Medication self-management toolkits for adults with multiple sclerosis: A scoping review

Background

Multiple sclerosis (MS) is an autoimmune disease that is often treated with multiple medications. Managing multiple medications, also known as polypharmacy, can be challenging for persons with MS. Toolkits are instructional resources designed to promote behaviour change. Toolkits may support medication self-management for adults with MS, as they have been useful in other populations with chronic conditions.

Objective

The main purpose of this review was to identify and summarize medication self-management toolkits for MS, as related to the design, delivery, components, and measures used to evaluate implementation and/or outcomes.

Methods

A scoping review was conducted following guidelines by JBI. Articles were included if they focused on adults (18 years or older) with MS.

Results

Six articles reporting on four unique toolkits were included. Most toolkits were technology-based, including mobile or online applications, with only one toolkit being paper-based. The toolkits varied in type, frequency, and duration of medication management support. Varying outcomes were also identified, but there were improvements reported in symptom management, medication adherence, decision-making, and quality of life. The six studies were quantitative in design, with no studies exploring the user experience from a qualitative or mixed-methods design.

Conclusions

There is limited research on medication self-management toolkits among adults with MS. Future development, implementation, and evaluation mixed-methods research are needed to explore user experiences and overall design of toolkits.

Test-retest reliability of three life balance measures in people with neuromuscular disease: the activity card sort-NL, the activity calculator, and the occupational balance questionnaire

Purpose: Life balance is a new and important concept in occupational therapy. New measurements are needed to assess and evaluate life balance and interventions aimed to achieve this concept. This article describes the test-retest reliability of three life balance measures: the Activity Calculator (AC), Activity Card Sort (ACS-NL(18-64)) and Occupational Balance Questionnaire (OBQ11-NL).Method: Data collection took place among 50 participants with neuromuscular diseases: facioscapulohumeral dystrophy (FSHD, n = 25) or mitochondrial myopathy (MM, n = 25). The AC, the ACS-NL(18-64) and the OBQ11-NL were assessed twice with an interval of one week. Intraclass correlation coefficients (ICC-agreement) were applied to examine test-retest reliability.Results: The ICC of the AC-average total day score was .95 (95% CI .91-.97), whereas the ICC of the weights allocated to each activity was 0.80 (95% CI .77-0.82). The ICC of the ACS-NL(18-64) percentage retained activities was 0.92 (95% CI 0.86 - 0.96) and the ICC of the importance score per activity was- .76 (95% CI . 0.68-0.89). The ICC of the OBQ11-NL total score was .76 (95% CI 0.62-0.86).Conclusion: All three tools showed good to excellent test-retest reliability in a sample of patients with FSHD or MM, which is promising for its use in clinical practice and research.

The impact of the COVID-19 pandemic on primary care physicians and nurses in Nova Scotia: a qualitative exploratory study

BACKGROUND

The COVID-19 pandemic has brought immense disruption worldwide, dramatically altering the ways we live, work and learn on a day-to-day basis; however, few studies have investigated this from the perspective of primary care providers. In this study, we sought to explore the experiences of primary care providers in the province of Nova Scotia, with the intention of understanding the impact of the COVID-19 pandemic on primary care providers' ability to provide care, their information pathways, and the personal and professional impact of the pandemic.

METHODS

We conducted an exploratory qualitative research study involving semistructured interviews conducted via Zoom videoconferencing or telephone with primary care providers (physicians, nurse practitioners and family practice nurses) who self-identified as working in primary health care in Nova Scotia from June 2020 to April 2021. We performed a thematic analysis involving coding and classifying data according to themes. Emergent themes were then interpreted by seeking commonalties, divergence, relationships and overarching patterns in the data.

RESULTS

Twenty-four primary care providers were interviewed. Subsequent analysis identified 4 interrelated themes within the data: disruption to work-life balance, disruptions to "non-COVID-19" patient care, impact of provincial and centralized policies, and filtering and processing an influx of information.

INTERPRETATION

Our findings showed that managing a crisis of this magnitude requires coordination and new ways of working, balancing professional and personal life, and adapting to already implemented changes (i.e., virtual care). A specific primary care pandemic response plan is essential to mitigate the impact of future health care crises.

A scoping review of medication self-management intervention tools to support persons with traumatic spinal cord injury

BACKGROUND

Persons with traumatic spinal cord injury (SCI) use multiple medications (polypharmacy) to manage the high number of secondary complications and concurrent conditions. Despite the prevalence of polypharmacy and challenges associated with managing medications, there are few tools to support medication self-management for persons with SCI.

OBJECTIVE

The purpose of this scoping review was to identify and summarize what is reported in the literature on medication self-management interventions for adults with traumatic SCI.

METHODS

Electronic databases and grey literature were searched for articles that included an adult population with a traumatic SCI and an intervention targeting medication management. The intervention was required to incorporate a component of self-management. Articles were double screened and data were extracted and synthesized using descriptive approaches.

RESULTS

Three studies were included in this review, all of which were quantitative. A mobile app and two education-based interventions to address self-management of SCI, medication management, and pain management, respectively, were included. Only one of the interventions was co-developed with patients, caregivers, and clinicians. There was minimal overlap in the outcomes measured across the studies, but learning outcomes (e.g., perceived knowledge and confidence), behavioural outcomes (e.g., management strategies, data entry), and clinical outcomes (e.g., number of medications, pain scores, functional outcomes) were evaluated. Results of the interventions varied, but some positive outcomes were noted.

CONCLUSIONS

There is an opportunity to better support medication self-management for persons with SCI by co-designing an intervention with end-users that comprehensively addresses self-management. This will aid in understanding why interventions work, for whom, in what setting, and under what circumstances.

