Planning & Implementing a Patient-Centered Intervention for Health Promotion

1
Planning Implementing a Patient-Centered
Intervention for Health Promotion

• Diane Ruth Lauver, PhD APRN BC FAAN
• Professor
• Primary Care Conference 11-15-06

2
Objectives

• Introduce theory guiding a program of research
• Present findings from descriptive study of
  patients goals
• Share the design for preliminary findings from
  feasibility study re health promotion in primary
  care

3
Health-related Goals Among Primary Care Patients

• Diane Ruth Lauver, PhD APRN BC FAAN
• Chiraporn Worawong, MSN, RN
• Christine Olsen, MSN RN WHNP
• University of Wisconsin-Madison School of
  Nursing
• Srimahasarakham Nursing College, Thailand
• Reproductive Health Center of Madison, Wisconsin

4
Acknowledgements

• Grant UW-Madison, School of Nursing Research
  Committee
• Recruitment Ann Baggot, MS WH NP, Carol
  Glassroth, MS APRN FNP, Kelly Kruse Nelles MS NP,
  Elaine Rosenblatt, MSN, APRN, BC, Jean Marie
  Sharp, MS WHNP
• Content Analyses Kim Ehlers, BS RN Sheryl
  Krause, MS, RN Jennifer Ohlendorf, MS, RN

5
Health-related Behaviors

• Associated with reduced risk of diseases
• Difficult/challenging to initiate maintain
• Intriguing

6
Interventions to promote health behaviors

• Have not often been individualized on
  characteristics salient to participants
• Have focused rarely on behaviors chosen by
  participants

7
Conceptual background

• Patient-centered interventions (PCIs) may be more
  effective than one-size-fits-all interventions
• Individualizing on participants health goals
  would be promising

8
Self-determination theory

• Autonomy vs. Control
• Motivation
• Competence
• Relatedness
• Respecting autonomy or not

9
Study 1 Aims

• Identify health-related goals in primary care
  patients
• Describe patients preferences about how to reach
  such goals
• Summarize implications for a PCI involving goals

10
Method

• Design Descriptive
• Settings Outpatient clinics
• Family practice
• Internal medicine
• Obstetric/gynecology
• Womens health

11
Sampling Criteria

• Patients seeking non-emergent care
• 18-75 years old
• Scheduled with nurse practitioners
• Able to communicate in English

12
Sample N 60

• 75 women
• Mean age 34.6 sd 12
• Mean years education 16
• Race Ethnicity
• 86.2 Caucasian/White
• 5.2 Asian/Pacific Islander
• 3.4 Latino 3.4 Multi-racial
• 1.7 Native American

13
Instruments

• Questions re health
• Values - future states desired
• Long-term goals - in next 2 months
• Short-term goal - in next week
• Preferences
• with whom
• how to address goals get information
• payment for services

14
Clinical, Social Demographic Measures

• Physical symptoms
• Symptom checklist w/ PRIME MD
• Health status
• Overall health function w/ EuroQOL
• Perceived health w/ Visual Analogue
• Social Demographic factors

15
Procedure

• Questionnaires were
• Anonymous
• Provided by clinic staff
• Returned
• On leaving clinic
• Mailed with SSAE

16
Data reduction

• Content analyses
• Themes
• Categories
• Codes

17
Results

• Mean physical symptoms 5.5 /15
• Health status
• Little disability
• Perceived health - very good

18
Common reasons for visit

• Have a preventive visit 35
• Have screening tests 32
• Treat symptoms 12

19
Goal Identification

• 92 - primary goal
• 35 - additional primary goal
• 52 - secondary goal
• 50 - primary secondary goals

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Primary Goals

• Get in better shape 40
• Lose weight 30
• Change consumption habits 7
• Manage stress 7
• Manage disease/illness 5

21
Secondary goals

• Change consumption habits 17
• Get in better shape 13
• Lose weight 7
• Manage stress 7
• Manage disease/illness 7

22
How could NP be of help?

• Provide information resources 32
• Monitor progress, status Encourage, Support,
  Help in genl 32
• Advise, Suggest in particular 22
• Help plan, Discuss routine,
• Collaboratively set goals 17

23
What method of interaction preferred initially?

• Face to face 25
  
  
• Email 22
  
  
• Phone 10
  
  
• Website 3
  
  

24
With whom prefer working?

• On own 56
• With peers in pairs 22
• In group 13

25
Discussion

• New information re patients goals
• Nearly all had health goals
• Most common goals
• Get in better shape
• Lose weight
• Preferences re how to address goals

26
Participants goals

• Reflect current public health policies concerns
• Consistent with practice initiatives
• Nursing
• Medicine
• Health education

27
Limitations

• Lack of diversity
• Education
• Gender
• Race Ethnicity
• Findings most applicable to samples similar to
  ours

28
Implications for practice

• Clinicians can
• Recognize many patients have health goals
• Assess patients goals
• Prepare to address common goals
• Getting in shape
• Controlling weight

29
Implications for Theory Research

• Test ideas from self-determination theory
• Autonomy re goals
• Perceived competence re goal progress
• Respectful interpersonal context re how

30
Proposed study

• An advanced practice nurse with MS (ex, NP)
• Collaborates 11 with participants
• Elicits refines goals re physical activity or
  diet
• Shares relevant information
• Monitors progress
• Offers encouragement suggestions
• In autonomy respecting relationship

31
Assessing the feasibility of a patient-centered,
goal-focused intervention

• Diane Lauver PhD AP RN BC
• Professor
• University of Wisconsin-Madison
• School of Nursing
• Funding NIH P20
• Patient-Centered Interventions

