What are the barriers and facilitators to goal-setting during rehabilitation for stroke and other acquired brain injuries? A systematic review and meta-synthesis

OBJECTIVE

To identify the barriers and facilitators to goal-setting during rehabilitation for stroke and other acquired brain injuries.

DATA SOURCES

AMED, Proquest, CINAHL and MEDLINE.

REVIEW METHODS

Two reviewers independently screened, extracted data and assessed study quality using the Mixed Methods Appraisal Tool and undertook thematic content analysis for papers examining the barriers and facilitators to goal-setting during stroke/neurological rehabilitation (any design). Last searches were completed in May 2016.

RESULTS

Nine qualitative papers were selected, involving 202 participants in total: 88 patients, 89 health care professionals and 25 relatives of participating patients. Main barriers were: Differences in staff and patients perspectives of goal-setting; patient-related barriers; staff-related barriers, and organisational level barriers. Main facilitators were: individually tailored goal-setting processes, strategies to promote communication and understanding, and strategies to avoid disappointment and unrealistic goals. In addition, patients' and staff's knowledge, experience, skill, and engagement with goal-setting could be either a barrier (if these aspects were absent) or a facilitator (if they were present).

CONCLUSION

The main barriers and facilitators to goal-setting during stroke rehabilitation have been identified. They suggest that current methods of goal-setting during inpatient/early stage stroke or neurological rehabilitation are not fit for purpose.

Goal Setting and Action Planning for Health Behavior Change

Health behavior change is challenging for most individuals, but there are many strategies that individuals can use to facilitate their behavior change efforts. Goal setting is one such strategy that assists individuals to identify specific behaviors to change and how to go about doing so. For many, however, simply setting a goal seldom leads to actual behavior change. For some, identifying an appropriate goal is difficult, while for others, putting goals into action is the roadblock. Two strategies may be of assistance for setting and achieving goals. First, consideration of key goal characteristics (eg, approach vs avoidance goals, performance vs mastery goals, level of difficulty) may result in selection of more appropriate and feasible goals. Second, action planning can help individuals put goals into action. Clinicians can help patients utilize these strategies to set and achieve goals for health behavior change.

Goal setting as a shared decision making strategy among clinicians and their older patients

OBJECTIVE

Older adults are less likely than other age groups to participate in clinical decision-making. To enhance participation, we sought to understand how older adults consider and discuss their life and health goals during the clinical encounter.

METHODS

We conducted six focus groups: four with community-dwelling older persons (n=42), one with geriatricians and internists (n=6), and one with rehabilitation nurses (n=5). Participants were asked to discuss: patients' life and health goals; communication about goals, and perception of agreement about health goals. Group interactions were tape-recorded, transcribed, and analyzed using content analysis.

RESULTS

All participants were willing to discuss goals, but varied in the degree to which they did so. Reasons for non-discussion included that goal setting was not a priority given limited time, visits focused on symptoms, mutual perception of disinterest, and the presumption that all patients' goals were the same.

CONCLUSION

Interventions to enhance goal setting need to address key barriers to promoting goals discussions. Participants recognized the benefits of goal setting, however, training and instruments are needed to integrate goal setting into medicine.

PRACTICE IMPLICATIONS

Setting goals initially and reviewing them periodically may be a comprehensive, time-efficient way of integrating patients' goals into their care plans.