Medication self-management interventions for persons with stroke: A scoping review

The use of multiple medications is common following a stroke for secondary prevention and management of co-occurring chronic conditions. Given the use of multiple medications post-stroke, optimizing medication self-management for this population is important. The objective of this scoping review was to identify and summarize what has been reported in the literature on interventions related to medication self-management for adults (aged 18+) with stroke. Electronic databases (Ovid Medline, Ovid Embase, EBSCO CINAHL, Ovid PsycINFO, Web of Science) and grey literature were searched to identify relevant articles. For inclusion, articles were required to include an adult population with stroke undergoing an intervention aimed at modifying or improving medication management that incorporated a component of self-management. Two independent reviewers screened the articles for inclusion. Data were extracted and summarized using descriptive content analysis. Of the 56 articles that met the inclusion criteria, the focus of most interventions was on improvement of secondary stroke prevention through risk factor management and lifestyle modifications. The majority of studies included medication self-management as a component of a broader intervention. Most interventions used both face-to-face interactions and technology for delivery. Behavioural outcomes, specifically medication adherence, were the most commonly targeted outcomes across the interventions. However, the majority of interventions did not specifically or holistically target medication self-management. There is an opportunity to better support medication self-management post-stroke by ensuring interventions are delivered across sectors or in the community, developing an understanding of the optimal frequency and duration of delivery, and qualitatively exploring experiences with the interventions to ensure ongoing improvement.

Managing Fatigue in Parkinson's Disease: Protocol for a Pilot Randomized Controlled Trial

Background. Fatigue is a disabling symptom of Parkinson’s disease (PD). Managing Fatigue: A Six-Week Energy Conservation Intervention was developed to improve the occupational performance of people with fatigue. Efficacy of this program has not been established in PD. Purpose. This study will assess feasibility of the Managing Fatigue: Individual Program (MFIP) delivered via videoconference, the Randomized Controlled Trial (RCT) protocol, and the preliminary effectiveness of the MFIP. Methods. A mixed-methods approach nested in a pilot RCT, randomizing 54 participants 1:1 to usual care or MFIP arms, will be employed to evaluate the feasibility and preliminary effectiveness of MFIP. Qualitative and quantitative data will be collected simultaneously. Implications. Results will identify evidence for establishing protocol requirements for a full-scale RCT. Knowledge of the effectiveness of the one-to-one videoconference delivery format of the program has the potential to enhance the accessibility and the quality of care of the PD population.

Managing everyday life: Self-management strategies people use to live well with neurological conditions

OBJECTIVE

This paper uses the Taxonomy of Everyday Self-management Strategies (TEDSS) to provide insight and understanding into the complex and interdependent self-management strategies people with neurological conditions use to manage everyday life.

METHODS

As part of a national Canadian study, structured telephone interviews were conducted monthly for eleven months, with 117 people living with one or more neurological conditions. Answers to five open-ended questions were analyzed using qualitative content analysis. A total of 7236 statements were analyzed.

RESULTS

Findings are presented in two overarching patterns: 1) self-management pervades all aspects of life, and 2) self-management is a chain of decisions and behaviours. Participants emphasized management of daily activities and social relationships as important to maintaining meaning in their lives.

CONCLUSION

Managing everyday life with a neurological condition includes a wide range of diverse strategies that often interact and complement each other. Some people need to intentionally manage every aspect of everyday life.

PRACTICE IMPLICATIONS

For people living with neurological conditions, there is a need for health providers and systems to go beyond standard advice for self-management. Self-management support is best tailored to each individual, their life context and the realities of their illness trajectory.

An exploration of attitudes and preferences towards medications among healthcare providers and persons with spinal cord injury/dysfunction: a qualitative comparison

PURPOSE

To compare the attitudes and preferences of persons with spinal cord injury/dysfunction (SCI/D) and healthcare providers regarding prescription medications, over-the-counter medications, and natural health products (NHPs).

MATERIALS AND METHODS

A qualitative study involving semi-structured interviews with healthcare providers (n = 32) and persons with SCI/D (n = 19) in Canada. Inductive descriptive and interpretive analyses were conducted using data display matrices and a constant comparative approach.

RESULTS

Participants described differing perceptions of therapeutic benefits based on medication type, with shared attitudes about the therapeutic benefits of prescription medications and differing views about the effectiveness of NHPs. Despite the perceived effectiveness of prescription medications, persons with SCI/D preferred to avoid them due to concerns about side effects, safety, and stigma. Persons with SCI/D were often concerned about the long-term safety of prescription medications, whereas providers focused more on medication-related addictions. Participants discussed stigma relating to prescription medications, NHPs, and medicinal marijuana.

CONCLUSION

Healthcare providers and persons with SCI/D described different attitudes about and preferences for pharmacotherapeutic products, contributing to challenges in optimizing medication management. Strategies to improve medication management include shared decision-making to incorporate patient preferences into care plans and explicit discussions about long-term medication safety. Further, steps are needed to combat the stigma associated with medication use.Implications for rehabilitationFollowing a person-centered approach to shared decision-making, prescribers should initiate explicit conversations about patient medication preferences, short and long-term prescription medication side effects, and alternative treatment options.Regarding prescription medication safety, persons with spinal cord injury/dysfunction focused on the long term impact of medications, while providers focused on medication-related addictions, highlighting a disconnect that should be discussed during initiation, continuation, or discontinuation of a medication.Providers should be mindful of the stigma associated with taking multiple prescription medications, including medicinal marijuana, as well as the stigma associated with over-the-counter medications and natural health products.Providers could benefit from education about spinal cord injury/dysfunction-specific prescription medications and could benefit from increased education about natural health products.

