Motivational interviewing in health care settings. Opportunities and limitations

Digital health outreach to promote postpartum screening after gestational diabetes: A randomized factorial pilot study

Objective

We examined the acceptability and feasibility of a multi-component digital health outreach intervention to promote uptake of guideline-recommended postpartum screening for type 2 diabetes among patients with gestational diabetes (GDM).

Methods

We conducted a 24 randomized factorial experiment as part of the Multiphase Optimization Strategy (MOST) preparation phase for developing behavioral interventions. Participants with current or recent GDM in an integrated healthcare system were randomized to receive an outreach message with up to four intervention components, designed to be self-administered in about 10 min and efficiently delivered online via REDCap: a streamlined values affirmation, personalized information on diabetes risk, an interactive motivational interviewing-based component, and an interactive action planning component. Patient-reported acceptability and feasibility outcomes were assessed via survey.

Results

Among 162 participants, 72% self-identified with a racial/ethnic minority group. Across components, acceptability scores averaged 3.9/5; ≥91% of participants read most or all of the outreach message; ≥89% perceived the amount of information as "about right"; and ≥ 87% completed ≥1 interactive prompt.

Conclusion

Each intervention component was acceptable to diverse patients and feasible to deliver in a brief, self-directed, online format.

Innovation

These novel components target unaddressed barriers to patient engagement in guideline-recommended postpartum diabetes screening and adapt theory-based behavior change techniques for large-scale use.

Motivational Interviewing improves postoperative nutrition goals within the Enhanced Recovery after Surgery (ERAS®) pathway in elective bowel surgery - A randomized clinical pilot trial

BACKGROUND & AIMS

Exploration whether Motivational Interviewing (MI) could be learned and implemented with ease within a surgical in-hospital setting and whether participation in the intervention led to significantly higher compliance with ERAS®-recommended protein intake goals. The individual healing process of many patients is delayed because they fail to cover their calorie requirement, which could be counteracted by a patient-centered conversational intervention that is new in perioperative practice.

METHODS

This patient-blinded pilot-RCT included 60 patients (≥18 years) following the certified ERAS® bowel protocol for colorectal surgery between March and August 2022. Five perioperative MI interventions were conducted by two health employees certified to perform MI. Key endpoints were the number of protein shakes drunk, calories of proteins ingested and overall calorie intake.

RESULTS

A total of 60 patients (34 men [56.7%]; mean [SD] age, 60.7 [13.3] years) were randomized. MI patient-group had significantly higher protein shake intake on all postoperative days except day 3. For days 0-3 MI group drank significantly more shakes overall (median 5.5 vs. 2.0; P = 0.004) and consumed more calories (median 1650.0 vs. 600.0 kcal; P = 0.004) and proteins (median 110.0 vs. 40.0 g; P = 0.005). Total calorie intake for each day by shakes and dietary intake was significantly higher in the MI-intervention group on day 2 (mean 1772.3 vs. 1358.9 kcal; P = 0.03).

CONCLUSIONS

MI may contribute to improve compliance with nutritional goals in the certified ERAS® protocol by increasing protein and calorie intake. The findings suggest further investigation of MI to help patients achieve their perioperative nutrition goals in different clinical settings.

TRIAL REGISTRATION

DRKS - Deutsches Register Klinischer Studien; DRKS-ID: DRKS00027863; https://drks.de/search/de/trial/DRKS00027863.

Associations of sedentary behavior and screen time with biomarkers of inflammation and insulin resistance

Sedentary behavior (SB) has been linked to risk factors of cardiometabolic disease, with inconsistent findings reported in the literature. We aimed to assess the associations of SB with multiple biomarkers of inflammation and insulin resistance in adults. Domain-specific SB, sitting time and moderate-to-vigorous physical activity (MVPA) were measured in 78 adults (mean ± SD 52.0 ± 10.8 y). Body fat percentage (BF%) was assessed using multi-frequency bioelectrical impedance. A blood draw assessed glucose, insulin, C-reactive protein (CRP), interleukin-6 (IL-6), tumor necrosis factor-alpha (TNF-α), leptin, and adiponectin. Adiponectin-leptin ratio (ALR), homeostasis model assessment of insulin resistance (HOMA-IR) and beta-cell function (HOMA-β) were calculated. Multivariable linear regression analyses, controlling for age, sex, MVPA, and BF%, were used to assess associations. After adjustment for age, sex and MVPA, total SB (7.5 ± 2.5 h/day) was positively associated with leptin, insulin, HOMA-IR, HOMA-β (Standardized Beta (β) range 0.21-0.32) and negatively associated with ALR (β = -0.24, p < 0.05 for all). Similarly, total sitting time (7.2 ± 2.9 h/day) was associated with TNF-α (β = 0.22) and ALR (β = -0.26). These associations were attenuated to non-significance after adjustment for BF%. Leisure screen time was detrimentally associated with IL-6 (β = 0.24), leptin (β = 0.21), insulin (β = 0.37), HOMA-IR (β = 0.37), and HOMA-β (β = 0.34), independent of age, sex and MVPA (p < 0.05 for all). Only the associations with insulin (β = 0.26), HOMA-IR (β = 0.26), and HOMA-β (β = 0.23) remained significant after further controlling BF% (p < 0.05). Self-reported SB is associated with biomarkers of inflammation and insulin resistance, independent of MVPA, and in some cases BF%.

The effect of nurse-led motivational interviewing based on the trans-theoretical model on promoting physical activity in healthy older adults: A randomized controlled trial

AIM

The aim of this study was to evaluate the effect of motivational interviewing based on the trans-theoretical model promoting physical activity in older adults.

METHODS

A randomized controlled trial study was conducted with 117 older adults (intervention group: 58, and control group: 59) between April and November 2019. The data were collected via a questionnaire, trans-theoretical model scales, the Physical Activity Scale for the Elderly, the Katz Activities of Daily Living scale and a pedometer. The 24-week intervention consisted of regular motivational interviewing. The control group received usual care at the family health centre.

RESULTS

Following the intervention, the Intervention Group showed significant improvements Exercise Processes of Change Scale, Exercise Self-Efficacy Scale and Perceived Benefits of the Decisional Balance Scale for Exercise. There was a significant difference between the groups in terms of stages of change. In the Intervention Group, 81.5% were in the contemplation stage in the pre-test, while in the post-test, 70.4% had transitioned to the action stage. In contrast, in the control group, 62.5% were in the contemplation stage initially, but in the post-test, only 9.3% had reached the action stage. The mean number of step counts increased significantly in favour of the Intervention Group, as did the Physical Activity Scale for the Elderly total score.

CONCLUSION

The trial indicated that after the trans-theoretical model-based motivational interviewing, the stages of change among the older adults improved, as did their exercise behaviours. It is recommended that the trans-theoretical model and motivational interviewing be used by nurses to improve healthy lifestyle stage behaviours in older adults.

Characteristics of self-management education and support programmes for people with chronic diseases delivered by primary care teams: a rapid review

BACKGROUND

Primary care actors can play a major role in developing and promoting access to Self-Management Education and Support (SMES) programmes for people with chronic disease. We reviewed studies on SMES programmes in primary care by focusing on the following dimensions: models of SMES programmes in primary care, SMES team's composition, and participants' characteristics.

METHODS

For this mixed-methods rapid review, we searched the PubMed and Cochrane Library databases to identify articles in English and French that assessed a SMES programme in primary care for four main chronic diseases (diabetes, cancer, cardiovascular disease and/or respiratory chronic disease) and published between 1 January 2013 and 31 December 2021. We excluded articles on non-original research and reviews. We evaluated the quality of the selected studies using the Mixed Methods Appraisal Tool. We reported the study results following the PRISMA guidelines.

RESULTS

We included 68 studies in the analysis. In 46/68 studies, a SMES model was described by focusing mainly on the organisational dimension (n = 24). The Chronic Care Model was the most used organisational model (n = 9). Only three studies described a multi-dimension model. In general, the SMES team was composed of two healthcare providers (mainly nurses), and partnerships with community actors were rarely reported. Participants were mainly patients with only one chronic disease. Only 20% of the described programmes took into account multimorbidity. Our rapid review focused on two databases and did not identify the SMES programme outcomes.

CONCLUSIONS

Our findings highlight the limited implication of community actors and the infrequent inclusion of multimorbidity in the SMES programmes, despite the recommendations to develop a more interdisciplinary approach in SMES programmes. This rapid review identified areas of improvement for SMES programme development in primary care, especially the privileged place of nurses in their promotion.

TRIAL REGISTRATION

PROSPERO 2021 CRD42021268290 .

Components in downstream health promotions to reduce sugar intake among adults: a systematic review

Excessive sugar consumption is well documented as a common risk factor for many Non-Communicable Diseases (NCDs). Thus, an adequate intervention description is important to minimise research waste and improve research usability and reproducibility. A systematic review was conducted to identify components in published evidence interventions pertaining to the health promotions on reducing sugar intake among adults. The review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement and used the Mixed Methods Appraisal Tool (MMAT) for quality appraisal. The period for the selected study was from 2000 to 2022, and articles were retrieved from Web of Science (WOS), Medline, Scopus, and PubMed. The target population was adults aged 18 years old and above who underwent intervention to assess the changes in their sugar intake. Data sources and all human epidemiologic studies were included. Out of the 9,333 papers identified, 25 were included. The overall quality of evidence of the studies was considered moderate. Apart from the characteristics of the reviewed studies, components of interventions are including the basis of theoretical or model for the intervention, which majority use Social Cognitive Theory, followed by PRECEDE-PROCEED model, socio-ecological and process-improvement theories and Transtheoretical Model; providers, who are commercial provider, qualified nutritionist, professor of nutrigenomics and nutrigenetics, doctor, dietitian nutritionist, lifestyle coaches, and junior public health nurses; duration of the intervention and follow-up time, varies from as short as one month to as long as 24 months; material provided either softcopy or hardcopy; tailoring approach, based on the individual goals, the process of change, genotype analysis, beliefs, barriers, and sociocultural norms; delivery mechanism either face-to-face or technology-mediated; and tools to measure the sugar consumption outcome mostly used Food Frequency Questionnaire (FFQ), besides 24-h dietary recalls, and food diaries. There are various components in downstream health promotion to reduce sugar intake among adults that can be adapted according to the local health promotion and intervention context. More well-designed interventions using integration components are encouraged in further studies.