Life Crafting as a Way to Find Purpose and Meaning in Life

Having a purpose in life is one of the most fundamental human needs. However, for most people, finding their purpose in life is not obvious. Modern life has a way of distracting people from their true goals and many people find it hard to define their purpose in life. Especially at younger ages, people are searching for meaning in life, but this has been found to be unrelated to actually finding meaning. Oftentimes, people experience pressure to have a "perfect" life and show the world how well they are doing, instead of following up on their deep-felt values and passions. Consequently, people may need a more structured way of finding meaning, e.g., via an intervention. In this paper, we discuss evidence-based ways of finding purpose, via a process that we call "life crafting." This process fits within positive psychology and the salutogenesis framework - an approach focusing on factors that support human health and well-being, instead of factors that cause disease. This process ideally starts with an intervention that entails a combination of reflecting on one's values, passions and goals, best possible self, goal attainment plans, and other positive psychology intervention techniques. Important elements of such an intervention are: (1) discovering values and passion, (2) reflecting on current and desired competencies and habits, (3) reflecting on present and future social life, (4) reflecting on a possible future career, (5) writing about the ideal future, (6) writing down specific goal attainment and "if-then" plans, and (7) making public commitments to the goals set. Prior research has shown that personal goal setting and goal attainment plans help people gain a direction or a sense of purpose in life. Research findings from the field of positive psychology, such as salutogenesis, implementation intentions, value congruence, broaden-and-build, and goal-setting literature, can help in building a comprehensive evidence-based life-crafting intervention. This intervention can aid individuals to find a purpose in life, while at the same time ensuring that they make concrete plans to work toward this purpose. The idea is that life crafting enables individuals to take control of their life in order to optimize performance and happiness.

Rehabilitation - a new approach. Part two: the underlying theories

This editorial considers how healthcare systems should approach the problems associated with ongoing, persistent symptoms and limitations on a person's ability to undertake activities. It starts from the premise, established in the first editorial, that the current reliance on the biomedical model of health and illness is no longer 'fit for purpose', and is one major cause of current difficulties within the health service. Among other problems, it may lead to the marginalisation of rehabilitation services, especially when resources are limited. This editorial describes and then highlights the implications of the holistic, biopsychosocial model of illness. It also outlines the rehabilitation process, demonstrating its similarity to the process used by medical services, with the primary difference being the centre of attention: disease for medical service, disability for rehabilitation services. The model of rehabilitation emphasises: the importance of being patient-centred and goal-directed in rehabilitation; the need for liaison by the team and learning by the patient; and that the patient needs to be encouraged and enabled to practice wanted activities.

Goal setting in diabetes self-management: taking the baby steps to success

OBJECTIVE

To evaluate the usefulness of a diabetes self-management guide and a brief counseling intervention in helping patients set and achieve their behavioral goals.

METHODS

We conducted a quasi-experimental study using a one group pretest posttest design to assess the effectiveness of a goal setting intervention along with a self-management guide. English- and Spanish-speaking patients with diabetes had one in-person session and two telephone follow-up calls with a non-clinical provider over a 12-16-week period. At each call and at the end of the study, we assessed success in achieving behavioral goals and problem solving toward those goals. Satisfaction with the self-management guide was assessed at the end of the study.

RESULTS

We enrolled 250 patients across three sites and 229 patients completed the study. Most patients chose to set goals in diet and exercise domains. 93% of patients achieved at least one behavioral goal during the study and 73% achieved at least two behavioral goals. Many patients exhibited problem solving behavior to achieve their goals. We found no significant differences in reported achievement of behavior goals by literacy or language. Patients were very satisfied with the guide.

CONCLUSIONS

A brief goal setting intervention along with a diabetes self-management guide helped patients set and achieve healthy behavioral goals.

PRACTICE IMPLICATIONS

Non-clinical providers can successfully help a diverse range of patients with diabetes set and achieve behavioral goals.

Cognitive behavioral game design: a unified model for designing serious games

Video games have a unique ability to engage, challenge, and motivate, which has led teachers, psychology specialists, political activists and health educators to find ways of using them to help people learn, grow and change. Serious games, as they are called, are defined as games that have a primary purpose other than entertainment. However, it is challenging to create games that both educate and entertain. While game designers have embraced some psychological concepts such as flow and mastery, understanding how these concepts work together within established psychological theory would assist them in creating effective serious games. Similarly, game design professionals have understood the propensity of video games to teach while lamenting that educators do not understand how to incorporate educational principles into game play in a way that preserves the entertainment. Bandura (2006) social cognitive theory (SCT) has been used successfully to create video games that create positive behavior outcomes, and teachers have successfully used Gardner's (1983) theory of multiple intelligences (MIs) to create engaging, immersive learning experiences. Cognitive behavioral game design is a new framework that incorporates SCT and MI with game design principles to create a game design blueprint for serious games.