Spinal cord injury/dysfunction and medication management: a qualitative study exploring the experiences of community-dwelling adults in Ontario, Canada

Purpose: To explore the attitudes, beliefs and experiences pertaining to the management of prescribed and unprescribed medications among community-dwelling adults with spinal cord injury/dysfunction (SCI/D) in Ontario, Canada.Materials and Methods: In-depth semi-structured interviews were conducted by telephone. Each interview was audio-recorded, transcribed verbatim and analyzed using inductive thematic analysis.Results: Of the 19 participants, 11 were male and 8 were female, with an age range from 36 to 76 years; 14 participants had traumatic SCI and 5 had non-traumatic spinal cord dysfunction. All but three participants were taking five or more medications, including prescription medications, over-the-counter medications and natural health products. The three main themes identified were: disruptive nature of medications, fear of negative outcomes and self-management: playing a critical role.Conclusions: Medication management is a complex, multifaceted and non-linear process. Persons with SCI/D described experiences with medication-taking that are not well understood by current medication management frameworks. Thus, it is essential to broaden our lens and situate persons with SCI/D medication-taking experiences within self-management frameworks to allow for a more comprehensive and reflective understanding of their experiences. Based on the findings from this study, recommendations for future research, practice and policy have been suggested.IMPLICATIONS FOR REHABILITATIONPersons with spinal cord injury/dysfunction identified numerous challenges and concerns with medication use post-injury.Educational medication management programs should be implemented post-discharge to improve the state of knowledge around medications (indication, side effects, strategies for taking medications) and how to optimize medication management.In order to optimize experiences and outcomes, there is a need for explicit and ongoing discussions around medication management between persons with spinal cord injury/dysfunction and their healthcare providers.

Exploring the perspectives on medication self-management among persons with spinal cord injury/dysfunction and providers

RATIONALE

Spinal cord injury/dysfunction (SCI/D) is an exemplar condition with a high prevalence of secondary complications, chronic conditions and use of multiple medications (polypharmacy). Optimizing medication self-management is important for persons with SCI/D to improve outcomes; however, there is a lack of research on how healthcare/service providers and persons with SCI/D experience medication self-management.

OBJECTIVE

To explore attitudes and experiences of medication self-management from the perspectives of persons with SCI/D and providers, and to explore the extent to which the Taxonomy of Everyday Self-management Strategies (TEDSS) framework captured participants' experiences with medication self-management.

METHODS

In-depth, semi-structured interviews were conducted by telephone until data saturation was reached. Interviews were transcribed verbatim and analyzed using constant comparative approaches. The TEDSS framework was adapted and applied deductively.

RESULTS

Fifty-one individuals participated in this study, 32 providers and 19 persons with SCI/D. Disease controlling strategies was the domain discussed in most detail by all participants. In this domain, participants discussed managing medications and treatments, monitoring/managing side effects, and controlling complications. Process strategies (problem-solving, decision-making) and resource strategies (seeking support) were the next most frequently discussed domains. Among all participant groups, there was a lack of detailed discussion of social interactions, health behaviour, and internal strategies. Medication self-management support was not extensively discussed by any group.

CONCLUSION

This study highlighted the complex nature of medication self-management. While persons with SCI/D and providers discussed similar components of the TEDSS framework, providers had minimal reflections on the impact of medication self-management on everyday life. This study identified the need for explicit discussions between providers and persons with SCI/D, involving all components of self-management and self-management support in order to improve medication self-management.

"The strategies are the same, the problems may be different": a qualitative study exploring the experiences of healthcare and service providers with medication therapy management for individuals with spinal cord injury/dysfunction

Background

Persons with spinal cord injury/dysfunction (SCI/D) often take multiple medications to treat their secondary complications and chronic conditions (multimorbidity). Multiple healthcare and service providers are often involved in care, which can result in increased risk of fragmentation of care. Optimal medication therapy management (MTM) is essential to ensure therapeutic benefit from medication regimens. However, little is known about the experiences of providers in supporting persons with SCI/D with MTM.

Methods

Telephone interviews were conducted to explore healthcare and service providers’ experiences with MTM for persons with SCI/D. Participants were recruited through clinical organizations and researchers’ personal contacts. Participants were purposefully selected for diversity in profession and were required to be English speaking and to have provided care to at least one person with SCI/D. The qualitative interviews followed a semi-structured interview guide. Data display matrices were used in a constant comparative process for descriptive and interpretive analysis.

Results

Thirty-two interviews were conducted from April to December 2018. Each profession had distinct views on their roles in facilitating MTM for persons with SCI/D, which aligned with their respective scopes of practice. Shared provider tasks included tailoring medications, providing education, and exploring medication alternatives. Most participants felt that the care they provided for persons with SCI/D was similar to the care that they provided to other patients, with some differences relating to the physical limitations and medical complexity associated with SCI/D. Five factors were identified that impacted participants’ abilities to provide MTM for persons with SCI/D: patient self-management skills, provider knowledge and confidence, provider-patient relationships, interprofessional collaboration, and provider funding models including the use of technology-supported consultations.

Conclusion

While participants described commonalities in the barriers and enablers associated with providing MTM to persons with SCI/D and other populations, there were unique considerations identified. These SCI/D-specific considerations resulted in recommendations for improvements in MTM for this population. Future research should include perspectives from persons with SCI/D.

A systematic review examining whether community-based self-management programs for older adults with chronic conditions actively engage participants and teach them patient-oriented self-management strategies

OBJECTIVE

To identify whether community-based Self-Management Programs (SMPs) actively engaged, or taught, individuals patient-oriented strategies; and whether having these attributes led to significant differences in outcomes.

METHODS

This systematic review included randomized controlled trials (RCTs)and cluster RCTs reporting on community-based SMPs with a group component for older adults with chronic conditions. The ways SMPS actively engaged participants and whether they taught patient-oriented strategies were analyzed. All study outcomes were reported.

RESULTS

The 31 included studies demonstrated community-based SMP programs actively engaged participants and provided strategies to improve health behaviour or care of their condition. Few included strategies to help manage the impact of conditions on their everyday lives. Seventy-nine percent of studies reported significant differences; variations in sample sizes and outcomes made it difficult to conclude whether having these attributes led to significant differences.

CONCLUSION

SMPs are not supporting older adults to use strategies to address the impact of conditions on their everyday lives, addressing the needs of older adults with multiple conditions, nor assessing outcomes that align with the strategies taught.

PRACTICE IMPLICATIONS

Health-care providers delivering SMPs to older adults need to tailor programs to the needs of older adults and assess whether participants are using strategies being proposed.