Embodied Conversational Agents Providing Motivational Interviewing to Improve Health-Related Behaviors: Scoping Review

BACKGROUND

Embodied conversational agents (ECAs) are advanced human-like interfaces that engage users in natural face-to-face conversations and interactions. These traits position ECAs as innovative tools for delivering interventions for promoting health-related behavior adoption. This includes motivational interviewing (MI), a therapeutic approach that combines brief interventions with motivational techniques to encourage the adoption of healthier behaviors.

OBJECTIVE

This study aims to identify the health issues addressed by ECAs delivering MI interventions, explore the key characteristics of these ECAs (eg, appearance, dialogue mechanism, emotional model), analyze the implementation of MI principles and techniques within ECAs, and examine the evaluation methods and primary outcomes of studies that use ECAs providing MI interventions.

METHODS

We conducted a scoping review following the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews) methodology. Our systematic search covered the PubMed, Scopus, IEEE Xplore, ACM Digital, and PsycINFO databases for papers published between January 2008 and December 2022. We included papers describing ECAs developed for delivering MI interventions targeting health-related behaviors and excluded articles that did not describe ECAs with human appearances and without the necessary evaluation or MI explanation. In a multistage process, 3 independent reviewers performed screening and data extraction, and the collected data were synthesized using a narrative approach.

RESULTS

The initial search identified 404 articles, of which 3.5% (n=14) were included in the review. ECAs primarily focused on reducing alcohol use (n=5, 36%), took on female representations (n=9, 64%), and gave limited consideration to user ethnicity (n=9, 64%). Most of them used rules-driven dialogue mechanisms (n=13, 93%), include emotional behavior to convey empathy (n=8, 57%) but without an automatic recognition of user emotions (n=12, 86%). Regarding MI implementation, of 14 studies, 3 (21%) covered all MI principles, 4 (29%) included all processes, and none covered all techniques. Most studies (8/14, 57%) conducted acceptability, usability, and user experience assessments, whereas a smaller proportion (4/14, 29%) used randomized controlled trials to evaluate behavior changes. Overall, the studies reported positive results regarding acceptability, usability, and user experience and showed promising outcomes in changes in attitudes, beliefs, motivation, and behavior.

CONCLUSIONS

This study revealed significant advancements in the use of ECAs for delivering MI interventions aimed at promoting healthier behaviors over the past 15 years. However, this review emphasizes the need for a more in-depth exploration of ECA characteristics. In addition, there is a need for the enhanced integration of MI principles, processes, and techniques into ECAs. Although acceptability and usability have received considerable attention, there is a compelling argument for placing a stronger emphasis on assessing changes in attitudes, beliefs, motivation, and behavior. Consequently, inclusion of more randomized controlled trials is essential for comprehensive intervention evaluations.

Does the Quality of Behavior Change Counseling in Routine HIV Care Vary According to Topic and Demand?

HIV clinicians face increasing time constraints. Our objective was to describe the prevalence and quality of behavior change counseling within routine HIV visits and to explore whether clinicians may provide lower quality counseling when facing increased counseling demands. We audio-recorded and transcribed encounters between 205 patients and 12 clinicians at an urban HIV primary care clinic. We identified and coded episodes of behavior change counseling to determine clinicians' consistency with motivational interviewing (MI) and used multi-level regression to evaluate counseling quality changes with each additional topic. Clinician counseling for at least one behavior was indicated in 92% of visits (mean 2.5/visit). Behavioral topics included antiretroviral medication adherence (80%, n = 163), appointment adherence (54%, n = 110), drug use (46%, n = 95), tobacco use (45%, n = 93), unsafe sex (43%, n = 89), weight management (39%, n = 80), and alcohol use (35%, n = 71). Clinician counseling was most MI-consistent when discussing drug and tobacco use and least consistent for medication and appointment adherence, unsafe sex, and alcohol use. In multilevel analyses, clinician counseling was significantly less MI-consistent (β = - 0.14, 95% CI - 0.29 to - 0.001) with each additional behavior change counseling need. This suggests that HIV ambulatory care be restructured to allocate increased time for patients with greater need for behavior change.

Psychosocial factors impacting community-based pressure ulcer prevention: A systematic review

BACKGROUND

Pressure ulcers are a major health concern. They have a significant impact on the healthcare system and individuals, reducing quality of life across several domains. In community settings, self-management behaviours are central to their prevention. However, adherence with pressure ulcer prevention guidelines remains low, with little evidence guiding the relationship between patients and healthcare professionals to establish a concordant partnership.

OBJECTIVE

To synthesise evidence on factors contributing to community-based pressure ulcer prevention using the Theoretical Domains Framework and the Capability, Opportunity, Motivation, Behaviour (COM-B) model of behaviour.

DESIGN

Mixed methods systematic review and narrative synthesis.

METHOD

Systematic searches were conducted in the CINAHL, Cochrane, EMBASE, PsycINFO, PubMed, Scopus, and Web of Science databases on 14th December 2022. Studies were eligible if they contained data on the factors associated with adherence and concordance with pressure ulcer prevention guidelines in the community for patients, caregivers, and healthcare professionals. Methodological quality was assessed using the Hawker tool. Findings were synthesised using the Theoretical Domains Framework. The resulting themes were mapped onto the Capability, Opportunity, Motivation, Behaviour (COM-B) model.

RESULTS

Thirty studies were included in the review, including quantitative, qualitative, and mixed methods research. The synthesis identified 12 of the 14 Theoretical Domains Framework domains, with knowledge, social influences, beliefs about consequences, and beliefs about capabilities the most prevalent. Although knowledge appears to be an important contributor to adherence with prevention guidelines, knowledge alone does not appear sufficient to achieve concordance. A concordant relationship was facilitated by healthcare professionals' knowledge, motivation to work alongside patients and their priorities, and interpersonal skills to build rapport and trust, whilst barriers included lack of healthcare professional skills to navigate sensitive issues, paternalistic views of patient compliance and organisational processes that impact building rapport.

CONCLUSIONS

Several psychosocial factors may affect the ability to achieve concordance between individuals, caregivers and healthcare professionals with pressure ulcer prevention guidelines in the community. However, data regarding the efficacy of behaviour change interventions targeting these constructs is limited, with further research required to guide intervention development in this area.

Using Motivational Interviewing to Increase HIV PrEP Initiation and Adherence: a Scoping Review

Despite evidence that pre-exposure prophylaxis (PrEP) reduces HIV risk, initiation and adherence remain low among vulnerable communities. Motivational interviewing (MI) can improve HIV prevention behaviors. However, limited research identifies how MI impacts PrEP uptake and adherence. This scoping review examines essential components of MI-based interventions that aimed to improve PrEP use, including the number and duration of sessions, counselor characteristics, and interview content. We searched four databases, PubMed, CINAHL Plus, Embase, and Web of Science, and reviewed 379 articles. Studies were considered if they (a) were published between 2012 and 2023, (b) used MI independently or part of a multi-component intervention strategy, and (c) focused on improving PrEP initiation or adherence. Seven articles met inclusion criteria. Regarding intervention components, the number of MI sessions varied and duration ranged between 15 and 60 min. MI counselors varied in credentialing and demographic characteristics. MI content included PrEP education, identifying initiation and adherence barriers, and strategizing ways to overcome barriers. MI is an important component of interventions that aim to improve PrEP initiation and adherence. However, the variability and limited details across studies hinder our ability to assess MI efficacy on PrEP initiation and adherence or replicate these approaches in future interventions.

LGBTQ + cultural competency training for health professionals: a systematic review

BACKGROUND

Health disparities experienced by LGBTQ + individuals have been partially attributed to health professionals' lack of cultural competence to work with them. Cultural competence, the intricate integration of knowledge, skills, attitudes, and behaviors that improve cross-cultural communication and interpersonal relationships, has been used as a training framework to enhance interactions between LGBTQ + patients and health professionals. Despite multiple published LGBTQ + cultural competency trainings, there has been no quantitative appraisal and synthesis of them. This systematic review assessed articles evaluating the design and effectiveness of these trainings and examined the magnitude of their effect on cultural competence outcomes.

METHODS

Included studies quantitatively examined the effectiveness of LGBTQ + cultural competency trainings for health professionals across all disciplines in various healthcare settings. 2,069 citations were retrieved from five electronic databases with 44 articles meeting inclusion criteria. The risk of bias in the included studies was assessed by two authors utilizing the Joanna Briggs Institute critical appraisal checklists. Data extracted included study design, country/region, sample characteristic, training setting, theoretical framework, training topic, modality, duration, trainer, training target, measurement instrument, effect size and key findings. This review followed the PRISMA statement and checklist to ensure proper reporting.

RESULTS

75% of the studies were published between 2017 and 2023. Four study designs were used: randomized controlled trial (n = 1), quasi-experimental pretest-posttest without control (n = 39), posttest only with control (n = 1) and posttest only without control (n = 3). Training modalities were multiple modalities with (n = 9) and without simulation (n = 25); single modality with simulation (n = 1); and with didactic lectures (n = 9). Trainings averaged 3.2 h. Ten studies employed LGBTQ + trainers. The training sessions resulted in statistically significant improvements in the following cultural competence constructs: (1) knowledge of LGBTQ + culture and health (n = 28, effect size range = 0.28 - 1.49), (2) skills to work with LGBTQ + clients (n = 8, effect size range = 0.12 - 1.12), (3) attitudes toward LGBTQ + individuals (n = 14, effect size range = 0.19 - 1.03), and (4) behaviors toward LGBTQ + affirming practices (n = 7, effect size range = 0.51 - 1.11).