Age-related changes in the temporal dynamics of executive control: a study in 5- and 6-year-old children

Based on the Dual Mechanisms of Control theory (Braver et al., 2007), this study conducted in 5- and 6-year-olds, tested for a possible shift between two modes of control, proactive vs. reactive, which differ in the way goal information is retrieved and maintained in working memory. To this end, we developed a children-adapted version of the AX-Continuous-Performance Task (AX-CPT). Twenty-nine 5-year-olds and 28-6-year-olds performed the task in both low and high working-memory load conditions (corresponding, respectively, to a short and a long cue-probe delay). Analyses suggested that a qualitative change in the mode of control occurs within the 5-year-old group. However, quantitative, more graded changes were also observed both within the 5-year-olds, and between 5 and 6 years of age. These graded changes demonstrated an increasing efficiency in proactive control with age. The increase in working memory load did not impact the type of dynamics of control, but had a detrimental effect on sensitivity to cue information. These findings highlight that the development of the temporal dynamics of control can be characterized by a shift from reactive to proactive control together with a more protracted and gradual improvement in the efficiency of proactive control. Moreover, the question of whether the observed shift in the mode of control is task dependant is debated.

Use of Accelerometer-Based Feedback of Walking Activity for Appraising Progress With Walking-Related Goals in Inpatient Stroke Rehabilitation: A Randomized Controlled Trial

BACKGROUND

Regaining independent ambulation is important to those with stroke. Increased walking practice during "down time" in rehabilitation could improve walking function for individuals with stroke.

OBJECTIVE

To determine the effect of providing physiotherapists with accelerometer-based feedback on patient activity and walking-related goals during inpatient stroke rehabilitation.

METHODS

Participants with stroke wore accelerometers around both ankles every weekday during inpatient rehabilitation. Participants were randomly assigned to receive daily feedback about walking activity via their physiotherapists (n = 29) or to receive no feedback (n = 28). Changes in measures of daily walking (walking time, number of steps, average cadence, longest bout duration, and number of "long" walking bouts) and changes in gait control and function assessed in-laboratory were compared between groups.

RESULTS

There was no significant increase in walking time, number of steps, longest bout duration, or number of long walking bouts for the feedback group compared with the control group (P values > .20). However, individuals who received feedback significantly increased cadence of daily walking more than the control group (P = .013). From the in-laboratory gait assessment, individuals who received feedback had a greater increase in walking speed and decrease in step time variability than the control group (P values < .030).

CONCLUSION

Feedback did not increase the amount of walking completed by individuals with stroke. However, there was a significant increase in cadence, indicating that intensity of daily walking was greater for those who received feedback than the control group. Additionally, more intense daily walking activity appeared to translate to greater improvements in walking speed.

From Shattered Goals to Meaning in Life: Life Crafting in Times of the COVID-19 Pandemic

The novel COVID-19 pandemic has created an extraordinary situation for our generation, with many countries being on lockdown. With this, new situation comes many psychological challenges not only for health care workers and people suffering from COVID-19 but also for the general population. Adapting to the new situation can be demanding. Experts have suggested that emotions during this situation are very similar to grief, and people experience emptiness and sadness about the loss of their normal lives, which can even lead to a loss of meaning in life. In this paper, we argue that life crafting could offer a way to help people cope with the situation and renew their sense of meaning. A life crafting intervention is based on theoretical insights from multiple areas of research, like positive psychology, expressive writing, and the salutogenesis framework. Life-crafting interventions help people find meaning in life by focusing on their ideal future, and helping them set goals, and make concrete plans to achieve those goals and overcome obstacles. Since having a clear purpose or meaning in life has been shown to have many benefits, we propose that it can also help people to cope with the psychological effects of the pandemic. A life-crafting intervention can offer people a chance to evaluate their goals in a time of uncertainty and rediscover meaning in life to guide them through these difficult times.

Effectiveness of Goal-Setting Telephone Follow-Up on Health Behaviors of Patients with Ischemic Stroke: A Randomized Controlled Trial

BACKGROUND

Adopting healthy behaviors is critical for secondary stroke prevention, but many patients fail to follow national guidelines regarding diet, exercise, and abstinence from risk factors. Compliance often decreases with time after hospital discharge, yet few studies have examined programs promoting long-term adherence to health behaviors. Goal setting and telephone follow-up have been proven to be effective in other areas of medicine, so this study evaluated the effectiveness of a guideline-based, goal-setting telephone follow-up program for patients with ischemic stroke.