Medication adherence for persons with spinal cord injury and dysfunction from the perspectives of healthcare providers: A qualitative study

Context: People with spinal cord injury and dysfunction (SCI/D) often take multiple medications (i.e. polypharmacy) to manage secondary health complications and multiple chronic conditions. Numerous healthcare providers are often involved in clinical care, increasing the risk of fragmented care, problematic polypharmacy, and conflicting health advice. These providers can play a crucial role in assisting patients with medication self-management to improve medication adherence. Design: A qualitative study involving telephone interviews, following a semi-structured guide that explored healthcare providers' conceptualization of factors impacting medication adherence for persons with SCI/D. The interviews were transcribed and analyzed descriptively and interpretively using a constant comparative process with the assistance of data display matrices. Analysis was guided by an ecological model of medication adherence. Setting and participants: Thirty-two healthcare providers from Canada, with varying clinical expertise. Intervention: Not Applicable. Outcome measures: Not Applicable. Results: Providers identified several factors that impact medication adherence for persons with SCI/D, which were grouped into micro (medication and patient-related), meso- (provider-related) and macro- (health system-related) factors. Medication-related factors included side effects, effectiveness, safety, and regimen complexity. Patient-specific factors included medication knowledge, preferences/expectations/goals, severity and type of injury, cognitive function/mental health, time since injury, and caregiver support. Provider-related factors included knowledge/confidence and trust. Health system-related factors included access to healthcare and access to medications. While providers were able to identify several factors influencing medication adherence, micro-level factors were the most frequently discussed. Conclusion: Findings from this study indicate that strategies to optimize medication adherence for persons with SCI/D should be multi-faceted.

The Taxonomy of Everyday Self-management Strategies (TEDSS): A framework derived from the literature and refined using empirical data

OBJECTIVE

To extend our understanding of self-management by using original data and a recent concept analysis to propose a unifying framework for self-management strategies.

METHODS

Longitudinal interview data with 117 people with neurological conditions were used to test a preliminary framework derived from the literature. Statements from the interviews were sorted according to the predefined categories of the preliminary framework to investigate the fit between the framework and the qualitative data. Data on frequencies of strategies complemented the qualitative analysis.

RESULTS

The Taxonomy of Every Day Self-management Strategies (TEDSS) Framework includes five Goal-oriented Domains (Internal, Social Interaction, Activities, Health Behaviour and Disease Controlling), and two additional Support-oriented Domains (Process and Resource). The Support-oriented Domain strategies (such as information seeking and health navigation) are not, in and of themselves, goal focused. Instead, they underlie and support the Goal-oriented Domain strategies. Together, the seven domains create a comprehensive and unified framework for understanding how people with neurological conditions self-manage all aspects of everyday life.

CONCLUSIONS

The resulting TEDSS Framework provides a taxonomy that has potential to resolve conceptual confusion within the field of self-management science.

PRACTICE IMPLICATIONS

The TEDSS Framework may help to guide health service delivery and research.

Self-management of pain and depression in adults with spinal cord injury: A scoping review

Context: Pain and depression are two prevalent secondary complications associated with spinal cord injury (SCI) that negatively impact health and well-being. Self-management strategies are growing in popularity for helping people with SCI to cope with their pain and depression. However, there is still a lack of research on which approaches are best suited for this population.Objective: The aim of this scoping review was to determine what is known about the self-management of pain and depression through the use of pharmacological and non-pharmacological therapies in adults with SCI.Methods: Seven electronic databases were searched for articles published between January 1, 1990 and June 13, 2017. Grey literature was searched and additional articles were identified by manually searching the reference lists of included articles.Results: Overall, forty-two articles met the inclusion criteria; with the majority reporting on the self-management of pain, rather than on depression or on both complications. Non-pharmacological interventions were more likely to include self-management strategies than pharmacological interventions. A limited number of studies included all of the core self-management tasks and skills.Conclusions: There are significant knowledge gaps on effective self-management interventions for pain and depression post-SCI. There is a need to develop interventions that are multi-faceted, which include both pharmacological and non-pharmacological therapies to address multimorbidity.

What we know about the purpose, theoretical foundation, scope and dimensionality of existing self-management measurement tools: A scoping review

OBJECTIVES

To identify self-report, self-management measures for adults with chronic conditions, and describe their purpose, theoretical foundation, dimensionality (multi versus uni), and scope (generic versus condition specific).

METHODS

A search of four databases (8479 articles) resulted in a scoping review of 28 self-management measures.

RESULTS

Although authors identified tools as measures of self-management, wide variation in constructs measured, purpose, and theoretical foundations existed. Subscales on 13 multidimensional tools collectively measure domains of self-management relevant to clients, however no one tool's subscales cover all domains.

CONCLUSIONS

Viewing self-management as a complex, multidimensional whole, demonstrated that existing measures assess different, related aspects of self-management. Activities and social roles, though important to patients, are rarely measured. Measures with capacity to quantify and distinguish aspects of self-management may promote tailored patient care.

PRACTICE IMPLICATIONS

In selecting tools for research or assessment, the reason for development, definitions, and theories underpinning the measure should be scrutinized. Our ability to measure self-management must be rigorously mapped to provide comprehensive and system-wide care for clients with chronic conditions. Viewing self-management as a complex whole will help practitioners to understand the patient perspective and their contribution in supporting each individual patient.

Reflections of patients and therapists on a multidisciplinary rehabilitation programme for persons with brachial plexus injuries

PURPOSE

There is lack of knowledge, evidence, and guidelines for rehabilitation interventions for persons with neuralgic amyotrophy (NA) or brachial plexus pathology. A first pilot study, evaluating the effect of an integrated rehabilitation programme, showed improvements in activity and participation levels.

AIM

To gain insight, from the perspective of patients and therapists, into the critical ingredients of the programme, that contributed to improvements in activity and participation.