32
Acknowledgements

• Recruitment Julie Setzkorn-Brown w/ Funneling
  Project, Julia Greenleaf
• Interveners Karen Cooper, RN MS MaryJo Borden,
  RN MS
• Research team Chiraporn Worawong, Colleen Foley,
  Rebecca West, Joseph Howell

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Study 2 1st Aim

• To assess feasibility of a patient-centered
  intervention focused on participants health
  goals based on SDT re
• Recruitment
• Retention of participants
• Delivery
• Acceptability of intervention

34
Study 2 2nd Aim

• Explore intervention effects --to estimate effect
  sizes power for future -- on
• Recommended health behaviors
• Goal attainment
• Perceived competence

35
Self-determination theory

• Autonomy vs. Control
• Motivation
• Competence
• Relatedness
• Respecting autonomy or not

36
SDT applied to Patient-centered Interventions re
Health behavior Goals
37
Method

• Design
• One group, pre- post-intervention
• based on SDT
• focused on goals re physical activity or diet
• 1 month post-intervention interview

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Setting

• Mid-west, USA
• Recruitment sites
• Primary care clinics
• Statewide program providing support for screening
  for those who cannot afford it

39
Sample

• Sought 40 community-dwelling adults
• 18- 65
• w/o new, untreated or unstable conditions
• Able to read, write English
• Obtained 54 participants, typically
• Caucasian
• Women
• Well-educated

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Intervention 1st Contact

• APN provided autonomy--supportive relationship
• Assessed values, long term goals, sub-goals
  (choice/autonomy)
• Collaboratively refined goals to be reasonable,
  safe
• Attainable (goals chosen, challenging, not too
  difficult characteristics for goal attainment)
• Elicited reasons (motivation)
• Identified obstacles problem-solved ways to
  overcome obstacles (perceived competence)
• Set realistic, challenging sub-goals for week
  (support goal progress perceived
  competence)

41
Intervention Follow-up contacts

• Weekly x 5
• In autonomy-supportive relationship, assess
  discuss
• Goals (choice, autonomy)
• Goal progress
• Obstacles dealing with them
• Refine goals to be attainable
• Support perceived competence

42
APN Intervener

• Selected for experience with
• Respecting others decisions, autonomy
• Counseling for behavior change
• Community-dwelling clients
• Trained by PI team
• Discussed SDT, research, proposal protocols
• Role played intervention w/ team friends
• Meetings every 1-2 weeks

43
Measures Pre- Post-Intervention

• Brief measures of physical activity,
  fruit/vegetable fat intake
• Perceived competence in engaging in desired
  health behavior

44
Assessments During the intervention

• APNs rated feasibility of intervention delivery
• Research team reviewed audio-tapes of APNs
  intervention delivery to assess validity

45
Measures Post-intervention

• Participants acceptability ratings
• Procedures
• Where, when, how, with whom
• Behavioral tools, from NIH
• Physical activity - 7-day recall
• Diet- Blocks fruit/veg fat

46
Procedures

• Volunteers called office
• RN
• screened callers,
• obtained pre-intervention measures,
• scheduled eligible participants with APN
• APN provided patient-directed, nurse facilitated
  discussion
• 1 month later RN obtained post-intervention
  measures

47
Preliminary Findings re Feasibility

• Recruitment
• More volunteers than expected 80 eligible
• Not from diverse populations
• Retention
• Good 83
• Delivery
• APNs rated feasibility highly (3.7-3.9/4 pts)
• Ratings of APN delivery for rigor - high

48
Findings Participants Acceptability

• Ratings - high (4.2-4.8/5 point scale)
• study met their needs
• nurse-intervener was helpful
• knowledgeable
• .

49
Findings Participants ratings

• Perceived competence w/ health behaviors improved
  over time
• Perceived autonomy support from APNs rated highly

50
Findings Participants Feedback

• Suggested
• lengthen intervention gt 6 weeks
• revise the goals work sheet
• decrease length of questionnaires

51
Goals attainment

• Type of goals
• --About ½ physical activity, about ½ diet
• 53 made some progress on program goals
• 1/4 achieved program goals
• 1/5 did not make progress on goals

52
Exploring Pre- Post- Behaviors

• Brief Behavior Measures - shift from little to
  more behavioral engagement
• Fruit/vegetable intake increased
• fat intake decreased
• aerobic physical activity improved,
• among participants with corresponding goals

53
Preliminary Conclusions

• Feasible to
• Recruit
• Retaining participants
• Deliver intervention by APNs
• Acceptability of process to participants

54
Findings lend support to ideas

• PCI could improve
• health goal attainment
• recommended health behavior
• perceived competence
• influence perceived autonomy support

55
Future research

• Design experimental 2 group study
• Longer longitudinal study
• Based on SDT goal theories
• Test efficacy of goal-focused PCI on health
  behavior bio-markers
• Seek a larger, more diverse sample

56
Future research

• Test mechanisms of perceived
• autonomy
• competence
• congruence
• Examine role of social desirability

57
Fidelity of intervention

• Met weekly
• Assessed APN interveners interactions on
  audiotapes reviewed written documents
• Assessed participants perceptions
• autonomy-support
• congruence of values, goals, subgoals

58
Preliminary findings re Validity

• Participants autonomy-support ratings were high
  (4.6-4.9/5 point scale)
• Perceived competence improved
• Participants ratings of concordance increased

59
Preliminary findings

• Type of reasons
• Gives me sense of control
• Ill feel better
• Decreases cravings for food
• Type of obstacles
• Lack of time
• Lack of knowledge
• Social gatherings interfere