METHODS

This was a multicenter, assessor-blinded, parallel-group, randomized controlled trial. Ninety-one stroke patients were randomized to either a control group or an intervention group. Intervention consisted of predischarge education and 3 goal-setting follow-up sessions conducted by phone. Data were collected at baseline and during the third and sixth months after hospital discharge.

RESULTS

Six months after discharge, patients in the intervention group exhibited significantly higher medication adherence than patients in the control group. There were no statistically significant differences in physical activity, nutrition, low-salt diet adherence, blood pressure monitoring, smoking abstinence, unhealthy use of alcohol, and modified Rankin Scale (mRS) scores between the 2 groups.

CONCLUSIONS

Goal-setting telephone follow-up intervention for ischemic stroke patients is feasible and leads to improved medication adherence. However, the lack of group differences in other health behavior subcategories and in themRS score indicates a need for more effective intervention strategies to help patients reach guideline-recommended targets.

A client-centred ADL intervention: three-month follow-up of a randomized controlled trial

Objective

The aim was to study a client-centred activities of daily living (ADL) intervention (CADL) compared with the usual ADL intervention (UADL) in people with stroke regarding: independence in ADL, perceived participation, life satisfaction, use of home-help service, and satisfaction with training and, in their significant others, regarding: caregiver burden, life satisfaction, and informal care.

Methods

In this multicentre study, 16 rehabilitation units were randomly assigned to deliver CADL or UADL. The occupational therapists who provided the CADL were specifically trained. Eligible for inclusion were people with stroke treated in a stroke unit ≤3 months after stroke, dependent in ≥two ADL, not diagnosed with dementia, and able to understand instructions. Data were collected at inclusion and three months thereafter. To detect a significant difference between the groups in the Stroke Impact Scale (SIS) domain “participation”, 280 participants were required. Intention-to-treat analysis was applied.

Results

At three months, there was no difference in the outcomes between the CADL group (n = 129) and the UADL group (n = 151), or their significant others (n = 87/n = 93) except in the SIS domain “emotion” in favour of CADL (p = 0.04).

Conclusion

The CADL does not appear to bring about short-term differences in outcomes and longer follow-ups are required.

Implicit theories about intelligence and growth (personal best) goals: Exploring reciprocal relationships

BACKGROUND

There has been increasing interest in growth approaches to students' academic development, including value-added models, modelling of academic trajectories, growth motivation orientations, growth mindsets, and growth goals.

AIMS

This study sought to investigate the relationships between implicit theories about intelligence (incremental and entity theories) and growth (personal best, PB) goals - with particular interest in the ordering of factors across time.

SAMPLE

The study focused on longitudinal data of 969 Australian high school students.

METHOD

The classic cross-lagged panel design (using structural equation modelling) was employed to shed light on the ordering of Time 1 growth goals, incremental theories, and entity theories relative to Time 2 (1 year later) growth goals, incremental theories, and entity theories.

RESULTS

Findings showed that Time 1 growth goals predicted Time 2 incremental theories (positively) and entity theories (negatively); Time 1 entity and incremental theories negatively predicted Time 2 incremental and entity theories respectively; but, Time 1 incremental theories and entity theories did not predict growth goals at Time 2.

CONCLUSION

This suggests that entity and incremental theories are negatively reciprocally related across time, but growth goals seem to be directionally salient over incremental and entity theories. Implications for promoting growth goals and growth mindsets are discussed.