MATERIALS AND METHODS

A qualitative study using semi-structured interviews with eight patients and five therapists (three occupational therapists and two physical therapists). Participants were asked to identify and describe factors regarding the rehabilitation that they perceived as positive and aspects of the programme that could be improved. Data were analysed using a constant comparative approach.

RESULTS

Patients reported (1) Time to diagnose: "Finally I'm in the right place;" (2) Awareness: "They gave me a mirror;" (3) Partnership: "There was real contact with the therapists; we made decisions together;" (4) Close collaboration: "Overlapping scopes of practice; doing the same from a different perspective;" and finally (5) Self-management: "Now I can do it myself." Therapists reported (1) "Patients knowledge and understanding is critical to success;" (2) "Activate problem solving and decision making;" (3) "Personalize your therapy; it's more than just giving exercises and information;" (4) "Constant consultation within the team; consistency in messages and approach;" and (5)" Ultimately the patient is in charge."

CONCLUSIONS

The critical ingredients, correspond well with each other and include a person-centred approach, education, support in problem solving and decision making and an integrated team approach. These ingredients provided the patients with confidence to take responsibility to manage their everyday lives, the ultimate goal of the programme. Implications for rehabilitation Both patients and therapists believe that the ability to self-manage and take control should be the outcome of high quality integrated rehabilitation programmes for patients with neuralgic amyotrophy and/or other brachial plexus injuries. A person-centred, collaborative, and integrated team approach, among all members of the team, are critical components of care delivery in personalised interventions. Critical programme ingredients are knowledge and education of both the patient and therapists; partnership between patient-therapist and within the team; patient activation and self-reflection; and personalised care. Patients recommend more options for personalisation of the intensity and duration of rehabilitation, the possibility to consult a psychologist and peer support within a group setting.

How adults with cardiac conditions in Singapore understand the Patient Activation Measure (PAM-13) items: a cognitive interviewing study

PURPOSE

Validation studies of the PAM-13 have found differences in scale performance, suggesting that health beliefs embedded in different cultures and/or self-management needs of different client groups influence how people respond to the items. The purpose of this study was to examine how adults with cardiac conditions in Singapore interpreted and responded to the PAM-13, to investigate possible reasons for differences in responses and to propose solutions to overcome them.

METHODS

We conducted retrospective cognitive interviews with 13 participants in an out-patient heart center. Interviews were transcribed and analyzed based on the framework approach to qualitative analysis. The four stages from Tourangeau's cognitive model were used as a framework to index the data from each item.

RESULTS

There was variation in comprehension of questions leading to variation in responses. Comprehension issues were due to terms perceived by participants to be vague and the use of English terms uncommon in Singapore. Cultural influences impacted decision processes and problems with response processes of the self-rating Likert scale surfaced.

CONCLUSIONS

This study reinforces the need to culturally adapt the tool, even when language translation is not necessary. Providing Likert scales with a larger number of may widen the relevance of PAM-13 in Singapore. Implications for rehabilitation Need to culturally adapt assessment tool, even when language translation is not necessary. Consider using Likert scales with a larger number of categories when using in Asian countries such as Singapore. Caution must be taken when using PAM-13 levels to decide interventions for each individual.

Validation of the Patient Activation Measure (PAM-13) among adults with cardiac conditions in Singapore

PURPOSE

The Patient Activation Measure (PAM-13) measures patients' knowledge, skill, and confidence in chronic condition self-management. The purpose of this study was to assess the validity of PAM-13 (English version) among English-speaking adults with cardiac conditions in Singapore.

METHODS

A cross-sectional study was conducted in a convenient sample of 270 heart clinic patients. Using the unitary concept of validity, evidence of (1) internal structure via data quality, unidimensionality, differential item functioning, and internal consistency, (2) response process through item difficulty and item fit using Rasch modeling, and (3) relationship to other variables via correlations with depression and self-efficacy were examined.

RESULTS

The item response was high with only one missing answer. All items had a small floor effect, but nine out of 13 items had a ceiling effect larger than 15 %. Cronbach's α was 0.86, and average inter-item correlations was 0.324. Results suggested unidimensionality; however, differences in item difficulty ranking were found. A low, negative correlation was found with depression, while a moderate, positive correlation was found with self-efficacy.

CONCLUSION

Evidence in all three areas of validity were mixed. Caution should be exercised when using categorical activation "level" to inform clinical decisions.

Examining the Elbow during Functional Activities

Elbow range of motion during functional activities was investigated using electrogoniometry, telemetry, and computer analysis. Five subjects awaiting elbow arthroplasty on rheumatoid arthritic elbows were compared to a control group. Differences (p ≤ .05) were found between the two groups on standing and telephone tests. The minimum angle (extreme extension) and the total arc of motion were significantly less in the group with arthritis. During the standing test the median extension angle was 35° for the group with rheumatoid arthritis and 15° for the control group, and for the telephone test the angles were 95° and 75°, respectively.

The experimental group did not consistently use their available range, but used movement patterns in a limited range. The information generated in the study has implications in the treatment of clients with rheumatoid arthritis.

Fatigue and Activity Patterns of People with Chronic Fatigue Syndrome

Although fatigue is the central symptom of people with chronic fatigue syndrome (CFS), relatively few reports in the literature examine the severity of this fatigue or the activity patterns of people with CFS. Using the Fatigue Severity Scale, the Nottingham Health Profile, the Human Activity Profile, and the Activity Record, severity of fatigue, health status, and activity patterns were investigated. People with CFS reported significantly higher levels of fatigue, poorer health status, and engagement in less energy-demanding activities ( P<0.001) than people without CFS. Those with CFS spent 16.18% (standard deviation [SD]=9.62) of their time resting compared with only 2.28% (SD=3.26) of the time spent by those without CFS ( P<0.05). Time spent in productive activities (household activities and work) was also significantly different, with the CFS group less involved ( P<0.05). This severity of fatigue and limitations in activity patterns warrant further attention. Frequent rest periods and energy conservation training may benefit these clients.

