A Qualitative Study of Multiple Health Behaviors in Adults with Multiple Sclerosis

Multiple Sclerosis Fatigue Self-Management: Strategies and Influencing Factors 5 Years After a Multimodal Intervention

BACKGROUND

Fatigue: Take Control (FTC) is a multimodal self-management program. Results of a previous clinical trial showed its effectiveness at improving fatigue related to multiple sclerosis (MS). The objectives of this study were to use the very long-term data from the FTC study to understand fatigue management strategies used 5 years after enrollment, identify facilitators and barriers to utilizing strategies, and explore the potential relationships between the strategy used and fatigue outcomes.

METHODS

This study adopted a cross-sectional survey design. A subset of the original FTC clinical trial participants was invited to complete the Modified Fatigue Impact Scale for fatigue severity measurement and a 17-item questionnaire about their fatigue management strategies 5 years after enrollment. Descriptive statistics and content analysis were used to analyze quantitative and qualitative data using the COM-B (capability, opportunity, motivation-behavior) model for behavior change as a framework.

RESULTS

Planning daily activities and prioritizing tasks were the fatigue management strategies most often reported. Facilitators to utilizing management strategies included access to enabling devices, paid professional help, companions, and maintaining a positive attitude. Barriers to implementing strategies included high cost, the presence of other health problems, and temperature sensitivity. Internal focused strategies showed a trend toward reducing fatigue impact when controlled for typology group assignment.

CONCLUSIONS

Future work may focus on promoting low-cost strategies to help people with MS manage fatigue. Internal factors (eg, motivation) play an important role in influencing the application of MS fatigue self-management strategies. Future clinical trials with larger sample sizes that assess the applicability of the COM-B model are warranted.

The effect of self-regulatory program based on Leventhal's model on the illness perception and resilience of people with multiple sclerosis

BACKGROUNDS

The study at hand seeks to examine the influence of a self-regulation program rooted in Leventhal's model on the illness perception and resilience of patients with multiple sclerosis (MS). By exploring the impact of Leventhal's model-based interventions, healthcare professionals can enhance their ability to effectively address the challenges associated with this disease. In addition, this research endeavor can serve as a valuable resource for the development of nursing knowledge in the realm of MS patient care.

MATERIALS AND METHODS

This study was a semiexperimental two-group study. The statistical population of the study consisted of all patients with RRMS-type MS in Shahrekord city. Ninety patients were initially selected through convenience sampling and then randomly allocated into intervention and control groups (each with 45 participants) using the Random Allocation software. Before the intervention program was provided, the patients' perception of the disease and their resilience were assessed using the Illness Perception Questionnaire-Revised (IPQ-R) and Connor-Davidson Resilience Scale (CD-RISC), respectively.

RESULTS

The intervention group had a mean age of 34.78 ± 4.27 years, whereas the control group had a mean age of 34.51 ± 4.43 years. After the Leventhal self-regulatory model, a statistically significant difference was observed in the mean scores of illness perception and the mean score of resilience between the intervention and control groups, both immediately and two months later, implying that the intervention group had a higher score in illness perception and the mean score of resilience (P value < 0.001).

CONCLUSION

Our study indicated that the Leventhal self-regulatory model had a significant positive effect on improving both illness perception and resilience in individuals with MS. Therefore, enhancing these factors among MS patients can have a tremendously positive impact on their psychological health, quality of life, and treatment adherence.

Engagement with three or more healthy lifestyle behaviours is associated with improved quality of life over 7.5 years in people with multiple sclerosis

BACKGROUND AND PURPOSE

People with multiple sclerosis (pwMS) report reduced quality of life (QoL). Engagement with healthy lifestyle behaviours, including consuming a healthy diet, regular physical activity, and adequate vitamin D exposure, is associated with higher QoL. We aim to assess whether individual lifestyle behaviours are more beneficial to QoL than others, and whether there are additive benefits to QoL by engaging in multiple healthy behaviours concurrently.

METHODS

Data from pwMS who completed an online survey at baseline, and at 2.5-, 5- and 7.5-year follow-up, were analysed. Behaviours assessed were consumption of a no-meat/dairy-plus-omega-3 supplementation diet, meditation practice, physical activity, non-smoking, and vitamin D exposure. Mental QoL (mQoL) and physical QoL (pQoL) were assessed by the Multiple Sclerosis Quality of Life (MSQOL-54) questionaire. Linear regression analyses were performed to assess associations of individual behaviours at baseline and follow-up time points with QoL, as well as between number of behaviours and QoL.