Text messaging intervention for teens and young adults with diabetes

Adolescents and young adults use text messaging as their primary mode of communication, thus providing an opportunity to use this mode of communication for mobile health (mHealth) interventions. Youth with diabetes are an important group for these mHealth initiatives, as diabetes management requires an enormous amount of daily effort and this population has difficulty achieving optimal diabetes management. Goal setting and self-efficacy are 2 factors in the management of diabetes. We examined the feasibility of a healthy lifestyle text messaging program targeting self-efficacy and goal setting among adolescents and young adults with diabetes. Participants, ages 16-21, were assigned to either a text messaging group, which received daily motivational messages about nutrition and physical activity, or a control group, which received paper-based information about healthy lifestyle. Both groups set goals for nutrition and physical activity and completed a measure of self-efficacy. Participants' mean age was 18.7 ± 1.6 years old, with diabetes duration of 10.0 ± 4.6 years, and A1c of 8.7 ± 1.7%. The text messaging intervention was rated highly and proved to be acceptable to participants. Self-efficacy, glycemic control, and body mass index did not change over the course of the short, 1-month pilot study. Positive, daily, motivational text messages may be effective in increasing motivation for small goal changes in the areas of nutrition and physical activity. These interventions may be used in the future in youth with diabetes to improve diabetes care. Utilizing more targeted text messages is an area for future research.

Goal-Based Shared Decision-Making: Developing an Integrated Model

Objective:

Definitions of shared decision-making (SDM) have largely neglected to consider goal setting as an explicit component. Applying SDM to people with multiple long-term conditions requires attention to goal setting. We propose an integrated model, which shows how goal setting, at 3 levels, can be integrated into the 3-talk SDM model.

Method:

The model was developed by integrating 2 published models.

Results:

An integrated, goal-based SDM model is proposed and applied to a patient with multiple, complex, long-term clinical conditions to illustrate the use of a visualization tool called a Goal Board. A Goal Board prioritizes collaborative goals and aligns goals with interventional options.

Conclusion:

The model provides an approach to achieve person-centered decision-making by not only eliciting and prioritizing goals but also by aligning prioritized goals and interventions.

Practice Implications:

Further research is required to evaluate the utility of the proposed model.

Efficacy of a Community-Based Technology-Enabled Physical Activity Counseling Program for People With Knee Osteoarthritis: Proof-of-Concept Study

Background

Current practice guidelines emphasize the use of physical activity as the first-line treatment of knee osteoarthritis; however, up to 90% of people with osteoarthritis are inactive.

Objective

We aimed to assess the efficacy of a technology-enabled counseling intervention for improving physical activity in people with either a physician-confirmed diagnosis of knee osteoarthritis or having passed two validated criteria for early osteoarthritis.

Methods

We conducted a proof-of-concept randomized controlled trial. The immediate group received a brief education session by a physical therapist, a Fitbit Flex, and four biweekly phone calls for activity counseling. The delayed group received the same intervention 2 months later. Participants were assessed at baseline (T0) and at the end of 2 months (T1), 4 months (T2), and 6 months (T3). Outcomes included (1) mean time on moderate-to-vigorous physical activity (MVPA ≥3 metabolic equivalents [METs], primary outcome), (2) mean time on MVPA ≥4 METs, (3) mean daily steps, (4) mean time on sedentary activities, (5) Knee Injury and Osteoarthritis Outcome Score (KOOS), and (6) Partners in Health scale. Mixed-effects repeated measures analysis of variance was used to assess five planned contrasts of changes in outcome measures over measurement periods. The five contrasts were (1) immediate T1-T0 vs delayed T1-T0, (2) delayed T2-T1 vs delayed T1-T0, (3) mean of contrast 1 and contrast 2, (4) immediate T1-T0 vs delayed T2-T1, and (5) mean of immediate T2-T1 and delayed T3-T2. The first three contrasts estimate the between-group effects. The latter two contrasts estimate the effect of the 2-month intervention delay on outcomes.

Results

We recruited 61 participants (immediate: n=30; delayed: n=31). Both groups were similar in age (immediate: mean 61.3, SD 9.4 years; delayed: mean 62.1, SD 8.5 years) and body mass index (immediate: mean 29.2, SD 5.5 kg/m²; delayed: mean 29.2, SD 4.8 kg/m²). Contrast analyses revealed significant between-group effects in MVPA ≥3 METs (contrast 1 coefficient: 26.6, 95% CI 4.0-49.1, P=.02; contrast 3 coefficient: 26.0, 95% CI 3.1-49.0, P=.03), daily steps (contrast 1 coefficient: 1699.2, 95% CI 349.0-3049.4, P=.02; contrast 2 coefficient: 1601.8, 95% CI 38.7-3164.9, P=.045; contrast 3 coefficient: 1650.5, 95% CI 332.3-2968.7; P=.02), KOOS activity of daily living subscale (contrast 1 coefficient: 6.9, 95% CI 0.1-13.7, P=.047; contrast 3 coefficient: 7.2, 95% CI 0.8-13.6, P=.03), and KOOS quality of life subscale (contrast 1 coefficient: 7.4, 95% CI 0.0-14.7, P=.049; contrast 3 coefficient: 7.3, 95% CI 0.1-14.6, P=.048). We found no significant effect in any outcome measures due to the 2-month delay of the intervention.