Validity and Reliability of the Activity Card Sort—Hong Kong Version

It is pertinent for occupational therapists to measure the changing patterns of activity engagement of older adults who might have undergone the process of aging, institutionalization, and illness. The Activity Card Sort was developed to measure the level of activity engagement in the main areas of occupational performance. This study examined the reliability, internal consistency, and construct validity of the Hong Kong version of the Activity Card Sort. Using expert panel reviews, 65 activities were identified as culturally appropriate for inclusion in the Hong Kong version. Sixty geriatric clients who had experienced a stroke participated in the evaluation. Results showed that the Hong Kong version of the Activity Card Sort was able to discriminate between clients with different levels of functioning ( t = −14.24; p = .00), and was positively associated with the Comprehensive Quality of Life Scale ( r = 0.86; p = .00). Excellent test—retest reliability ( r = 0.98) and internal consistency ( r = 0.89) were demonstrated. The findings suggest the Hong Kong version of the Activity Card Sort is a reliable and valid instrument to use with the Hong Kong Chinese elderly population.

Outcomes and impact of community-based rehabilitation programmes in Chinese communities

PURPOSE

To identify the most common and most valued outcomes of community-based rehabilitation (CBR) in Chinese communities and to map these to the CBR evaluation framework.

METHOD

A multiple, embedded case study design was used. Four CBR programmes in China met the criteria for inclusion and participated. Data collection, via participant "story telling", followed the procedures of the most significant change technique (MSC) over a period for five months. Content analysis with thematic coding was used to detect the common significant changes described in "top-rated" stories and in the entire pool of stories. Meta-analysis using the CBR framework was carried out to enrich the understanding of programme outcomes.

RESULTS

A total of 101 stories were collected in the two rounds of story collection from the four programmes. Aggregated results demonstrated that, across all programmes, 78.21% of stories focused on changes in people with disabilities, 9.9% described aspects of programme development, 8.91% reported on outcomes related to CBR workers, and only 2.97% were focused on advocacy. When mapped against the elements of the CBR framework the MSCs among these four programmes were (1) psychosocial changes, (2) increased family participation and (3) improved physical functioning.

CONCLUSIONS

CBR practice in Chinese communities remains orientated towards an approach of functional rehabilitation rather than community-based inclusive development. Implications for rehabilitation Community-based rehabilitation is a strategy for community-based inclusive development. Commonly reported significant outcomes of community-based rehabilitation programmes in China focus on changes in psychosocial and physical status of people with disabilities and family participation. Community-based rehabilitation in China continues to focus on traditional rehabilitation. New efforts and directions are needed to also include goals of equity and community inclusion. Further efforts to promote the use of CBR guideline with the goal of facilitating inclusion and equal participation are strongly recommended.

The Patient Activation Measure: a validation study in a neurological population

PURPOSE

To assess the validity of the Patient Activation Measure (PAM13) of patient activation in persons with neurological conditions.

METHODS

"The Everyday Experience of Living with and Managing a Neurological Condition" (The LINC study) surveyed 948 adults with neurological conditions residing in Canada in 2011 and 2012. Using data for 722 respondents who met coding requirements for the PAM-13, we examined the properties of the measure using principle components analysis, inter-item correlations and Cronbach's alpha to assess unidimensionality and internal consistency. Rasch modeling was used to assess item performance and scaling. Construct validity was assessed by calculating associations between the PAM and known correlates.

RESULTS

PAM-13 provides a suitably reliable and valid instrument for research in patients with neurological conditions, but scaling problems may yield measurement error and biases for those with low levels of activation. This is of particular importance when used in clinical settings or for individual client care. Our study also suggests that measurement of activation may benefit from tailoring items and scaling to specific diagnostic groups such as people with neurological conditions, thus allowing the PAM-13 to recognize unique attributes and management challenges in those conditions.

CONCLUSIONS

The PAM-13 is an internally reliable and valid tool for research purposes. The use of categorical activation "level" in clinical settings should be done with caution.

Curriculum evaluation: linking curriculum objectives to essential competencies

BACKGROUND

The essential competencies of occupational therapy practice are agreed upon and documented (ACOTRO, 2003), yet they have not been used to evaluate educational programs.

PURPOSE

To evaluate the match between the planned curriculum and the nationally recognized competencies that define safe, effective, and ethical practice.

METHODS

Utilizing a comparative and systematic approach, course learning objectives in the approved curriculum map were matched to the ACOTRO (2003) competencies.

FINDINGS

A total of 218 links were made between the 179 learning objectives and the 30 essential competencies. There were no links to three competencies. Learning objectives were not equally represented across the ACOTRO units; initial analyses indicate the distribution is likely appropriate.

IMPLICATIONS

This novel evaluative process allowed critical appraisal and subsequent minor revision of Dalhousie curriculum. The appropriate, relative weighting of curriculum content is unknown and is a professional issue for discussion by regulators, educators, and the profession at large.

The role and influence of 'champions' in a community-based lifestyle risk modification programme

This article describes the training and implementation of the Waist Disposal Challenge in service clubs in Western Australia in 2009-2010. Ninety-three Champions from 52 clubs were trained to deliver educational presentations to 1100 peers and facilitate a BMI competition among 764 peers. Champions reported significant improvements in their knowledge and confidence to motivate their peers to make changes to their diet and physical activity with 82% of participants completing the BMI competition and on average 58% experiencing and sustaining a BMI reduction for 12 months. It is evident that the Champions had influenced the uptake and success of the intervention.

Self-management programs conducted within a practice setting: who participates, who benefits and what can be learned?

OBJECTIVE

To investigate the impact of generic and diabetes-specific self-management programs offered in a real world context.

METHODS

A quasi-experimental design with 12-week follow-up compared Living with a Chronic Condition and Living with Diabetes. Self-report data collected included: Self-management Knowledge and Skills; Health Related Quality of Life (HRQOL); Depression; Social Isolation; Loneliness; Self-efficacy; and Health Behaviours.