RESULTS

At baseline, healthy diet and regular physical activity were associated with higher mQoL (5.3/100 and 4.0/100) and higher pQoL (7.8/100 and 6.7/100). Prospectively, diet was positively associated with mQoL, and physical activity with both mQoL and pQoL. At baseline, engagement with ≥3 behaviours was positively associated with mQoL and pQoL, with additive positive associations for each additional behaviour. Prospectively, engagement with ≥3 behaviours was positively associated with mQoL and pQoL, with strongest associations observed with engagement with five behaviours.

CONCLUSION

Consumption of a healthy diet, and regular physical activity, are both potential interventions to improve QoL. Engagement with multiple lifestyle behaviours may provide additional benefits and should be encouraged and supported for multiple sclerosis management.

The barriers and facilitators to health-promoting lifestyle behaviors among people with multiple sclerosis during the coronavirus disease 2019 pandemic: a content analysis study

BACKGROUND AND AIM

Health-promoting lifestyle behaviors (HPLBs) have a significant impact on disease management among people with multiple sclerosis (MS). However, the coronavirus disease 2019 (COVID-19) pandemic has significantly affected lifestyle of all individuals, particularly patients with chronic diseases. The present study aimed to explore the barriers and facilitators to HPLBs among people with MS during the COVID-19 pandemic.

METHODS

This qualitative study was conducted in Iran. Participants were sixteen people with MS purposively selected from the central MS clinic of a referral specialty neuroscience hospital in Tehran, Iran. Data were collected via in-depth semi-structured face-to-face interviews and concurrently analyzed through conventional content analysis.

FINDINGS

The mean of participants' age was 37.93 years and most participants were female (81.25%). The major barriers to HPLBs were lack of knowledge, limited access to resources, and poor health status, while the major facilitators were attention to inner abilities and social support.

CONCLUSION

Many different factors such as lack of knowledge, limited access to resources, poor health status, awareness, and social support can influence engagement in HPLBs among people with MS. Healthcare authorities and policymakers need to use quality educational and supportive interventions to improve knowledge, health literacy, perceived support, self-efficacy, and self-care ability among people with MS during the COVID-19 pandemic.

Facilitators of and Barriers to Adherence to Dietary Interventions Perceived by Women With Multiple Sclerosis and Their Support Persons

Background:

People with multiple sclerosis (MS) frequently report implementing dietary strategies as part of their personal wellness programs; however, little is known about the perceived themes of healthy behavior change in people with MS.

Methods:

Semistructured one-on-one interviews were conducted with 20 women with MS enrolled in 2 different restrictive dietary intervention studies and their 18 self-identified support persons consisting of partners and adult children. Interviews were transcribed, coded, categorized, and then grouped into summative themes. The frequency of issues being mentioned as facilitators of or barriers to diet adherence was evaluated to identify possible differences in perceived experiences between women with MS and their support persons during the studies.

Results:

Five qualitative themes were identified: (1) personal motivation, (2) diet components, (3) time, (4) support, and (5) resource access. Major facilitators of dietary adherence were positive support from support persons and study staff, access to resources, symptom improvement, and personal motivation. Major barriers included the novelty of the study diet, lack of cooking skills, no change in or worsening of symptoms, lack of diet knowledge, and food preferences and temptations. Symptom severity was more frequently reported as a barrier to study diet adherence among participants with secondary progressive MS.

Conclusions:

Methods to enhance personal motivation and ensure positive support from support persons and study staff may improve study diet adherence. Due to the unique challenges faced by people with MS, future studies should tailor interventions to their unique MS cohort to increase diet adherence.

Experiences of and attitudes to lifestyle modification for the management of multiple sclerosis: A qualitative analysis of free-text survey data

BACKGROUND

Growing evidence suggests a role of lifestyle modification in improved health outcomes for people with multiple sclerosis (pwMS); however, perspectives of pwMS who engage in lifestyle modification are lacking.

OBJECTIVE

We explored perspectives of pwMS regarding the modification of lifestyle-related risk factors in multiple sclerosis (MS) for disease management to understand attitudes to and experiences of lifestyle modification as part of self-management from a patient perspective.

DESIGN

Participants were ≥18 years and English speaking who responded to a free-text open-ended question in the Health Outcomes and Lifestyle In a Sample of pwMS (HOLISM), an international online survey. Responses were analysed utilizing inductive thematic analysis.

RESULTS

Under the exploration of lifestyle modification, themes describing the experiences and attitudes of participants included practical challenges and physical and psychological barriers, enablers of change and experienced outcomes. Although participants reported some practical and psychological challenges to adoption and maintenance of lifestyle behaviours, many expressed an ability to gain control of MS through engagement with lifestyle behaviours and the development of hope and optimism that accompanied this sense of control, at times leading to a sense of personal transformation.