CONCLUSIONS

The findings of this review highlight the potential of LGBTQ + cultural competency training to enhance cultural competence constructs, including (1) knowledge of LGBTQ + culture and health, (2) skills to work with LGBTQ + clients, (3) attitudes toward LGBTQ + individuals, and (4) behaviors toward LGBTQ + affirming practices, through an interdisciplinary and multi-modal approach. Despite the promising results of LGBTQ + cultural competency training in improving health professionals' cultural competence, there are limitations in study designs, sample sizes, theoretical framing, and the absence of longitudinal assessments and patient-reported outcomes, which call for more rigorous research. Moreover, the increasing number of state and federal policies that restrict LGBTQ + health services highlight the urgency of equipping health professionals with culturally responsive training. Organizations and health systems must prioritize organizational-level changes that support LGBTQ + inclusive practices to provide access to safe and affirming healthcare services for LGBTQ + individuals.

Pilot Trial of a Smartphone-Based Intervention to Reduce Alcohol Consumption among Veterans with HIV

Veterans engage in disproportionate levels of alcohol use, which can impact treatment outcomes among veterans with HIV. The TRAC (Tracking and Reducing Alcohol Consumption) intervention, which combines smartphones, mobile breathalyzers, and motivational interviewing (MI), was developed to help reduce alcohol use among this population. This study reports results of an 8-week pilot trial of TRAC among veterans with HIV (N = 10). Participants attended weekly MI sessions conducted via videoconferencing or phone and completed twice-daily self-monitoring of alcohol consumption using breathalyzers and surveys. They also completed pre- and post-intervention questionnaires and a qualitative interview. Analyses explored adherence to self-monitoring tasks, perceptions of the intervention, and preliminary effects of TRAC on alcohol use and readiness to change drinking behavior. Participants completed 76% of breathalyzer readings and 73% of surveys and completed more daytime than evening monitoring tasks. AUDIT hazardous drinking scores significantly decreased between baseline and post-test. Qualitative interviews revealed positive attitudes toward the technologies and MI sessions. Overall, this pilot demonstrated that the TRAC intervention has potential to reduce alcohol use among veterans with HIV, though additional effort is needed to improve adherence to mobile monitoring. Results were used to refine the intervention in preparation for a randomized controlled trial.

Using the COM-B model and Behaviour Change Wheel to develop a theory and evidence-based intervention for women with gestational diabetes (IINDIAGO)

BACKGROUND

In South Africa, the prevalence of gestational diabetes (GDM) is growing, concomitant with the dramatically increasing prevalence of overweight/obesity among women. There is an urgent need to develop tailored interventions to support women with GDM to mitigate pregnancy risks and to prevent progression to type 2 diabetes post-partum. The IINDIAGO study aims to develop and evaluate an intervention for disadvantaged GDM women attending three large, public-sector hospitals for antenatal care in Cape Town and Soweto, SA. This paper offers a detailed description of the development of a theory-based behaviour change intervention, prior to its preliminary testing for feasibility and efficacy in the health system.

METHODS

The Behaviour Change Wheel (BCW) and the COM-B model of behaviour change were used to guide the development of the IINDIAGO intervention. This framework provides a systematic, step-by-step process, starting with a behavioural analysis of the problem and making a diagnosis of what needs to change, and then linking this to intervention functions and behaviour change techniques to bring about the desired result. Findings from primary formative research with women with GDM and healthcare providers were a key source of information for this process.

RESULTS

Key objectives of our planned intervention were 1) to address women's evident need for information and psychosocial support by positioning peer counsellors and a diabetes nurse in the GDM antenatal clinic, and 2) to offer accessible and convenient post-partum screening and counselling for sustained behaviour change among women with GDM by integrating follow-up into the routine immunisation programme at the Well Baby clinic. The peer counsellors and the diabetes nurse were trained in patient-centred, motivational counselling methods.

CONCLUSIONS

This paper offers a rich description and analysis of designing a complex intervention tailored to the challenging contexts of urban South Africa. The BCW was a valuable tool to use in designing our intervention and tailoring its content and format to our target population and local setting. It provided a robust and transparent theoretical foundation on which to develop our intervention, assisted us in making the hypothesised pathways for behaviour change explicit and enabled us to describe the intervention in standardised, precisely defined terms. Using such tools can contribute to improving rigour in the design of behavioural change interventions.

TRIAL REGISTRATION

First registered on 20/04/2018, Pan African Clinical Trials Registry (PACTR): PACTR201805003336174.

Encouragement of patients' self-management in primary care for the prevention of cardiovascular diseases (DECADE): protocol for a cluster randomised controlled trial

INTRODUCTION

Cardiovascular diseases are the most common cause of death in Germany and among the most frequent reasons for encounters in primary care. Most patients with cardiovascular risks (CVRs) have difficulties implementing health-promoting behavioural changes. In this study, a complex intervention containing evidence-based patient materials and structured follow-up consultations are intended to strengthen patients' self-management to improve health behaviour.

METHODS AND ANALYSIS

In this cluster randomised controlled trial, we investigate the effects of the intervention "Decision aid, action planning and follow-up support for patients to reduce the 10-year risk of cardiovascular diseases" (DECADE) using a 2×2 design. All patients, including the control group (CG), receive a CVR calculation. Three intervention groups (IGs) receive one or both of two different components of the DECADE intervention: IG1 (patient materials), IG2 (follow-up consultations) and IG3 (patient materials and follow-up consultations). The study was planned to be conducted with 77 general practitioners in 3 German regions and a target sample size of 924 patients. The observation period for each patient amounts to 12 months with three patient surveys: baseline (t0), after 6 and 12 months (t1 and t2). The primary outcome is patient activation (Patient Activation Measure 13 (PAM13-D)) at t1. Secondary outcomes include PAM13-D at t2 and further patient-reported and clinical outcomes at t1 and t2. We will also analyse the cost-effectiveness of the intervention, the degree of usage and satisfaction with the intervention.

ETHICS AND DISSEMINATION

The study was first approved by the lead ethics committee of the University of Freiburg on 15 April 2021 (vote number: 21-1078) and subsequently by the other ethics committees in the study regions (Ethics committee of medical association Baden-Württemberg (B-F-2021-078), Ethics Committee of the Technische Universität Dresden, Dresden (BO-EK-251052021), Ethics Committee of the State Chamber of Physicians of Saxony (EK-BR-92/21-1), Ethics Committee of the Hamburg Medical Association (2021-200013-BO-bet)). Informed consent is required for patients to participate in the study. The results of this study will be published in peer-reviewed journals and presented at congresses by the DECADE team. The DECADE lead management will communicate the results to the funder of this study.

TRIAL REGISTRATION NUMBER

German Clinical Trials Register, DRKS00025401 (registration date: 21 June 2021); International Clinical Trials Registry Platform, DRKS00025401.

Oral health promotion in acute hospital setting: a quality improvement programme

Tooth extraction is the most common hospital procedure for children aged 6-10 years in England. Tooth decay is almost entirely preventable and is inequitably distributed across the population: it can cause pain, infection, school absences and undermine overall health status.An oral health programme (OHP) was delivered in a hospital setting, comprising: (1) health promotion activities; (2) targeted supervised toothbrushing (STB) and (3) staff training. Outcomes were measured using three key performance indicators (KPI1: percentage of children/families seeing promotional material; KPI2: number of children receiving STB; KPI3: number of staff trained) and relevant qualitative indicators. Data were collected between November 2019 and August 2021 using surveys and data from the online booking platform.OHP delivery was impacted by COVID-19, with interventions interrupted, reduced, eliminated or delivered differently (eg, in-person training moved online). Despite these challenges, progress against all KPIs was made. 93 posters were deployed across the hospital site, along with animated video 41% (233/565) of families recalled seeing OHP materials across the hospital site (KPI1). 737 children received STB (KPI2), averaging 35 children/month during the active project. Following STB, 96% participants stated they learnt something, and 94% committed to behaviour change. Finally, 73 staff members (KPI3) received oral health training. All people providing feedback (32/32) reported learning something new from the training session, with 84% (27/32) reporting that they would do things differently in the future.Results highlight the importance of flexibility and resilience when delivering QI projects under challenging conditions or unforeseen circumstances. While results suggest that hospital-based OHP is potentially an effective and equitable way to improve patient, family and staff knowledge of good oral health practices, future work is needed to understand if and how patients and staff put into practice the desired behaviour change and what impact this may have on oral health outcomes.

