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Planning & Implementing a Planning & Implementing a Patient-Centered Intervention Patient-Centered Intervention
for Health Promotionfor Health Promotion
Diane Ruth Lauver, PhD APRN BC FAAN
Professor
Primary Care Conference 11-15-06
Objectives 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
Health-related Goals Among Health-related Goals Among Primary Care PatientsPrimary 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
AcknowledgementsAcknowledgements
• 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
Health-related BehaviorsHealth-related Behaviors
• Associated with reduced risk of diseases
• Difficult/challenging to initiate & maintain
• Intriguing
Interventions to promote Interventions to promote health behaviorshealth behaviors
• Have not often been individualized on characteristics salient to participants
• Have focused rarely on behaviors chosen by participants
Conceptual Conceptual backgroundbackground
• Patient-centered interventions (PCIs) may be more effective than one-size-fits-all interventions
• Individualizing on participants’ health goals would be promising
Self-determination theorySelf-determination theory
• Autonomy vs. Control
–Motivation• Competence
• Relatedness
–Respecting autonomy or not
Study 1: AimsStudy 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
MethodMethod
• Design: Descriptive
• Settings: Outpatient clinics
–Family practice– Internal medicine–Obstetric/gynecology –Women’s health
Sampling CriteriaSampling Criteria
• Patients seeking non-emergent care
• 18-75 years old
• Scheduled with nurse practitioners
• Able to communicate in English
Sample Sample NN = 60 = 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
InstrumentsInstrumentsQuestions 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
Clinical, Social & Clinical, Social & Demographic MeasuresDemographic Measures
• Physical symptoms
– Symptom checklist w/ PRIME MD• Health status
– Overall health & function w/ EuroQOL
– Perceived health w/ Visual Analogue
• Social & Demographic factors
ProcedureProcedure
Questionnaires were
–Anonymous–Provided by clinic staff–Returned
•On leaving clinic •Mailed with SSAE
ResultsResults
• Mean physical symptoms = 5.5 /15
• Health status
– Little disability– Perceived health - very good
Common reasons for visitCommon reasons for visit
• Have a preventive visit 35%
• Have screening tests 32%
• Treat symptoms 12%
Goal IdentificationGoal Identification
• 92% - primary goal
• 35% - additional primary goal
• 52% - secondary goal
• 50% - primary & secondary goals
Primary GoalsPrimary Goals
• Get in better shape 40%
• Lose weight 30%
• Change consumption habits 7%
• Manage stress 7%
• Manage disease/illness 5%
Secondary goalsSecondary goals
• Change consumption habits 17%
• Get in better shape 13%
• Lose weight 7%
• Manage stress 7%
• Manage disease/illness 7%
How could NP be of How could NP be of help?help?
• Provide information & resources 32%
• Monitor progress, status; Encourage, Support, Help in gen’l 32%
• Advise, Suggest in particular 22%
• Help plan, Discuss routine,
Collaboratively set goals 17%
What method of What method of interaction preferred interaction preferred
initially?initially?• Face to face 25%
• Email 22%
• Phone 10%
• Website 3%
With whom prefer working?With whom prefer working?