CONCLUSION

Findings highlight the challenges experienced by pwMS in adopting lifestyle modifications for disease management as well as the positive benefits from following healthy lifestyle behaviours. Our findings may form the basis of more focussed qualitative explorations of the experiences and outcomes of lifestyle modification in MS in the future.

PATIENT CONTRIBUTION

Consenting pwMS completed a survey capturing data on demographics, clinical course, lifestyle behaviours and health outcomes.

CoachMS, an innovative closed-loop, interdisciplinary platform to monitor and proactively treat MS symptoms: A pilot study

Background

There are numerous challenges to treating co-occurring symptoms in multiple sclerosis (MS).

Objective

To pilot the feasibility of a novel symptom management platform, CoachMS, to monitor MS symptoms (bladder function, ambulation, and mood: BAM) and respond to changes in real-time.

Methods

In this 12-week randomized controlled pilot trial, participants’ symptoms were monitored using weekly questionnaires and remote ambulatory monitoring (Fitbit Flex2®). Behavioral change principles used included shared goal setting at 2 weeks. Between weeks 2-12, the CoachMS group received targeted contact and interventions if symptoms worsened; the control group were treated through usual clinic practice. Our outcomes were feasibility (retention, adherence and acceptability; primary) and proportion of recommended treatments pursued (secondary); efficacy was explored.

Results

Of 21 participants enrolled, 13 (62%) completed the study; protocol adherence was excellent. CoachMS participants demonstrated greater follow-through with clinical recommendations than controls (OR 9.3, 95% CI (0.9, 97.6)). As a cohort, each BAM symptom tended to improve. Suicidality was detected in one control participant, resulting in urgent evaluation and hospitalization.

Conclusions

The innovative CoachMS platform was feasible and acceptable in this cohort with baseline BAM symptoms. It could represent an accessible, cost-effective tool to monitor MS symptoms in real-time; a larger trial is planned.

Beyond supervised therapy: Promoting behavioral changes in people with MS

A critical aspect of many rehabilitation interventions for people with multiple sclerosis (MS) is incorporating strategies that support behavior change. The main purpose of this topical review was to summarize recent randomized clinical trials (RCTs) of rehabilitation interventions in which participants learn and apply skills or engage in healthy behaviors. The Capability, Opportunity, Motivation, and Behavior (COM-B) framework was used to broadly classify behavior-change strategies. The included RCTs varied widely in terms of dosing, delivery format, and types of interventionist. Commonly used behavior-change strategies include education, persuasion, and training. We recommend that researchers and clinicians use frameworks like Behavior Change Wheel and Behavior Change Technique Taxonomy to describe and classify intervention strategies used to promote behavior change. We also recommend more sophisticated RCTs be conducted (e.g. sequential multiple assignment randomized trial and three-arm RCTs) to better understand ways of promoting behavior change in rehabilitation interventions.

Randomized controlled trial of SystemCHANGE™ weight management intervention in neurological conditions

OBJECTIVE

This randomized controlled pilot study examined the feasibility and efficacy of a SystemCHANGE™ (SC) weight management intervention in adults with either multiple sclerosis or stroke.

METHODS

Participants (n = 61) were randomized into two interventions: SC, which taught skills to modify personal environments, or active-control (AC), which taught health behavior guidelines. Sessions were held weekly for 12 weeks. Feasibility measures included recruitment and attrition rates. The primary outcome of body weight and secondary outcomes of emotional well-being and healthy behaviors were measured before and after the interventions.

RESULTS

Average recruitment rate was 3.6 participants per month. Attrition rate was 14.8%. On average, 9.1 sessions were completed for SC and 10.7 for AC. Differences in weight loss were non-significant between interventions (P = 0.182), but significantly declined across both interventions (P = 0.011). Physical activity (P = 0.002), depression (P < 0.001), anxiety (P = 0.023), and self-efficacy (P = 0.022) all significantly improved for SC compared to AC.

CONCLUSIONS

SC was feasible to implement and efficacious in improving secondary outcomes of emotional well-being and healthy behaviors, but was not efficacious in improving the primary outcome of weight loss. More research is needed to optimize SC.

PRACTICE IMPLICATIONS

SC might be an alternative approach to cognitive-behavioral therapy for promoting emotional well-being and healthy behaviors.

Motivational interviewing to promote health outcomes and behaviour change in multiple sclerosis: a systematic review

OBJECTIVE

To examine the evidence for motivational interviewing when used to assist individuals with multiple sclerosis manage their healthcare.