Mind-Body Intervention for Dysfunctional Breathing in Chronic Obstructive Pulmonary Disease: Feasibility Study and Lessons Learned

Purpose: Dysfunctional breathing behaviors are prevalent in chronic obstructive pulmonary disease (COPD). Although these behaviors contribute to dyspnea, abnormal carbon dioxide (CO2) levels, and COPD exacerbations, they are modifiable. Current dyspnea treatments for COPD are suboptimal, because they do not adequately address dysfunctional breathing behaviors and anxiety together. We developed a complementary mind-body breathlessness therapy, called capnography-assisted respiratory therapy (CART), that uses real-time CO2 biofeedback at the end of exhalation (end-tidal CO2 or ETCO2), to target dysfunctional breathing habits and improve dyspnea treatment and pulmonary rehabilitation (PR) adherence in COPD. The study aim was to test the feasibility of integrating CART with a traditional, clinic-based PR program in an urban setting. Methods: We used a feasibility pre- and post-test design, with 2:1 randomization to CART+PR or control (PR-alone) groups, to test and refine CART. Multi-component CART consisted of six, 1-h weekly sessions of slow breathing and mindfulness exercises, ETCO2 biofeedback, motivational counseling, and a home program. All participants were offered twice weekly, 1-h sessions of PR over 10 weeks (up to 20 sessions). Results: Thirty-one participants with COPD were enrolled in the study. Approximately a third of participants had symptoms of psychological distress. Results showed that CART was feasible and acceptable based on 74% session completion and 91.7% homework exercise completion (n = 22). Within-group effect sizes for CART+PR were moderate to large (Cohen's d = 0.51-1.22) for reduction in resting Borg dyspnea (anticipatory anxiety) and respiratory rate, St. George's Respiratory Questionnaire (SGRQ) respiratory symptoms; and increase in Patient-Reported Outcomes Measurement Information System (PROMIS) physical function and physical activity; all p < 0.05. Conclusions: CART is a new mind-body breathing therapy that targets eucapnic breathing, interoceptive function, and self-regulated breathing to relieve dyspnea and anxiety symptoms in COPD. Study findings supported the feasibility of CART and showed preliminary signals that CART may improve exercise tolerance, reduce dyspnea, and enhance PR completion by targeting reduced dysfunctional breathing patterns (CTR No. NCT03457103).

Developments in respiratory self-management interventions over the last two decades

This paper describes developments in the fields of asthma and COPD self-management interventions (SMIs) over the last two decades and discusses future directions. Evidence around SMIs has exponentially grown. Efficacy on group level is convincing and both asthma and COPD SMIs are currently recommended by respiratory guidelines. Core components of asthma SMIs are defined as education, action plans, and regular review, with some discussion about self-monitoring. Exacerbation action plans are defined as an integral part of COPD management. Patient's adherence to SMI's is however inadequate and significantly reducing the intervention's impact. Adherence could be improved by tailoring of SMIs to patients' needs, health beliefs, and capabilities; the use of shared decision making; and optimising the communication between patients and health care providers. Due to the COVID-19 pandemic, digital health innovations have rapidly been introduced and expanded. Digital technology use may increase efficiency, flexibility, and efficacy of SMIs. Furthermore, artificial intelligence can be used to e.g., predict exacerbations in action plans. Research around digital health innovations to ensure evidence-based practice is of utmost importance. Current implementation of respiratory SMIs is not satisfactory. Implementation research should be used to generate further insights, with cost-effectiveness, policy (makers), and funding being significant determinants.

Patient and Provider Prediabetes Knowledge, Attitudes, and Behaviors in a Large Urban Family Medicine Practice

One-third of U.S. adults have prediabetes, but only 11% are aware of their condition. Many do not receive education or treatment. The purpose of this study is to understand family medicine providers’ and patients’ attitudes, knowledge, and behaviors regarding prediabetes and its management, to guide future management interventions. Cross-sectional surveys of providers ( n = 54, 57% response rate) and patients with prediabetes ( n = 148, 16.5% response rate) were administered at a large urban academic family medicine practice. Nearly all providers agree prediabetes screening is important, but over half were unaware of the national Diabetes Prevention Program (DPP) and most do not prescribe metformin to eligible patients. Over half of patients reported being told they have prediabetes but <5% had been referred to DPP and over half were unaware of medication options. In open-ended responses, providers suggested nutrition counseling resources and an improved DPP referral process to improve prediabetes care. Patients requested clear diagnosis, education on treatment options, and nutritional counseling. This study indicates that notable gaps continue to exist in provider and patient understanding and management of prediabetes, suggesting that interventions to improve prediabetes care should include more effective counseling on diagnosis and treatment and expanding access to nutrition and educational resources.

Attitudes and experiences towards the application of motivational interviewing by podiatrists working with people with diabetes at high-risk of developing foot ulcers: a mixed-methods study

Background

Podiatrists are key professionals in promoting adequate foot self-care for people with diabetes at high-risk of developing foot ulcers. However, merely informing patients about the advantages of foot self-care is insufficient to realise behavioural change. Motivational interviewing (MI) is a promising person-centred communication style that could help to create a working alliance between healthcare providers and patient to improve foot self-care. This study aims to observe and analyse the application of MI in consultations carried out by MI-trained and non-MI-trained podiatrists with their patients, and explore podiatrists’ attitudes and experiences towards MI.

Methods

Eighteen podiatrists (median age: 28.5 years, 10 female and 8 male) followed a three-day basic training in MI and 4 podiatrists (median age: 38.5 years, 4 female) were not trained in MI. To observe and rate the MI-fidelity in daily clinical practice, audio recordings from the MI-trained and non-MI-trained podiatrists were scored with the Motivational Interviewing Treatment Integrity code. Individual, semi-structed, in-depth interviews were conducted with the MI-trained podiatrists to explore their attitudes towards and experiences with MI. These data sources were triangulated to describe the effect of training podiatrists in MI for their clinical practice.

Results

The MI-trained podiatrists scored significantly higher than the non-MI-trained podiatrists on two of four global MI-related communication skills (empathy, p = 0.008 and change talk, p = 0.008), on one of five core MI-adherent behaviours (affirmation, p = 0.041) and on one of the other behaviour counts (simple reflections, p = 0.008). The podiatrists mainly reported their attitudes and experiences regarding partnership and cultivating change talk, during the interviews. In addition, they also mentioned facilitators and barriers to using MI and indicated whether they experienced MI as having added value.

Conclusions

The MI-trained podiatrists used the principles of MI at a solid beginner proficiency level in their clinical practice in comparison to the non-MI-trained podiatrists, who did not reach this level. This achievement is in accordance with the basic MI-training they received. This multi-method study reveals that podiatrists can be effectively trained in applying MI in daily clinical practice.

Trial registration

Netherlands Trial Register NL7710. Registered: 6 May 2019.

Effectiveness of an intervention to overcome influenza vaccine hesitancy in specialty clinic patients

BACKGROUND

Individuals on immunosuppressive therapies experience greater morbidity and mortality due to vaccine-preventable illnesses, but there are low rates of adherence to immunization guidelines within this population.

OBJECTIVE

To determine the effectiveness of clinician-led education, patient-centered dialogue, and immediately available immunization on influenza vaccination uptake in patients taking immunosuppressive therapies.

METHOD

We used a controlled before-and-after quasi-experimental design to evaluate our quality improvement intervention occurring from September 2019 to March 2020, with follow-up through July 2020. The study included 2 dermatology practices wherein nursing staff offered influenza vaccination during patient rooming (standard care). Within each practice, clinicians either implemented the intervention or provided only standard care. Patients received the intervention or standard care depending on the clinician they visited. Patients seen at the 2 clinics during the intervention period were included in analyses if they were taking or newly prescribed immunosuppressant medication at the time of their visit. We examined influenza immunization status for 3 flu seasons: 2017-2018 (preintervention), 2018-2019 (preintervention), and 2019-2020 (intervention).

INTERVENTION

Immunosuppressed patients initially declining an influenza vaccine were provided dermatologist-led education on the benefits of immunization. Dermatologists explored and addressed individual patients' immunization concerns. Influenza vaccination was then offered immediately postdialogue.

RESULTS

Analyses included 201 dermatology patients who were prescribed or currently taking immunosuppressive medication (intervention group [72.6%], comparison group [27.4%]). During the intervention period, 91.1% of the intervention group received influenza vaccination compared to 56.4% of the comparison group. Vaccination trends from 2018-2019 (preintervention) to 2019-2020 (intervention) differed significantly between groups (χ2 = 22.92, P < .001), with greater improvement in the intervention group. In 2019-2020, influenza vaccination was more likely in the intervention group relative to the comparison group (odds ratio: 16.22, 95% confidence interval: 5.55-47.38). In the subset of patients that had never received an influenza vaccine, influenza immunization in 2019-2020 was more common in the intervention group (75.8%, 25/33) relative to the comparison group (13.3%, 2/15, P < .001).

CONCLUSION

The intervention successfully addressed vaccine hesitancy and improved influenza immunization rates in an immunosuppressed population receiving care from a specialty clinic. Implementing a similar model across specialty clinics may improve vaccination rates for influenza, coronavirus disease 2019, and other vaccine-preventable illnesses in other populations.

Brief behaviour change counselling in non-communicable diseases in Mangochi, Southern Malawi: a hypothetical acceptability study

INTRODUCTION

Brief behaviour change counselling (BBCC) approaches have shown some potential in reversing and/or decreasing the effects of behavioural risk factors (harmful alcohol, smoking, physical inactivity and unhealthy diets). However, BBCC is new in Malawi. Thus, we explored the acceptability of brief behaviour change counselling using 5 As and a guiding style from motivational interviewing (BBCC + 5 As + GS) among health providers, policy-makers and patients living with noncommunicable diseases (NCDs) in the Mangochi district located in Malawi.

METHODS

An exploratory qualitative cross-sectional study used purposive sampling to select 44 respondents. We conducted group discussions with five focus groups that included patients. We also carried out nine key-informant interviews with healthcare providers and policy-makers. Data were managed and organized with Atlas.ti. cloud and analysed using the thematic framework approach.

FINDINGS

Several themes, categories, and their subcategories emerged from the interviews. Participants perceived the introduction and delivery of BBCC + 5As + GS in Mangochi as smooth. However, they predicted a few challenges such as time and space to conduct the intervention, cultural bottlenecks caused by low education level, age differences between healthcare providers and patients, low provider- to- patient ratio and high provider turnover. For this method to be adopted, a simplified format is deemed necessary to improve effectiveness with patients. This technique can only be sustained if training opportunities are provided and if positive testimonies are given by beneficiaries. Incorporation of a continuous quality improvement cycle targeting challenges must be part of the intervention. Participants perceived that BBCC will contribute to developing the listening ability of healthcare providers. This would help in providing personalized and cost-effective care relevant to Mangochi. The participants also perceived that BBCC + 5As + GS will be affordable, credible and useful.