Conclusions

Our counseling program improved MVPA ≥3 METs, daily steps, activity of daily living, and quality of life in people with knee osteoarthritis. These findings are important because an active lifestyle is an important component of successful self-management.

Trial Registration

ClinicalTrials.gov NCT02315664; https://clinicaltrials.gov/ct2/show/NCT02315664 (Archived by WebCite at http://www.webcitation.org/6ynSgUyUC)

Theory building, replication, and behavioral priming: where do we need to go from here?

This article suggests that the field of behavioral priming, which is basically a technique, is in need of theory building. Guidelines from successful theory building by induction in the realm of conscious motivation (namely, goal setting and self-efficacy) are suggested. The process would include replication with variation, identifying the logical relation between a given prime and the action in question, discovering moderators and mediators, and clarifying the relationship between the conscious mind and the subconscious.

Time Perspective and Age: A Review of Age Associated Differences

We investigate the relationship between age and the five dimensions of time perspective measured by the Zimbardo Time Perspective Inventory (ZTPI) (past negative, past positive, present hedonistic, present fatalistic, and future). Time perspective is related to well-being, decision-making, level of development, and many other psychological issues. Hence, the existence of a systematic relationship between time perspective and age should be considered in all studies for which time is a relevant variable. However, no specific research about this has been conducted. We collected 407 papers that referenced the ZTPI between 2001 and 2015. From those, 72 studies met our inclusion criteria. They included 29,815 participants from 19 countries whose age spans most phases of adulthood (from 13.5 to 75.5 years, mean 28.7). We analyzed these studies adapting meta-analytical techniques. We found that present hedonistic and past negative dimensions are negatively related to aging with partial eta squared effect sizes of roughly 0.15. Our results have implications for the design of studies related to time as our findings highlight the importance of taking into account the differences associated with age.

Optimizing Students' Mental Health and Academic Performance: AI-Enhanced Life Crafting

One in three university students experiences mental health problems during their study. A similar percentage leaves higher education without obtaining the degree for which they enrolled. Research suggests that both mental health problems and academic underperformance could be caused by students lacking control and purpose while they are adjusting to tertiary education. Currently, universities are not designed to cater to all the personal needs and mental health problems of large numbers of students at the start of their studies. Within the literature aimed at preventing mental health problems among students (e.g., anxiety or depression), digital forms of therapy recently have been suggested as potentially scalable solutions to address these problems. Integrative psychological artificial intelligence (AI) in the form of a chatbot, for example, shows great potential as an evidence-based solution. At the same time, within the literature aimed at improving academic performance, the online life-crafting intervention in which students write about values and passions, goals, and goal-attainment plans has shown to improve the academic performance and retention rates of students. Because the life-crafting intervention is delivered through the curriculum and doesn't bear the stigma that is associated with therapy, it can reach larger populations of students. But life-crafting lacks the means for follow-up or the interactiveness that online AI-guided therapy can offer. In this narrative review, we propose to integrate the current literature on chatbot interventions aimed at the mental health of students with research about a life-crafting intervention that uses an inclusive curriculum-wide approach. When a chatbot asks students to prioritize both academic as well as social and health-related goals and provides personalized follow-up coaching, this can prevent -often interrelated- academic and mental health problems. Right on-time delivery, and personalized follow-up questions enhance the effects of both -originally separated- intervention types. Research on this new combination of interventions should use design principles that increase user-friendliness and monitor the technology acceptance of its participants.