DATA SOURCES

The Cochrane, Embase, PsycINFO and PubMed databases were searched for studies published between 1983 and December 2019. The reference lists of included studies were additionally examined and Scopus citation searches conducted.

REVIEW METHODS

Study screening and data extraction were independently completed by two reviewers. Randomised controlled trials comparing motivational interviewing interventions for multiple sclerosis to usual care, wait-list or other active intervention controls were examined. Studies were assessed using the Cochrane Risk of Bias tool. Standardised mean differences (Hedges' g), 95% confidence intervals and P values were calculated for all health and behavioural outcomes.

RESULTS

Ten randomised controlled trials, involving a pooled sample of 987 adults with relapsing-remitting or progressive multiple sclerosis and mild to moderate impairment, were identified. Most trials had a low or unclear risk of methodological bias. Motivational interviewing, when used in conjunction with other counselling or rehabilitation techniques, resulted in significant immediate medium-to-very large improvements in multiple physical, psychological, social and behavioural outcomes (range: g = .34-2.68). Maintenance effects were promising (range: g = .41-1.11), although less frequently assessed (N_studies = 5) and of limited duration (1-7 months). Individual and group-based interventions, delivered in-person or by telephone, were all effective.

CONCLUSIONS

Motivational interviewing is a flexible counselling technique that may improve rehabilitation care for multiple sclerosis. However, evidence for persisting benefits to health outcomes and behaviour is currently limited.

The impact of pharmacological treatment on patients with multiple sclerosis

BACKGROUND

Multiple sclerosis has considerable effects on patients' quality of life, limiting their daily activities and influencing their lifestyle. Additionally, adapting to pharmacological treatments represents a challenge for many patients.

OBJECTIVE

The aim of this study was to explore the views and experiences of Spanish patients with multiple sclerosis regarding their pharmacological treatment.

METHODS

A qualitative phenomenological study was conducted with 20 patients with Multiple Sclerosis from a hospital Neurology Unit. Data were collected through in-depth interviews and researchers' field notes. A systematic text condensation analysis was performed. The Consolidated Criteria for Reporting Qualitative Research and the Standards for Reporting Qualitative Research guidelines were followed.

RESULTS

Twenty patients with Multiple Sclerosis completed the study. The mean age was 39.7 years (SD: 9,17). A thematic description of all the data collected was performed based on four descriptive themes which emerged from the analysed material: a) Undergoing the injections, b) Coping strategies, with two subthemes, resignation and integrating the treatment into their life, c) Other methods of pharmacological administration, and d) Dealing with discomfort. For patients with multiple sclerosis, their experience with pharmacological treatment is an apprenticeship which is sometimes met with resignation and discomfort. Patients must learn to take responsibility for their treatment, seeking other routes of administration, as well as integrating these changes into their daily life.

CONCLUSIONS

Qualitative research offers insight into the way patients with Multiple Sclerosis experience their pharmacological treatment, and may be helpful in establishing a fruitful relationship with these patients.

Understanding barriers, enablers, and long-term adherence to a health behavior intervention in people with multiple sclerosis

Background: The optimal management strategy for multiple sclerosis (MS), and many other chronic diseases, likely involves health behavior modification. Multimodal behavioral interventions may be most effective, but little is known about long-term adherence in people with MS.Methods: This qualitative study assessed barriers and enablers to long-term adherence by people with MS who self-selected for a 5-day health behavior intervention 3-5 years prior. Thirteen women and five men participated in semi-structured phone interviews, which were transcribed and thematically analyzed.Results: The experience was described as useful for information gathering, decision making, and practical strategies regarding health behaviors. The majority still followed supplementation and dietary recommendations most of the time, although consuming non-recommended food while eating out was common. Support at home, ability and enjoyment in food preparation, and ability to resist unhealthy foods were both barriers and enablers. Adherence to "time-consuming" exercise and meditation recommendations were less common and episodic. Many reported competing interests on time from work and family; and barriers including injuries and symptoms, weather, financial or geographical barriers, and lack of person-centred support and motivation. Increased fitness and mobility, weight loss, and a sense of accomplishment and control were advantages and motivators. Practical and attitudinal strategies employed included planning, tailoring activities to ability and preference, and self-monitoring.Conclusion: While most people attempted to engage with all components of the intervention initially, only some still engaged with all components, and none to the recommended levels. These data can inform future quantitative studies and health behavior interventions.Implications for rehabilitationA multimodal group lifestyle intervention may be useful to assist people with multiple sclerosis in information gathering, decision making, attitudinal changes, and practical strategies regarding health behaviors; as well as providing a sense of hope for the future and control over wellbeing.While participants are unlikely to engage with all components of a multimodal intervention to the recommended level, they are likely to make improvements to one or more health behaviors.Experiential learning, including going through recipes and ingredient lists, and practicing meditation and physical exercises, is helpful to instigate behavior change.The initiation and maintenance of behavior change was assisted by support from family, friends, and health practitioners; and practical strategies employed by participants, including planning, self-monitoring, and tailoring activities to ability and preference.