CONCLUSION

We found a high acceptability rate of BBCC among stakeholders in NCDs clinics in Mangochi. There are a number of areas where BBCC + 5As + GS could be improved to increase the acceptability. Accordingly, a study of feasibility and preliminary efficacy is warranted to determine other prerequisites for the implementation of a large-scale trial using this BBCC+ 5 As + GS, and to fully understand the implementation requirements of a full trial in Mangochi.

Engaging Patients in Smoking Cessation Treatment within the Lung Cancer Screening Setting: Lessons Learned from an NCI SCALE Trial

Offering smoking cessation treatment at lung cancer screening (LCS) will maximize mortality reduction associated with screening, but predictors of treatment engagement are not well understood. We examined participant characteristics of engagement in an NCI SCALE cessation trial. Eligible LCS patients (N = 818) were randomized to the Intensive arm (8 phone counseling sessions +8 weeks of nicotine replacement therapy (NRT)) vs. Minimal arm (3 sessions + 2 weeks of NRT). Engagement was measured by number of sessions completed (none, some, or all) and NRT mailed (none vs. any) in each arm. In the Intensive arm, those with ≥some college (OR = 2.1, 95% CI = 1.1, 4.0) and undergoing an annual scan (OR = 2.1, 95% CI = 1.1, 4.2) engaged in some counseling vs. none. Individuals with higher nicotine dependence were more likely (OR = 2.8, 95% CI = 1.3, 6.2) to request NRT. In the Minimal arm, those with higher education (OR = 2.1, 95% CI = 1.1, 3.9) and undergoing an annual scan (OR = 2.0, 95% CI = 1.04, 3.8) completed some sessions vs. none. Requesting NRT was associated with more pack-years (OR = 1.9, 95% CI = 1.1, 3.5). Regardless of treatment intensity, additional strategies are needed to engage those with lower education, less intensive smoking histories, and undergoing a first scan. These efforts will be important given the broader 2021 LCS guidelines.

Study protocol for fertility preservation discussions and decisions: A family-centered psychoeducational intervention for male adolescents and emerging adults newly diagnosed with cancer and their families

Many childhood cancer survivors desire biological children but are at risk for infertility after treatment. One option for mitigating risk is the use of fertility preservation prior to gonadotoxic therapy. Adolescents and emerging adults may rely on their parents to help them decide whether to use fertility preservation. While this is often a collaborative process, it is currently unknown how parents can optimally support adolescents and emerging adults through this decision. To address this gap, we developed a family-centered, psychoeducational intervention to prompt adolescents and emerging adults to reflect on their future parenthood goals and attitudes towards fertility preservation, as well as to prompt their parents (or other caregivers) to reflect on their own and their child's perspectives on the topic. In this randomized controlled trial, families will be randomized to either the standard of care control group (fertility consult) or the intervention group. After their fertility consult, adolescents and emerging adults and parents in the intervention group will complete a fertility preservation values clarification tool and then participate in a guided conversation about their responses and the fertility preservation decision. The primary expected outcome of this study is that participation in the intervention will increase the use of fertility preservation. The secondary expected outcome is an improvement in decision quality. Chi-square analyses and t-tests will evaluate primary and secondary outcomes. The goal of this intervention is to optimize family-centered fertility preservation decision-making in the context of a new cancer diagnosis to help male adolescents and emerging adults achieve their future parenthood goals.

Feasibility and Short-Term Effects of a Multi-Component Emergency Department Blood Pressure Intervention: A Pilot Randomized Trial

Background

Emergency department (ED) visits can be opportunities to address uncontrolled hypertension. We sought to compare short‐term blood pressure measures between the Vanderbilt Emergency Room Bundle (VERB) intervention and usual care plus education.

Methods and Results

We conducted a randomized trial of 206 adult patients with hypertension and elevated systolic blood pressure (SBP) presenting to 2 urban emergency departments in Tennessee, USA. The VERB intervention included educational materials, a brief motivational interview, pillbox, primary care engagement letter, pharmacy resources, and 45 days of informational and reminder text messages. The education arm received a hypertension pamphlet. After 78 participants were enrolled, text messages requested confirmation of receipt. The primary clinical outcome was 30‐day SBP. The median 30‐day SBP was 122 and 126 mm Hg in the VERB and education arms, respectively. We estimated the mean 30‐day SBP to be 3.98 mm Hg lower in the VERB arm (95% CI, −2.44 to 10.4; P=0.22). Among participants enrolled after text messages were adapted, the respective median SBPs were 121 and 130 mm Hg, and we estimated the mean 30‐day SBP to be 8.57 mm Hg lower in the VERB arm (95% CI, 0.98‒16.2; P=0.027). In this subgroup, the median response rate to VERB text messages was 56% (interquartile range, [26%‒80%]).

Conclusions

This pilot study demonstrated feasibility and found an improvement in SBP for the subgroup for whom interactive messages were featured. Future studies should evaluate the role of interactive text messaging as part of a comprehensive emergency department intervention to improve blood pressure control.

Registration

URL: https://www.clinicaltrials.gov; Unique identifier: NCT02672787.

Dietary and physical activity changes and adherence to WCRF/AICR cancer prevention recommendations following a remotely delivered weight loss intervention for female breast cancer survivors: The Living Well after Breast Cancer randomized controlled trial

BACKGROUND

Diet, exercise, and weight management are key in improving outcomes for breast cancer survivors, with international recommendations for cancer survivors relating to these behaviors. However, few behavioral interventions have reported outcomes aligned specifically with these recommendations.

OBJECTIVE

To evaluate a remotely delivered weight loss intervention versus usual care for female breast cancer survivors, on changes in multiple diet and physical activity behaviors.

DESIGN

A randomized controlled trial with assessments at study baseline, 6-, 12- and 18 months (i.e., mid-intervention, post-intervention, and non-contact follow-up).

PARTICIPANTS/SETTING

Participants were recruited between October 2012 and December 2014 through hospitals in Brisbane (Australia) and the state-based cancer registry. Eligible participants (female, 18-75 years, BMI 25-45 kg/m², diagnosed with stage I-III breast cancer in previous two years) were randomly allocated to intervention (n=79) or usual care (n=80).

INTERVENTION

Participants randomized to the intervention group received 22 counseling telephone calls targeting diet and physical activity aimed at achieving 5-10% weight loss, and optional text messages, over 12 months. Usual care participants received their standard medical care and brief feedback following each assessment, which was similar to that provided to intervention participants with the exception that usual care participants' results were not compared to national and study recommendations.

MAIN OUTCOME MEASURES

Dietary intake (24-hour recalls); physical activity (hip-worn Actigraph); sitting time (thigh-worn activPAL3); and, adherence to World Cancer Research Fund/American Cancer Research Institute (WCRF/AICR) recommendations for cancer survivors (0-7 score) were measured at each assessment, with data collected between November 2012 and October 2016.

STATISTICAL ANALYSES PERFORMED

Intervention effects were assessed by linear mixed models, accounting for repeated measures and baseline values. Significance was set at P<0.05.

RESULTS

At baseline, participants were (mean±SD) aged 55±9 years, with a BMI of 31.4±5.0 kg/m², 10.7±5.0 months post-diagnosis, and primarily non-minority. At baseline, only 8% (n=12) of participants met ≥5/7 WCRF/AICR recommendations (mean±SD WCRF/AICR adherence score: 3.8±1.0). At 12 months, significant intervention effects were observed in walking/running ( +21 mins/week; 95%CI: 4, 38) and WCRF/AICR adherence scores (+0.3 points; 95%CI: 0.0, 0.6) only. At 18 months, significant intervention effects were observed for energy intake (-229 kcal/day energy; 95%CI: -373, -84), total fat (-10 g/day; 95%CI: -18, -2), and saturated fat (-5 g/day; 95%CI: -9, -1), and were sustained for WCRF/AICR adherence scores (+0.5 points; 95%CI: 0.2, 0.8).

CONCLUSIONS

This remotely delivered weight loss intervention led to sustained improvements in WCRF/AICR adherence scores, and some improvements in diet and physical activity. These findings provide support for the health benefit of programs targeting lifestyle behaviors in line with cancer survivor recommendations, and the potential for dissemination of such programs following treatment for early-stage female breast cancer.

Sustainability of weight loss from a family-centered pediatric weight management program integrated in primary care

BACKGROUND

A 6-month pediatric weight loss program showed modest success, but the sustainability of this success after 12 months was unclear. The present study aims tomeasure the medium-term effectiveness of family-based weight management in pediatric primary care to reduce body weight in children living with obesity.

METHODS

In a retrospective cohort study, children ages 3 to 17 years with obesity in Kaiser Permanente Orange County, California, who enrolled in a weight management program between April 2014 and December 2018 (FB-WMG, n = 341) were compared to children referred but not enrolled (Ref-CG, n = 317) and controls matched by sex, age, zip code and BMI (Area-CG, n = 801). The relative distance from the median BMI-for-age at months 0, 6, and 12 were expressed as difference-in-differences (DID) using multivariable linear regressions with robust standard error.

RESULTS

The baseline BMI-for-age was 98.6 (SD 1.08) percentile in FB-WMG, 98.2 (SD 1.22) percentile in Ref-CG, and 98.6 (1.13 in Area-CG). FB-WMG had a median of 3 visits (P25 1 visit, P75 5 visits) in the first 6 months. Despite a more considerable decrease in the relative distance to the median BMI-for-age in FB-WMG children with 3+ visits after 6 months, the success obtained was not sustained at 12 months (DID FB-WMG vs Area-CG -0.34, 95% CI - 3.00 to 2.33%, FB-WMG vs Ref-CG -0.39, 95% CI - 3.14 to 2.35%). At 12 months, there was no statistical significant difference between the three groups (FB-WWG, Ref-CG, Area-CG).