The feasibility, acceptability, and outcomes of PRIME-D: A novel mobile intervention treatment for depression

BACKGROUND

Despite decades of research and development, depression has risen from the fifth to the leading cause of disability in the United States. Barriers to progress in the field are (1) poor access to high-quality care; (2) limited mental health workforce; and (3) few providers trained in the delivery of evidence-based treatments (EBTs). Although mobile platforms are being developed to give consumers greater access to high-quality care, too often these tools do not have empirical support for their effectiveness. In this study, we evaluated PRIME-D, a mobile app intervention that uses social networking, goal setting, and a mental health coach to deliver text-based, EBT's to treat mood symptoms and functioning in adults with depression.

METHODS

Thirty-six adults with depression remotely participated in PRIME-D over an 8-week period with a 4-week follow-up, with 83% retained over the 12-week course of thestudy.

RESULTS

On average, participants logged into the app 5 days/week. Depression scores (PHQ-9) significantly improved over time (over 50% reduction), with coach interactions enhancing these effects. Mood-related disability (Sheehan Disability Scale (SDS)) also significantly decreased over time with participants no longer being impaired by their mood symptoms. Overall use of PRIME-D predicted greater gains in functioning. Improvements in mood and functioning were sustained over the 4-week follow-up.

CONCLUSIONS

Results suggest that PRIME-D is a feasible, acceptable, and effective intervention for adults with depression and that a mobile service delivery model may address the serious public health problem of poor access to high-quality mental health care.

Management of chronic hypertension in older men: an exploration of patient goal-setting

OBJECTIVE

Goal-setting is an approach to collaborative chronic care that involves clinicians and patients working together to set goals and to initiate and maintain specific self-care behaviors. Using patients' own perspectives, this study describes how goals for the self-management of hypertension are developed and whether or not they conform to the characteristics of effective goal-setting.

METHODS

Qualitative methodology was used to explore the process of setting self-management goals for hypertensive patients. Thirty patients participated in semi-structured interviews that ascertained the detail and specificity of self-care goals, timing and quality of feedback for setting and monitoring goals and the role of family members and caregivers in setting goals.

RESULTS

Patients understood the risks associated with hypertension, had intentions to control their disease, reported conducting at least one self-care task and set informal goals for themselves; however, these goals lacked the characteristics needed to initiate and maintain behavior change.

CONCLUSION

Patient goal-setting is underdeveloped and poorly supported in chronic hypertension care. Future studies need to examine ways to support effective goal-setting.

PRACTICE IMPLICATIONS

As part of chronic hypertension care, health care providers should incorporate time and support for dedicated goal-setting to improve the effectiveness of self-management behaviors.

Will older persons and their clinicians use a shared decision-making instrument?

OBJECTIVE

To examine experiences of older persons and their clinicians with shared decision making (SDM) and their willingness to use an SDM instrument.

DESIGN

Qualitative focus group study.

PARTICIPANTS

Four focus groups of 41 older persons and 2 focus groups of 11 clinicians, purposively sampled to encompass a range of sociodemographic and clinical characteristics. APPROACH AND MAIN RESULTS: Audiotaped responses were transcribed, coded independently, and analyzed by 3 reviewers using the constant comparative method. Patient participants described using informal facilitators of shared decision making and supported use of an SDM instrument to keep "the doctor and patient on the same page." They envisioned the instrument as "part of the medical record" that could be "referenced at home." Clinician participants described the instrument as a "motivational and educational tool" that could "customize care for individual patients." Some clinician and patient participants expressed reluctance given time constraints and unfamiliarity with the process of setting participatory clinical goals.

CONCLUSIONS

Participants indicated that they would use a shared decision-making instrument in their clinical encounters and attributed multiple functions to the instrument, especially as a tool to facilitate agreement with treatment goals and plans.