Dietary responses to a multiple sclerosis diagnosis: a qualitative study

BACKGROUND/OBJECTIVES

Multiple sclerosis (MS) is an immune-mediated disease with no known cure and insufficient evidence to support a special therapeutic diet to alter symptom management or disease progression. Several studies have reported dietary changes made by people with MS, but there has been limited investigation into experiences surrounding diet in those recently diagnosed. This study explored responses to diet after a recent diagnosis of MS in people living in Western Australia.

SUBJECTS/METHODS

Eleven adults with MS (mean time since diagnosis 8 months) participated in semi-structured interviews focusing on responses to diet since MS diagnosis. Interviews were transcribed, coded and analysed using grounded theory principles.

RESULTS

Three theme responses emerged; (1) the perceived incompatibility of lack of/or generalised dietary advice with disease seriousness at the time of diagnosis; (2) extensive personal research and information seeking with difficulty judging credibility, and (3) self-experimentation with diet to either control MS symptoms or to cure MS.

CONCLUSIONS

Given the seriousness of the disease, there is a perceived gap in dietary information provided at the time of diagnosis. Healthcare professionals should address concerns with alternative therapeutic diets advertised to treat or cure MS, and clearly convey the reasoning for the general healthy dietary recommendations. This would better align advice with the perceptions about the role of diet in MS, assist people with MS in need of information and minimise dietary self-experimentation. Future research should explore the importance of diet for those who have had MS for a longer period of time.

Exploring the Specific Needs of Persons with Multiple Sclerosis for mHealth Solutions for Physical Activity: Mixed-Methods Study

Background

Multiple sclerosis (MS) is one of the world’s most common neurologic disorders, with symptoms such as fatigue, cognitive problems, and issues with mobility. Evidence suggests that physical activity (PA) helps people with MS reduce fatigue and improve quality of life. The use of mobile technologies for health has grown in recent years with little involvement from relevant stakeholders. User-centered design (UCD) is a design philosophy with the goal of creating solutions specific to the needs and tasks of the intended users. UCD involves stakeholders early and often in the design process. In a preliminary study, we assessed the landscape of commercially available MS mobile health (mHealth) apps; to our knowledge, no study has explored what persons with MS and their formal care providers think of mHealth solutions for PA.

Objective

The aim of this study was to (1) explore MS-specific needs for MS mHealth solutions for PA, (2) detect perceived obstacles and facilitators for mHealth solutions from persons with MS and health care professionals, and (3) understand the motivational aspects behind adoption of mHealth solutions for MS.

Methods

A mixed-methods design study was conducted in Kliniken Valens, Switzerland, a clinic specializing in neurological rehabilitation. We explored persons with MS and health care professionals who work with them separately. The study had a qualitative part comprising focus groups and interviews, and a quantitative part with standardized tools such as satisfaction with life scale and electronic health (eHealth) literacy.

Results

A total of 12 persons with relapsing-remitting MS and 12 health care professionals from different backgrounds participated in the study. Participants were well-educated with an even distribution between genders. Themes identified during analysis were MS-related barriers and facilitators, mHealth design considerations, and general motivational aspects. The insights generated were used to create MS personas for design purposes. Desired mHealth features were as follows: (1) activity tracking, (2) incentives for completing tasks and objectives, (3) customizable goal setting, (4) optional sociability, and (5) game-like attitude among others. Potential barriers to mHealth apps adoption were as follows: (1) rough on-boarding experiences, (2) lack of clear use benefits, and (3) disruption of the health care provider-patient relationship. Potential facilitators were identified: (1) endorsements from experts, (2) playfulness, and (3) tailored to specific persons with MS needs. A total of 4 MS personas were developed to provide designers and computer scientists means to help in the creation of future mHealth solutions for MS.

Conclusions

mHealth solutions for increasing PA in persons with MS hold promise. Allowing for realistic goal setting and positive feedback, while minimizing usability burdens, seems to be critical for the adoption of such apps. Fatigue management is especially important in this population; more attention should be brought to this area.