CONCLUSIONS

The initial success in weight management was not sustained in the absence of continued support for healthy lifestyle changes. Based on current evidence, continued support is necessary to maintain and promote success beyond a brief 6 month intervention. Long-term pediatric weight management programs are needed to promote continuing progress.

Cost effectiveness of a controlled lifestyle intervention for pregnant women with obesity

Background

The Mighty Mums antenatal lifestyle intervention is a person-centered behavioral intervention focusing on nutrition and physical activity for pregnant women with obesity (body mass index [BMI] ≥30). The aim of this study was to evaluate the costs and clinical outcomes of adding the Mighty Mums intervention to standard antenatal care.

Methods

Participants in the intervention group (n = 434) received motivational talks with their midwife and a selection of physical and/or nutritional activities in addition to antenatal care. Control participants (n = 867) from adjacent geographic areas received standard antenatal care. Costs for staff, unit costs for specific activities, and registered costs for specialized antenatal care were analyzed for associations with gestational weight gain and self-reported health. Results are reported for the intention-to-treat (ITT) population and a per protocol (PP) population identified by participation in the intervention. Analyses included bootstrapped linear regressions adjusted for background characteristics that differed significantly between groups.

Results

The average costs were SEK 9727 higher (95% confidence interval [CI]: 6677 to 12,777) among participants in the intervention group than in the control ITT population and SEK 8655 (95% CI 4586 to 12,724) higher than in the PP population. The cost increase per 1 kg reduction in gestational weight gain was SEK 12,369 in the ITT population and SEK 7209 for the PP population.

Conclusion

Participation in the Mighty Mums intervention was associated with higher costs, but also reduced gestational weight gain. The cost per kilogram reduction in gestational weight gain was low, particularly in the PP population. A future decision to implement this behavioral intervention in standard care should take into account society’s willingness to pay per unit reduction in gestational weight gain.

Trial registration

The study is registered at ClinicalTrials.gov, Identifier: NCT03147079.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-021-04098-5.

The Impact of Motivational Interview on Self-Efficacy, Beliefs About Medicines and Medication Adherence Among Adolescents with Asthma: A Randomized Controlled Trial

PURPOSE

This study aimed to determine the impact of MI on self-efficacy, beliefs about medicines and medication adherence among adolescents with asthma.

METHOD

This randomized controlled trial conducted on 52 adolescents with asthma referring to the Pediatric Medical Center in Tehran, Iran. They were randomly assigned to the control and intervention groups. The educational intervention consisted of 3 one-hour sessions per week, which was held individually in the areas of medication adherence, beliefs about medicines and self-efficacy. Four validated questionnaires including demographic characteristics, medication adherence, self-efficacy and beliefs about medicines were completed by self-report both before the MI and 40 days after the end of the intervention.

RESULTS

In the baseline, the two groups were homogeneous in terms of demographic characteristics and outcome measures. At the post-test, the mean scores of the three outcome measures in the intervention group were reported higher compared to the scores in the control group (p < 0.05). The difference between the mean scores in medication adherence, beliefs about medicines and self-efficacy in the post-test between the two groups, even with the elimination of the effect pre-test scores, were significant (p < 0.05).

CONCLUSIONS

The results of this study showed that MI can be effective in improving medication adherence, beliefs about medicines, and self-efficacy.

PRACTICE IMPLICATIONS

The primary goal in the treatment of patients with asthma is asthma control by using corticosteroids. MI is one of the interventions that can simultaneously provide motivation, readiness, beliefs about medicine and self-efficacy for behavioral changes (medication adherence) in patients with asthma.

Approaching Alcohol Use Disorder After Liver Transplantation for Acute Alcoholic Hepatitis

Severe alcoholic hepatitis portends a high risk of mortality without liver transplantation. Transplant outcomes in patients with severe alcoholic hepatitis exhibit a strong inverse association with post-transplant alcohol relapse. The ingredients most central to ameliorating alcohol relapse risk may include destigmatized post-transplant alcohol monitoring, a nonpunitive clinician-patient partnership, and multimodal therapies to maintain abstinence and mitigate high-risk drinking. We here review the core principles of post-liver transplant management specific to alcohol use disorder.

Adherence to an eHealth Self-Management Intervention for Patients with Both COPD and Heart Failure: Results of a Pilot Study

Background

Chronic obstructive pulmonary disease (COPD) and chronic heart failure (CHF) often coexist and share periods of symptom deterioration. Electronic health (eHealth) might play an important role in adherence to interventions for the self-management of COPD and CHF symptoms by facilitating and supporting home-based care.

Methods

In this pilot study, an eHealth self-management intervention was developed based on paper versions of multi-morbid exacerbation action plans and evaluated in patients with both COPD and CHF. Self-reporting of increased symptoms in diaries was linked to an automated decision support system that generated self-management actions, which was communicated via an eHealth application on a tablet. After participating in self-management training sessions, patients used the intervention for a maximum of four months. Adherence to daily symptom diary completion and follow-up of actions were analyzed. An add-on sensorized (Respiro^®) inhaler was used to analyze inhaled medication adherence and inhalation technique.

Results

In total, 1148 (91%) of the daily diaries were completed on the same day by 11 participating patients (mean age 66.8 ± 2.9 years; moderate (55%) to severe (45%) COPD; 46% midrange left ventricular function (LVF) and 27% reduced LVF). Seven patients received a total of 24 advised actions because of increased symptoms of which 11 (46%) were followed-up. Of the 13 (54%) unperformed advised actions, six were “call the case manager”. Adherence to inhaled medication was 98.4%, but 51.9% of inhalations were performed incorrectly, with “inhaling too shortly” (<1.25 s) being the most frequent error (79.6%).

Discussion

Whereas adherence to completing daily diaries was high, advised actions were inadequately followed-up, particularly the action “call the case manager”. Inhaled medication adherence was high, but inhalations were poorly performed. Future research is needed to identify adherence barriers, further tailor the intervention to the individual patient and analyse the intervention effects on health outcomes.

Does education of primary care professionals promote patient self-management and improve outcomes in chronic disease? An updated systematic review

BACKGROUND

Primary care has a vital role in supporting patient autonomy to enable people with long-term conditions to manage their own health and wellness. Evidence is needed on whether education and training of health professionals helps support patient self-management and improves outcomes. The authors' first systematic review included only two articles showing patient outcomes following health professional training for promoting patient self-management.

AIM

To present an updated review undertaken from September 2013 to August 2018.

DESIGN & SETTING

A systematic review was undertaken using the PRISMA guidelines, following the methodology of the first review and is outlined in the PROSPERO registered protocol.

METHOD

Six databases were searched - Cochrane Library, PubMed, ERIC, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and PsycINFO - in addition to web searches, hand searches, and bibliographies for articles published from 1 September 2013 to 31 August 2018.

RESULTS

The updated systematic review showed more evidence is now available with 18 articles in the 5-year period from the 4284 abstracts located. Twelve of these articles showed a difference between intervention and control groups. Of the 18 articles identified, 11 were assessed as having a low risk of bias and five overall were rated of weak quality. The educational interventions with health professionals spanned a range of techniques and modalities, and many incorporated multiple interventions including patient components. There may be a lack of adoption owing to several challenges, including that complex interventions may not be delivered as planned and are difficult to assess, and owing to patient engagement and the need for ongoing follow-up.

CONCLUSION

More high-quality research is needed on what methods work best, for which patients, and for what clinical conditions in the primary care setting. The practical implications of training healthcare professionals require specific attention.

Training diabetes healthcare practitioners in motivational interviewing: a systematic review

Diabetes presents significant self-care challenges that require sustained motivation. Motivational Interviewing (MI) has substantial support in enhancing motivation for behavioural change, but its effective application in routine healthcare requires practitioners to acquire and use related skills. The aim of this systematic review was to investigate the impact of MI training on MI-related skills of practitioners who provide diabetes healthcare. PubMed, EMBASE and PsycINFO were searched using the terms motivational interviewing, motivation enhancement, and diabetes. Two assessors independently screened titles, abstracts and full texts for papers reporting the impact of MI training on diabetes healthcare practitioners' outcomes. Of 625 abstracts screened, 22 papers from 17 unique studies were included. All 17 studies reported some improvement in MI skills, with 14 finding improvements in more than 50% and three less than 35%. However, the risk of bias and outcome measures varied widely between studies. All studies showed diabetes healthcare practitioners acquired and applied MI skills post-training, to varying levels. Findings suggest training should include education, role play, and ongoing supervision to maintain skills.

Type 2 diabetes remission: How does it work?

Type 2 diabetes mellitus (Type 2 DM) is a chronic disease which rise is closely linked to the obesity epidemic and which requires long-term medical attention to limit the development of its wide-ranged complications. Many of these complications arise from the combination of resistance to insulin action, inadequate insulin secretion, and excessive or inappropriate glucagon secretion. The increasing evidence of its remission state has been discussed in the literature. Here we report on a patient with metabolic syndrome who underwent a structured therapeutic lifestyle changes (TLC) therapy which eventually led to remission of Type 2 DM.

Implementation of the Living Well During Pregnancy Telecoaching Program for Women at High Risk of Excessive Gestational Weight Gain: Protocol for an Effectiveness-Implementation Hybrid Study

Background

Despite comprehensive guidelines for healthy gestational weight gain (GWG) and evidence for the efficacy of dietary counseling coupled with weight monitoring on reducing excessive GWG, reporting on the effectiveness of interventions translated into routine antenatal care is limited.

