will use an enhanced care planning tool, My Own Health Report (MOHR), to screen patients for health behavior, mental health, and social needs. Patients will be supported by a patient navigator, who will help patients prioritize needs, create care plans, and write a personal narrative to guide the care team. Patients will update care plans every 1 to 2 weeks. Second, we will create community-clinical linkage to help address patients’ needs. The linkage will include community resource registries, personnel to span settings (patient navigators and a community health worker), and care team coordination across team members through MOHR.

Discussion

This study will help inform efforts by primary care clinicians to help address unhealthy behaviors, mental health needs, and social risks as a strategy to better control MCC.

Trial registration

ClinicalTrials.gov: NCT03885401. Registered on 19 September 2019.

A web-based intervention to promote physical activity in adolescents and young adults with cystic fibrosis: protocol for a randomized controlled trial

BACKGROUND

Regular participation in physical activity by people with cystic fibrosis (CF) promotes positive clinical and health outcomes including reduced rate of decline in lung function, fewer hospitalizations and greater wellbeing. However adherence to exercise and activity programs is low, in part due to the substantial daily therapy burden for young people with CF. Strict infection control requirements limit the role of group exercise programs that are commonly used in other clinical groups. Investigation of methods to promote physical activity in this group has been limited. The Active Online Physical Activity in Cystic fibrosis Trial (ActionPACT) is an assessor-blinded, multi-centre, randomized controlled trial designed to compare the efficacy of a novel web-based program (ActivOnline) compared to usual care in promoting physical activity participation in adolescents and young adults with CF.

METHODS

Adolescents and young adults with CF will be recruited on discharge from hospital for a respiratory exacerbation. Participants randomized to the intervention group will have access to a web-based physical activity platform for the 12-week intervention period. ActivOnline allows users to track their physical activity, set goals, and self-monitor progress. All participants in both groups will be provided with standardised information regarding general physical activity recommendations for adolescents and young adults. Outcomes will be assessed by a blinded assessor at baseline, after completion of the intervention, and at 3-months followup. Healthcare utilization will be assessed at 12 months from intervention completion. The primary outcome is change in moderate-to-vigorous physical activity participation measured objectively by accelerometry. Secondary outcomes include aerobic fitness, health-related quality of life, anxiety and depression and sleep quality.

DISCUSSION

This trial will establish whether a web-based application can improve physical activity participation more effectively than usual care in the period following hospitalization for a respiratory exacerbation. The web-based application under investigation can be made readily and widely available to all individuals with CF, to support physical activity and exercise participation at a time and location of the user's choosing, regardless of microbiological status.

TRIAL REGISTRATION

Clinical trial registered on July 13, 2017 with the Australian and New Zealand Clinical Trials Register at (ACTRN12617001009303).

Patient-centred goal setting in a hospice: a comparative case study of how health practitioners understand and use goal setting in practice

BACKGROUND

Goal setting is recognised as an important way of supporting people to live as actively as possible until death. However, there is little agreement about how goal setting should be handled or delivered by health professionals in everyday practice.

AIM

To investigate health-care practitioners' understanding and practice of patient-centred goal setting in a hospice.

METHODS

A comparative case study of 10 healthcare practitioners in one hospice. Non-participant observations (n=28), semi-structured interviews (n=10) and case-note analysis (n=67) were undertaken. Data were analysed using framework analysis.

RESULTS

Participants viewed goal setting as part of routine practice. However, goal setting focused around what was seen as important from the health practitioner's perspective, rather than being patient-centred. Participants' goal-setting practice was implicit and opportunities to support patients to pursue goals were missed. Participants emphasised problem solving and alleviating symptoms rather than focusing on patient priorities and establishing patient-centred goals.

CONCLUSION

While goal setting is valued, it is practiced in an implicit, practitioner-centred and inconsistent manner. A more explicit, person-centred goal setting process may support practitioners more consistently in helping patients to identify their priorities and enhance their quality of life.

Self-management support for chronic disease in primary care: frequency of patient self-management problems and patient reported priorities, and alignment with ultimate behavior goal selection

Background

To enable delivery of high quality patient-centered care, as well as to allow primary care health systems to allocate appropriate resources that align with patients’ identified self-management problems (SM-Problems) and priorities (SM-Priorities), a practical, systematic method for assessing self-management needs and priorities is needed. In the current report, we present patient reported data generated from Connection to Health (CTH), to identify the frequency of patients’ reported SM-Problems and SM-Priorities; and examine the degree of alignment between patient SM-Priorities and the ultimate Patient-Healthcare team member selected Behavioral Goal.

Methods

CTH, an electronic self-management support system, was embedded into the flow of existing primary care visits in 25 primary care clinics and was used to assess patient-reported SM-Problems across 12 areas, patient identified SM-Priorities, and guide the selection of a Patient-Healthcare team member selected Behavioral Goal. SM-Problems included: BMI, diet (fruits and vegetables, salt, fat, sugar sweetened beverages), physical activity, missed medications, tobacco and alcohol use, health-related distress, general life stress, and depression symptoms. Descriptive analyses documented SM-Problems and SM-Priorities, and alignment between SM-Priorities and Goal Selection, followed by mixed models adjusting for clinic.

Results

446 participants with ≥ one chronic diseases (mean age 55.4 ± 12.6; 58.5% female) participated. On average, participants reported experiencing challenges in 7 out of the 12 SM-Problems areas; with the most frequent problems including: BMI, aspects of diet, and physical activity. Patient SM-Priorities were variable across the self-management areas. Patient- Healthcare team member Goal selection aligned well with patient SM-Priorities when patients prioritized weight loss or physical activity, but not in other self-management areas.

Conclusion

Participants reported experiencing multiple SM-Problems. While patients show great variability in their SM-Priorities, the resulting action plan goals that patients create with their healthcare team member show a lack of diversity, with a disproportionate focus on weight loss and physical activity with missed opportunities for using goal setting to create targeted patient-centered plans focused in other SM-Priority areas. Aggregated results can assist with the identification of high frequency patient SM-Problems and SM-Priority areas, and in turn inform resource allocation to meet patient needs.

Trial registration

ClinicalTrials.gov ID: NCT01945918.