Physiotherapists' views, perceived knowledge, and reported use of psychosocial strategies in practice

Background: Research has addressed the usefulness of psychosocial strategies within physiotherapy, as part of a biopsychosocial model. A lack of current research in Australia concerning the views of physiotherapists, from a range of practice areas, regarding a variety of strategies, suggests the need for broader exploration. Methods: This research employed a cross-sectional survey asking Australian physiotherapists (n = 251) to rate their perceived importance and perceived benefits of psychosocial strategies; perceived positive effects on rehabilitation outcomes and adherence; confidence in applying strategies, and perceived benefits of further training. Data were analyzed using descriptive statistics, Crosstabs with Chi-Squared Tests of Contingencies and Spearman's Rank-Order Correlations. Results: Physiotherapists reported that having knowledge of such strategies was important and considered them beneficial for practice. Respondents rated highly their perceived knowledge about goal setting and positive reinforcement, both of which were reported as most used in practice. Approximately one quarter of physiotherapists reported using cognitive behavioral therapy and motivational interviewing. Physiotherapists communicated a lack of confidence to apply psychosocial strategies in their practice, and desired further training. Conclusion: Physiotherapists could benefit from tailored instruction regarding psychosocial strategies at a level appropriate to, and within their scope of practice. This could enhance their practice from a biopsychosocial perspective, subsequently improving outcomes for their patients.

Physical Activity and Its Correlates in Youth with Multiple Sclerosis

OBJECTIVES

To investigate physical activity levels in youth with multiple sclerosis and monophasic acquired demyelinating syndromes ([mono-ADS], ie, children without relapsing disease) compared with healthy controls and to determine factors that contribute to engagement in physical activity. We hypothesized that greater physical activity goal setting and physical activity self-efficacy would be associated with greater levels of vigorous physical activity in youth with multiple sclerosis.

STUDY DESIGN

A total of 68 consecutive patients (27 multiple sclerosis, 41 mono-ADS) and 37 healthy controls completed fatigue, depression, Physical Activity Self-Efficacy Scale, perceived disability, Exercise Goal-Setting scale, and physical activity questionnaires, and wore an accelerometer for 7 days. All patients had no ambulatory limitations (Expanded Disability Status Scale, scores all <4).

RESULTS

Youth with multiple sclerosis engaged in fewer minutes per day of vigorous (P = .009) and moderate and vigorous physical activity (P = .048) than did patients with mono-ADS and healthy controls. A lower proportion of the group with multiple sclerosis (63%) reported participating in any strenuous physical activity than the mono-ADS (85%) and healthy control (89%) groups (P = .020). When we adjusted for age and sex, the Physical Activity Self-Efficacy Scale and Exercise Goal-Setting scale were associated positively with vigorous physical activity in the group with multiple sclerosis. Fatigue and depression did not predict physical activity or accelerometry metrics.

CONCLUSIONS

Youth with multiple sclerosis participate in less physical activity than their counterparts with mono-ADS and healthy controls. Physical activity self-efficacy and exercise goal setting serve as potentially modifiable correlates of physical activity, and are measures suited to future interventions aimed to increase physical activity in youth with multiple sclerosis.

An exploratory analysis of the self-reported goals of individuals with chronic upper-extremity paresis following stroke

PURPOSE

To classify the self-identified goals of individuals post-stroke with chronic upper extremity (UE) paresis, and determine if age, UE functional capacity and pre-stroke hand dominance influence overall goal selection.

METHOD

Sixty-five subjects participated. Using the Canadian Occupational Performance Measure (COPM) to establish treatment goals, the top five goals were categorized using the Occupational Therapy Practice Framework into five categories: activities of daily living (ADLs), instrumental activities of daily living (IADLs), leisure, work and general UE movement. A Chi-square analysis determined if age, UE functional capacity (measured by the Action Research Arm Test) and UE hand dominance influenced individual goal selection.

RESULTS

The majority of goals were in the ADL (37%) and IADL (40%) categories. A small percentage (12%) was related to general UE movement. Individuals with moderate UE functional capacity identified more ADL goals than those with higher UE functional capacity. There was not a difference between age and UE dominance across all five goal areas.

CONCLUSIONS

Individuals with chronic UE paresis had specific goals that were not influenced by age or hand dominance, but partially influenced by severity. General UE movement goals were identified less than goals related to specific activities.

IMPLICATIONS FOR REHABILITATION

Considering the specificity of individual goals following stroke, it is recommended that clinicians regularly utilize a goal setting tool to help establish client goals. It is recommended that clinicians further inquire about general goals in order to link upper extremity deficits to functional activity limitations. Age, upper extremity functional capacity and hand dominance have little influence on the rehabilitation goals for individuals with chronic paresis after stroke.