Objective

This study aims to implement and evaluate the Living Well during Pregnancy (LWdP) program in a large Australian antenatal care setting. Specifically, the LWdP program will be incorporated into usual care and delivered to a population of pregnant women at risk of excessive GWG through a dietitian-delivered telephone coaching service.

Methods

Metrics from the RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) framework will guide the evaluation in this hybrid effectiveness-implementation study. All women aged ≥16 years without pre-exiting diabetes with a prepregnancy BMI >25 kg/m² and gaining weight above recommendations at <20 weeks’ gestation who are referred for dietetic care during the 12-month study period will be eligible for participation. The setting is a metropolitan hospital at which approximately 6% of the national births in Australia take place each year. Eligible participants will receive up to 10 telecoaching calls during their pregnancy. Primary outcomes will be service level indicators of reach, adoption, and implementation that will be compared with a retrospective control group, and secondary effectiveness outcomes will be participant-reported anthropometric and behavioral outcomes; all outcomes will be assessed pre- and postprogram completion. Additional secondary outcomes relate to the costs associated with program implementation and pregnancy outcomes gathered through routine clinical service data.

Results

Data collection of all variables was completed in December 2020, with results expected to be published by the end of 2021.

Conclusions

This study will evaluate the implementation of an evidence-based intervention into routine health service delivery and will provide the practice-based evidence needed to inform decisions about its incorporation into routine antenatal care.

International Registered Report Identifier (IRRID)

DERR1-10.2196/27196

Effects of training podiatrists to use imagery-based motivational interviewing when treating people with diabetes-related foot disease: a mixed-methods pilot study

BACKGROUND

Self-care in diabetes related foot disease (DFD) is challenging and contributes to poor outcomes. Motivational Interviewing (MI) can engage people in self-care and modifying it by integrating imagery may further improve its outcomes. No previous studies have trained podiatrists in using MI to address DFD self-care. This was the first study on training podiatrists to conduct imagery-based motivational interviewing (MI) when treating people with DFD, and to examine impacts on MI related skills, job satisfaction and subjective experiences in a mixed-methods pilot study.

METHODS

Eleven recruited podiatrists (median age: 35 years, 9 female and 2 male) received two 4-h training sessions, and three received subsequent mentoring. MI and imagery skills were rated using validated tools during two clinical sessions per participant at baseline, and 2- and 12-weeks post-training. Job satisfaction was assessed at baseline and 12 weeks. Semi-structured interviews at 12 weeks were analysed using the framework approach.

RESULTS

Significant improvements over time (p = .006-.044) with substantial effect sizes (η2 = .50-.67) were found in three of four global MI related communication skills and two of four MI behaviours. However, effects on these indices were not sustained to 12 weeks, and imagery was rarely used. Job satisfaction was high at baseline and unchanged at follow-up (p = 0.34, η2 = .100). In qualitative interviews, MI training and skills were valued, but significant challenges in using MI when treating people with DFD were reported.

CONCLUSION

Training podiatrists in MI may have potential but more training, observation and mentoring appear needed to obtain sustained communication changes in practice.

Fidelity of motivational interviewing with families in high-caries-risk children

OBJECTIVES

Motivational interviewing (MI) is a promising behavioural intervention for prevention of dental caries in children. Few studies have reported on fidelity of MI delivered in dental settings. The aim of this paper is to explore the fidelity of implementing MI in a clinical dental practice setting, as part of an intervention study investigating caries-preventive effects of MI delivered to high-caries-risk children and their primary caregivers.

METHODS

Three oral health therapy clinicians trained in MI (counsellors) provided MI to high-caries-risk children and their primary caregivers. All MI sessions (n = 34) were audio-recorded and analysed using the MI Treatment Integrity code 4.2.1. Qualitative analysis of counsellor self-reflections identified barriers to MI delivery.

RESULTS

All counsellors were found to adhere to the MI process and demonstrated fair to good MI proficiency for global scores, with a mean (95% CI) of 3.3 (3.1-3.4) recorded for technical scores and 3.6 (3.5-3.8) for relational scores. The mean (95% CI) per cent complex reflections was 23% (19.4-27.1) and the mean reflection:question ratio was 0.7 (0.6-0.9). No significant differences were observed between counsellors for MI proficiency. Cultural barriers, environmental distractions, participant dental anxiety and counsellor tendency towards prescriptive advice-giving were identified by counsellors as hindrances to effective MI.

CONCLUSIONS

Motivational interviewing is a skill which requires multifaceted training, practice and mentoring to meet accepted proficiency thresholds. Monitoring of MI using a validated tool is essential to ensure delivery as intended and accurately attribute outcomes to the intervention. Dental organizations intending to implement MI for caries prevention should be aware of the demands on time and resources required to deliver proficient MI and monitor fidelity.

Experiences of self-management support in patients with diabetes and multimorbidity: a qualitative study in Norwegian general practice

Aim:

The purpose of this study was to explore how patients with diabetes and multimorbidity experience self-management support by general practitioners (GPs), nurses and medical secretaries in Norwegian general practice.

Background:

Self-management support is recognised as an important strategy to improve the autonomy and well-being of patients with long-term conditions. Collaborating healthcare professionals (cHCPs), such as nurses and medical secretaries, may have an important role in the provision of self-management support. No previous study has explored how patients with diabetes and multimorbidity experience self-management support provided by cHCPs in general practice in Norway.

Methods:

Semi-structured interviews with 11 patients with type 1 diabetes mellitus (T1DM) or type 2 diabetes mellitus (T2DM) with one or more additional long-term condition were performed during February–May 2017.

Findings:

Patients experienced cHCPs as particularly attentive towards the psychological and emotional aspects of living with diabetes. Compared to GPs, whose appointments were experienced as stressful, patients found cHCPs more approachable and more likely to address patients’ questions and worries. In this sense, cHCPs complemented GP-led diabetes care. However, neither cHCPs nor GPs were perceived to involve patients’ in clinical decisions or goal setting during consultations.

Translating research into practice: outcomes from the Healthy Living after Cancer partnership project

BACKGROUND

Healthy Living after Cancer (HLaC) was a national dissemination and implementation study of an evidence-based lifestyle intervention for cancer survivors. The program was imbedded into existing telephone cancer information and support services delivered by Australian state-based Cancer Councils (CC). We report here the reach, effectiveness, adoption, implementation, and maintenance of the program.

METHODS

In this phase IV study (single-group, pre-post design) participants - survivors of any type of cancer, following treatment with curative intent - received up to 12 nurse/allied health professional-led telephone health coaching calls over 6 months. Intervention delivery was grounded in motivational interviewing, with emphasis on evidence-based behaviour change strategies. Using the RE-AIM evaluation framework, primary outcomes were reach, indicators of program adoption, implementation, costs and maintenance. Secondary (effectiveness) outcomes were participant-reported anthropometric, behavioural and psychosocial variables including: weight; physical activity; dietary intake; quality-of-life; treatment side-effects; distress; and fear of cancer recurrence and participant satisfaction. Changes were evaluated using linear mixed models, including terms for timepoint (0/6 months), strata (Cancer Council), and timepoint x strata.

RESULTS

Four of 5 CCs approached participated in the study. In total, 1183 cancer survivors were referred (mostly via calls to the Cancer Council telephone information service). Of these, 90.4% were eligible and 88.7% (n = 791) of those eligible consented to participate. Retention rate was 63.4%. Participants were mostly female (88%), aged 57 years and were overweight (BMI = 28.8 ± 6.5 kg/m2). Improvements in all participant-reported outcomes (standardised effect sizes of 0.1 to 0.6) were observed (p < 0.001). The program delivery costs were on average AU$427 (US$296) per referred cancer survivor.

CONCLUSIONS

This telephone-delivered lifestyle intervention, which was feasibly implemented by Cancer Councils, led to meaningful and statistically significant improvements in cancer survivors' health and quality-of-life at a relatively low cost.

TRIAL REGISTRATION

Australian and New Zealand Clinical Trials Registry (ANZCTR) - ACTRN12615000882527 (registered on 24/08/2015).

Getting from Here to There: Motivational Interviewing and Other Techniques to Promote Healthy Aging

Successful health behavior change relies on the autonomy of the individual who is driven toward personally meaningful, positive goals. The medical practitioner and health care team can use several techniques to facilitate such change effectively, including motivational interviewing, cognitive behavioral restructuring, appreciative inquiry, and positive psychology techniques. Older adults can be supported to make change, and may have greater capacity to maintain those changes due to increased levels of conscientiousness. Positive psychology approaches may be effective in older adults, due to evidence that, as individuals age, they tend to prioritize activities that bring them satisfaction and emotional well-being.

The effectiveness of body age-based intervention in workplace health promotion: Results of a cohort study on 9851 Danish employees

Introduction

The aging population emphasize the need for effective health promotion interventions. The workplace is a prioritized setting for health promotion to reach widely within a population. Body age can be used as a health-risk estimate and as a motivational tool to change health behavior. In this study we investigate body age-based intervention including motivational interview and its effect on health, when applied to real life workplace health promotion.

Material and methods

Body age-based intervention was performed in 90 companies on 9851 Danish employees from 2011–2017. Metabolic risk factors were assessed, body age score was determined and an individualized motivational interview was conducted at baseline and follow-up. Change in body age score, single risk factors, smoking habits and metabolic syndrome were analyzed. The body age score is a composite score comprising 11 weighted variables. A body age score ≤ 0 is preferred, as this elicit a younger/healthier or equal body age compared to chronological age.

Results

At 1.3 year follow-up the unhealthiest employees were less likely to participate. Within follow-up participants (39%, n = 3843) body age had improved by a decline in mean body age score of -0.6 and -0.7 years for men and women, respectively (p<0.001). Number of employees with metabolic syndrome had decreased from 646 at baseline to 557 at follow-up (p = 0.005) and 42% of smokers had quit smoking (p<0.001).