RESULTS

Participants (N=458) in the two programs differed on almost all baseline measures. Both demonstrated statistically significant improvements in Self-management Knowledge and Skills, as well as reductions in depression. In addition to younger age, low HRQOL, high self-efficacy and Positive and Active Engagement in Life, were the clinical factors most likely to lead to improvements in HRQOL and self-efficacy. Changes in different characteristics predicted different outcomes.

CONCLUSION

Both generic and disease-specific programs led to improved outcomes, despite the two programs attracting significantly different participants. Referral patterns also differed but GP referral rates were low for both.

PRACTICE IMPLICATIONS

Positive participant outcomes can be achieved in real life clinical settings. While younger people with a positive attitude may appear to gain more, it is important to encourage people from low socio-economic status to enter these programs so that social inequalities in health are not worsened.

Vision self-management for older adults: a randomised controlled trial

BACKGROUND/AIMS

Ageing of the population will result in unprecedented numbers of older adults living with age-related vision loss (ARVL). Self-management models improve health outcomes and reduce healthcare costs; however, the principles have rarely been applied in low vision services.

METHODS

A two-armed randomised controlled trial of older adults (n=77) with ARVL compared 'usual care' provided by a not-for-profit community agency with an extended model of care (usual care+self-management group intervention). The primary outcome variable (participation in life situations) was measured using the Activity Card Sort. Secondary outcome measures examined general health and vision-specific domains.

RESULTS

The intention-to-treat analysis demonstrated that the extended model produced significantly better participation in life situations at post-test when compared with the usual care only group. Gains were made regardless of whether participants were, or were not, depressed at baseline. The addition of the self-management group was also successful in significantly reducing depression, increasing physical and mental health, generalised and domain-specific self-efficacy, and adjustment to ARVL. With the exception of adjustment and mental health, differences were still apparent at 12 weeks' follow-up.

CONCLUSION

Addition of self-management significantly improved general health and vision-specific rehabilitation outcomes for older adults with ARVL.

Evaluation of a rural chronic disease self-management program

INTRODUCTION

Internationally, the prevalence of long-term health conditions is at epidemic proportions. Australia is no exception. The Australian Government's 'Better Health Initiative' has 5 key strategies to build better health care, one of which is the adoption of self-management and self-management support. Self-management allows people to manage their condition and the consequences it brings to their lives in partnership with their health providers. The purpose of this article was to report both the process and patient outcomes following the introduction of the Stanford Chronic Disease Self-Management Program (CDSMP) into an existing service in an Australian rural setting.

METHODS

Implementation processes were evaluated using semi-structured interviews conducted with managers, lay and health professional course leaders and participants about positive and negative aspects of providing the CDSMP. Participant outcomes were evaluated using a modified pre-test, post-test design to evaluate changes in activity participation and self-management knowledge and skills.

RESULTS

Both negative and positive aspects of providing the program were represented by two key themes: (1) program content and quality; and (2) logistics of delivery. Throughout the interviews, managers and leaders, and course participants offered recommendations that were thematically grouped into 3 categories: (1) enhancing quality; (2) improving the logistics; and (3) providing resources. Comparison of activity levels with a community sample indicated that participants had significantly decreased participation levels. Scores on the Health Education Impact Questionnaire v2 (heiQ - RETRO) demonstrated statistically better scores at post-test on the domains of 'self monitoring', 'insight' and 'health service navigation' with a trend towards significance on 3 other domains.

CONCLUSIONS

Future implementation of CDSMPs in rural areas will be encouraged by these patient outcomes, and informed by the qualitative findings from managers, leaders and course participants.

Targeting health disparity in breast cancer: insights into women's knowledge of their cancer profile in Malaysia

OBJECTIVE

Poor health literacy is positively associated with poorer quality of health decision-making and health outcomes in women facing a cancer diagnosis. In developing countries, poor access to complete and accurate information continues to pose a challenge for women. This paper describes the knowledge of Malaysian women with regard to breast cancer and how participation in a self-management program can improve the situation.

METHODS

Secondary analysis of data collected during a clinical trial on women newly diagnosed with breast cancer (n=147) was performed to examine baseline knowledge of breast cancer profile. Knowledge levels of women in the experimental (n= 69) group attending a self-management program were compared to a control group (n= 78) to determine change in the level of knowledge over time.

RESULTS

At baseline, a high percentage of women were unaware of their breast cancer profile. Not a single woman had knowledge of all six basic characteristics; 83% did not know their HER2 status, type of breast cancer (68%), grade of cancer cell (64%), hormonal receptor status (55%), size of breast cancer (18%) and/or their stage of breast cancer (13%). At post intervention, there was significantly better knowledge within the experimental group.

CONCLUSION

Malaysian women in this cohort study demonstrated very low levels of knowledge of their cancer profile. Clinical implications for countering treatment-decision difficulties include the need for a shift in the way information and services are delivered to allow women to take a more active role in their own care. Multi-modal efforts including basic information dissemination to increase women's knowledge can contribute to narrowing of the gap in health disparity.

Understanding the complex interplay between tourism, disability and environmental contexts

PURPOSE

To explore and describe the complex issues and factors related to participation in tourism as perceived by people with disabilities in Hong Kong.

METHOD

Naturalistic inquiry using key informant interviews and focus groups with 86 people with disabilities. Interviews were transcribed, translated and coded to develop themes and relationships. Triangulation of three investigators from different backgrounds occurred.

RESULTS

The Process of Becoming Travel Active emerged as a six-stage process, intricately related to the personal/disability context and the environmental/travel context. Personal and environmental factors contribute to the six-stage model explaining the complex interplay between tourism, disability and environmental context.

CONCLUSION

Understanding the complexity provides insight into ways to increase active participation in tourism. Health, tourism and disability sectors have a role to play in the development of accessible tourism.

Measuring changes in activity participation of older Australians: validation of the Activity Card Sort-Australia

OBJECTIVES

This study explored the psychometric properties of the Australian version of the Activity Card Sort (ACS-Aus), a recently developed measure of activity participation for use with older adults. Concurrent, convergent construct, and discriminative construct validity were examined.