• On own 56%
• With peers in pairs 22%
• In group 13%
DiscussionDiscussion
• 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
Participants’ goalsParticipants’ goals
• Reflect current public health policies & concerns
• Consistent with practice initiatives
–Nursing–Medicine–Health education
LimitationsLimitations
• Lack of diversity– Education– Gender– Race & Ethnicity
• Findings most applicable to samples similar to ours
Implications for Implications for practicepractice
Clinicians can:
–Recognize many patients have health goals
–Assess patients’ goals–Prepare to address common goals •Getting in shape •Controlling weight
Implications for Theory & Implications for Theory & ResearchResearch
• Test ideas from self-determination theory
– Autonomy re: goals– Perceived competence re: goal
progress– Respectful interpersonal context re:
how
Proposed studyProposed studyAn advanced practice nurse with MS (ex, NP)
• Collaborates 1:1 with participants
• Elicits & refines goals re: physical activity or diet
• Shares relevant information
• Monitors progress
• Offers encouragement & suggestions
• In autonomy respecting relationship
Assessing the feasibility of a Assessing the feasibility of a patient-centered, goal-focused patient-centered, goal-focused
interventionintervention
Diane Lauver PhD AP RN BC
Professor
University of Wisconsin-Madison
School of Nursing
Funding: NIH P20
Patient-Centered Interventions
AcknowledgementsAcknowledgements
• 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
Study 2: 1Study 2: 1stst Aim 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
Study 2: 2Study 2: 2ndnd Aim Aim
• Explore intervention effects --to estimate effect sizes & power for future -- on
– Recommended health behaviors– Goal attainment– Perceived competence
Self-determination Self-determination theorytheory
• Autonomy vs. Control
– Motivation• Competence
• Relatedness
–Respecting autonomy or not
SDT applied to Patient-centered SDT applied to Patient-centered Interventions re: Health behavior GoalsInterventions re: Health behavior Goals
Individualized behavioral goals & practical plans to attain goals & feedback on goal attainment
Improved health outcomes
Autonomy re behavior change
Perceived competence for behavior change
Initial & maintained behavior change
Intervention
Mediator
Outcomes
MethodMethod
Design:
– One group, pre- post-intervention
– based on SDT
– focused on goals re: physical activity or diet
– 1 month post-intervention interview
SettingSetting
• Mid-west, USA
• Recruitment sites
– Primary care clinics
– Statewide program providing support for screening for those who cannot afford it
SampleSample
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
Intervention: 1Intervention: 1stst Contact 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)
Intervention: Follow-up Intervention: Follow-up contacts 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
APN IntervenerAPN 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
Measures: Pre- & Post-InterventionMeasures: Pre- & Post-Intervention
• Brief measures of physical activity, fruit/vegetable & fat intake
• Perceived competence in engaging in desired health behavior
Assessments: During the Assessments: During the interventionintervention
• APNs rated feasibility of intervention delivery
• Research team reviewed audio-tapes of APNs intervention delivery to assess validity
Measures: Post-Measures: Post-interventionintervention
• Participants’ acceptability ratings
– Procedures•Where, when, how, with whom
• Behavioral tools, from NIH
– Physical activity - 7-day recall– Diet- Block’s fruit/veg & fat
ProceduresProcedures
• 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
Preliminary Findings re: Preliminary Findings re: FeasibilityFeasibility
• 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
Findings: Participants’ Findings: Participants’ AcceptabilityAcceptability
• Ratings - high (4.2-4.8/5 point scale)
– study met their needs– nurse-intervener was helpful & – knowledgeable.
Findings: Participants’ Findings: Participants’ ratingsratings
• Perceived competence w/ health behaviors improved over time
• Perceived autonomy support from APNs rated highly
Findings: Participants’ Findings: Participants’ Feedback Feedback
Suggested
– lengthen intervention > 6 weeks
–revise the goals work sheet–decrease length of questionnaires
Goals & attainmentGoals & 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
Exploring Pre- Post- Exploring Pre- Post- Behaviors 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
Preliminary ConclusionsPreliminary Conclusions
• Feasible to
– Recruit – Retaining participants– Deliver intervention by APNs– Acceptability of process to
participants
Findings lend support to Findings lend support to ideasideas
PCI could improve
health goal attainment
recommended health behavior
perceived competence &
influence perceived autonomy support
Future researchFuture 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
Future researchFuture research
• Test mechanisms of perceived
autonomy
competence
congruence
• Examine role of social desirability
Fidelity of interventionFidelity of intervention
Met weekly
Assessed APN intervener’s interactions on audiotapes & reviewed written documents
Assessed participants’ perceptions
autonomy-support
congruence of values, goals, subgoals
Preliminary findings re: Preliminary findings re: ValidityValidity
• Participants’ autonomy-support ratings were high (4.6-4.9/5 point scale)
• Perceived competence improved
• Participants’ ratings of concordance increased