Conclusion

On the basis of this study, we suggest that body age assessment motivates to participate in workplace health promotion, affect high risk behavior such as smoking thus have potential in public health promotion.

Study protocol for a sequential multiple assignment randomized trial (SMART) to improve physical activity in employed women

INTRODUCTION

Physical activity monitors, motivational text messages, personal calls, and group meetings, have proven to be efficacious physical activity interventions. However, individual participant response to these interventions varies drastically. A SMART design (sequential multiple assignment randomized trial) provides an effective way to test interventions that start with an initial treatment and then transition to an augmented treatment for non-responders. We describe a SMART to determine the most effective adaptive intervention to increase physical activity (steps, moderate-to-vigorous physical activity) and improve cardiovascular health among employed women who are not regularly physically active. The SMART uses combinations of four treatments: 1) enhanced physical activity monitor (Fitbit wearable activity monitor and mobile app with goal setting and physical activity prescription), 2) text messages, 3) personal calls, and 4) group meetings.

METHODS

Participants (N = 312) include women ages 18-70 employed at a large academic medical center. Women will be randomized to an initial intervention, either an enhanced physical activity monitor or enhanced physical activity monitor + text messaging. Non-responders to the initial intervention at 2 months will be randomized to either personal calls or groups meetings for the next 6 months. At 8 months, all participants will return to only an enhanced physical activity monitor until their final 12-month assessment.

DISCUSSION

Results of this study will add to the literature on improving physical activity in employed women. This study will identify effective interventions for women who respond to less intensive treatments, while maximizing benefits for those who need a more intensive approach.

Effectiveness of motivational interviewing on improving Care for Patients with type 2 diabetes in China: A randomized controlled trial

Background

To assess the effects of a motivational interviewing (MI)-based patient empowerment program (PEP) on type 2 diabetes mellitus (DM) patient self-management compared to traditional diabetes health education.

Methods

Two hundred and twenty-five patients, recruited from community health centers (CHCs) and the family medicine clinic in the University of Hong Kong-Shenzhen Hospital in Shenzhen, were randomly assigned to the intervention or control groups. Patients in the intervention group (n = 117) received a four-session PEP in small groups over 1 month by trained nurses and doctors. The control group (n = 108) received the traditional lecture-style health education on DM. All the patients were followed up for 3 months. Outcomes included problem areas in diabetes (PAID) that measures diabetes-related emotional distress, patient enablement index (PEI), mental health, patient satisfaction respectively as well as lifestyle behaviors were assessed at baseline, post-activity and 3 months.

Results

At post-intervention and the 3-month follow-up, the PAID score improved significantly in the intervention group (12.7 ± 13.6, 5.8 ± 7.6) compared to the control group (22.7 ± 22.8, 11.7 ± 14.6). No difference was found between groups for changes to exercise, diet, and medication adherence. The PEI score improved significantly at the 3-month follow-up in the MI group (7.27 ± 2.45 vs 5.81 ± 2.97).

Conclusion

The PEP has a significant effect on improving diabetes-related distress, but MI was not significantly different from the traditional health education programs when it comes to the readiness to change.

Trial registration

NCT04120844, ClinicalTrials.Gov. Date of registration: October 9th 2019 (Retrospectively registered).

Dental RECUR Randomized Trial to Prevent Caries Recurrence in Children

The purpose of this study was to determine the efficacy of a dental nurse-delivered intervention-the Dental RECUR Brief Negotiated Interview for Oral Health (DR-BNI)-in reducing the recurrence of dental caries in children who have a primary tooth extracted. It was based on a 2-arm multicenter randomized controlled trial with blinded outcome assessment. Participants were 5- to 7-y-old children (n = 241) scheduled to have primary teeth extracted in 12 UK centers. Test intervention parents (n = 119) received DR-BNI led by trained dental nurses. DR-BNI is a 30-min structured conversation informed by motivational interviewing with a forward focus to prevent future caries. Preventive goals are agreed, and a review appointment is made with child's general dental practitioner, who is advised to treat the child as being at high caries risk. The control intervention (n = 122) was a parent-nurse conversation about child's future tooth eruption, with advice given to visit a general dental practitioner as usual. At baseline, the DR-BNI group's mean dmft was 6.8, and the control group's was 6.3. A median of 5 teeth were extracted, mainly under general anesthesia. Final dental assessments were conducted by a single examiner visiting 189 schools 2 y after intervention; 193 (80%) of 241 children were examined. In the control group, 62% developed new caries in teeth that were caries-free or unerupted at baseline, as compared with 44% in the test group, a significant reduction (P = 0.021). The odds of new caries experience occurring were reduced by 51% in the DR-BNI group as compared with control. There was a 29% decrease in the relative risk of new caries experience in the DR-BNI group as compared with control. This single low-cost, low-intensity intervention was successful in significantly reducing the risk of recurrence of dental caries in children. This trial has implications for changing pediatric dental practice internationally. Training in and implementation of a motivational interviewing-informed brief intervention provides opportunities for dental nurses to facilitate behavior change improving the oral health of children at high caries risk (ISRCTN 24958829).

Self-management support in cardiovascular consultations by advanced practice nurses trained in motivational interviewing: An observational study

OBJECTIVE

This observational study explores advanced practice nurses' (APN) performance in secondary prevention and self-management support in patients with cardiovascular disease.

METHODS

Real-life consultations in three outpatient clinics were recorded on audio and analysed. First, discussed (sub)categories were determined using five categories of self-management: symptom management, treatment, biomedical cardiovascular risk factors, psychosocial consequences, and lifestyle changes. Second, the extent in which motivational interviewing aspects were applied was determined using the Behaviour Change Counselling Index (BECCI).

RESULTS

In total, 49 consultations performed by five female APNs were analysed. Physical topics were discussed in 98% and psychological subthemes in 41% of the consultations. Although not all components of motivational interviewing were applied, talking about current behaviour and behaviours that should change were discussed, and information was provided. Especially setting targets and exchanging ideas on how to reach behavioural goals were applied to a small extent.

CONCLUSION

Well-trained APNs in the current study do not carry out motivational interviewing in a structural and complete manner according to BECCI and do not discuss all self-management categories.

PRACTICE IMPLICATIONS

Psychological topics should be more integrated in providing self-management support by APNs and the application of motivational interviewing should be enhanced by regularly and repeated training.

What Is the Effect of Health Coaching Delivered by Physical Therapists? A Systematic Review of Randomized Controlled Trials

BACKGROUND

Health coaching has emerged as an intervention for improving health behaviors. Given the recent increased integration of health coaching into physical therapist practice, there has been a subsequent rise in research examining the effects of health coaching provided by physical therapists. However, there is a lack of literature summarizing the effectiveness of health coaching delivered by physical therapists in changing patient health behaviors.

PURPOSE

The purpose of this study was to systematically review the effects of health coaching delivered by physical therapists on promoting participant health behaviors.

DATA SOURCES

Cochrane, CINAHL, MEDLINE, PEDro, PsycINFO, and Web of Science databases were searched from inception to May 26, 2018, to identify randomized controlled trials examining the effects of health coaching delivered by physical therapists.

STUDY SELECTION

Two reviewers independently screened titles, abstracts, and full texts according to inclusion and exclusion criteria to determine study eligibility.

DATA EXTRACTION

Methodological quality was assessed using Physiotherapy Evidence Database (PEDro) scores. Risk of bias was assessed using the Cochrane Collaboration risk-of-bias assessment tool. Data were extracted using a standardized data extraction form describing study methods, design, and outcomes.

DATA SYNTHESIS

Eleven trials met the inclusion criteria for this study. Health coaching produced positive effects on physical activity (6 studies) as well as physiological and psychological secondary outcomes.

LIMITATIONS

The inclusion of only 11 randomized controlled trials in this review could limit the generalizability of the findings. The heterogeneity of the findings precluded the performance of a meta-analysis.

CONCLUSIONS

Research on the effectiveness of health coaching delivered by physical therapists on health behavior outcomes is mixed. Data indicate statistically significant changes in some health behavior, physiological, and psychological outcomes.

Challenges and strategies for hypertension management: qualitative analysis of small primary care practices with varying blood pressure control

BACKGROUND

Electronic health record (EHR) data on blood pressure (BP) control among patients with hypertension show that practices' rates vary greatly. This suggests providers use different approaches in managing hypertension, and so we aimed to explore challenges small primary care practice providers face and strategies they use to manage patients' BP. We explored differences between providers with high and low BP control rates to help inform future quality improvement work.

METHODS

In 2015, we recruited practices in New York City with five or fewer providers. We employed a stratified purposeful sampling method, using EHR data to categorize small practices into groups based on the proportion of patients with hypertension whose last BP was <140/90: high control (>= 80%), average control (60-80%) and low control (<60%). We conducted semi-structured qualitative interviews with clinicians from 23 practices-7 high control, 10 average control and 6 low control-regarding hypertension management. We used a combined inductive/deductive approach to identify key themes, and these themes guided a comparison of high and low BP control providers.

RESULTS

Small practice providers reported treatment non-adherence as one of the primary challenges in managing patients' hypertension, and described using patient education, relationship building and self-management tools to address this issue. Providers differed qualitatively in the way they described using these strategies; high BP control providers described more actively engaging and listening to patients than low control providers did.

CONCLUSIONS

How providers communicate with patients may impact outcomes-future quality improvement initiatives should consider trainings to improve patient-provider communication.

Redesigning care for older people to preserve physical and mental capacity: WHO guidelines on community-level interventions in integrated care

Islene Araujo de Carvalho and coauthors discuss the WHO guidelines on integrated care for older people.