METHODS

The study included 93 Australian adults aged 60-95 years. Participants completed the ACS-Aus, as well as an existing Australian measure of activity participation (The Adelaide Activities Profile) and an Australian measure of subjective well-being (the Personal Well-being Index).

RESULTS

The ACS-Aus demonstrated moderate concurrent validity (r = 0.434), moderate convergent construct validity (r = 0.354), and strong discriminative validity (P = 0.000).

CONCLUSIONS

The World Health Organization has recently promoted participation as an important component of the healthy ageing process. This study has validated the use of the ACS-Aus in measuring participation of community-dwelling older adults in Australia.

The Impact of Age-Related Vision Loss

Age-related vision loss is a condition affecting the quality of life of an ever-increasing number of older adults. The purposes of this study were to describe the impact of age-related vision loss, identify the factors that influence adaptation, and describe the perceived problem areas in the daily lives of older adults. Twenty-two older adults with vision loss participated in four focus groups. Analysis of transcripts revealed that the main themes were the impact of vision loss, factors that aid adaptation, and participation in meaningful activities. Findings from the focus group study revealed the importance of considering participants' physical loss of vision in the context of their psychological, occupational, and social worlds. This study pointed to the importance of occupation in adaptation to age-related vision loss and yielded many recommendations that could be integrated into models of low vision rehabilitation. Future research is now required to evaluate the implementation of these recommendations and further develop evidence-based practice in this field.

Active citizens or passive recipients: how Australian young adults with cerebral palsy define citizenship

BACKGROUND

Citizenship participation by young adults has reciprocal benefits both for the individual and for society. This paper provides an insight into the ways young people with cerebral palsy (CP) perceive their citizenship experiences, and also examines factors which may influence citizenship participation for this group.

METHOD

Qualitative methodology was used to explore perceptions of citizenship experiences in young people with CP. Nine participants (aged 18-30 years), were interviewed using a semi-structured interview format.

RESULTS

Four themes emerged: (i) contribution, (ii) inclusion, (iii) equal opportunity, and (iv) a barrier-free context.

CONCLUSION

The nine participants indicated that they aspired to make a contribution to society, play an active role, be accepted by others, and live with dignity and respect, as well as pursue their dreams and passions.

Using the Actigraph to measure physical activity of people with disabilities: an investigation into measurement issues

This study investigates measurement issues when using the Actigraph motion sensor to measure the physical activity of people with disabilities. Four volunteers with rheumatoid arthritis participated in the study. Activity levels were measured using the Actigraph over four consecutive weekdays. Activity counts were determined using Actigraph Standard Software. The daily percent of waking time spent at each intensity level was calculated and a weighted average calculated to determine a single daily measure of activity. The variability of measurement, over 1, 2, 3 and 4 days, was examined using these weighted and rolling averages. Activity counts were very low, with over 50% of waking time spent in the 'very low' intensity category, demonstrating a marked floor effect. Little variability (+/-0.11 counts/min) in the level of physical activity was found across 1-4 days. The limited variability (consistency across days) in combination with the floor effect indicates that a 1-day data collection period is adequate. The limitations of the Actigraph are thus related to the existing software options, which have been designed for people without rheumatoid arthritis. The Actigraph does not appear to be a sensitive measure in people performing very low physical activity.

Attitudes to disability of Russian occupational therapy and nursing students

Positive student attitudes toward disability are essential to client-centred rehabilitation. Instilling such attitudes in students enrolled in the first occupational therapy (OT) and post-diploma nursing management (NM) courses in Russia was a key objective of the curriculum development team. The team's aim was to combat the traditional Russian attitude of pity, dependence and marginalization. To this end, the introductory classes were developed and taught by teachers from the All Russia Society of Disabled (ARSD). This paper examines the attitudes to disability in Russia and compares the attitudes of three groups of students. Students in the OT and NM programmes (n = 18) in Volgograd were compared to other nursing students in the same college (n = 21) and to nursing students in a Moscow medical school (n = 20). All completed the Scale of Attitudes Toward Disabled Persons (SADP). The Kruskal-Wallis and Mann-Whitney U statistics revealed that students in the OT and NM programmes had significantly more positive scores (P = 0.01) than either of the other groups. This suggests that the strategies adopted by the curriculum team were successful in developing positive attitudes in students.

Evaluating a new mobility device: feedback from women with disabilities in India

PURPOSE

To gather the opinions of potential wheeled mobility device users at an early stage in the design process to ensure the development of technology which would meet their functional needs.

METHOD

Eight women with bilateral lower extremity disabilities living in Gujarat state, India, participated in this study. The women were introduced to a working model of a new wheeled ground mobility device (GADI2) for a brief trial and participated in a feedback interview which solicited information on different aspects of the design, specifically the interface between the device and the user, the physical environment and the sociocultural environment. Both qualitative and quantitative data were collected and analysed.

RESULT

Although the overall response to the device was positive, there was a lack of consensus in some of the feedback gathered. There were varying opinions across the participants and recommendations were often in opposition to what would typically be recommended in a traditional rehabilitation setting.

CONCLUSIONS

This study investigates and discusses the research findings from a rehabilitation perspective with a focus on the functional versus technical design aspects. The importance of involving potential consumers in the design of technology is highlighted. The small sample size and lack of consensus in some of the results indicates the need for further research and field testing of this new mobility device design.

Designing appropriate rehabilitation technology: a mobility device for women with ambulatory disabilities in India

Mobility is an essential requirement for personal independence and social participation. For persons with an ambulatory disability, a lack of mobility creates barriers to the realization of these goals. In developed countries, significant research and development has resulted in the technological advancement of assistive devices. Unfortunately, transfer of these technologies to developing countries has proven difficult. Consequently, effort has been directed at designing appropriate technology in these countries--most often in the form of wheelchairs and hand-driven tricycles. For activities within and around the home, however, especially in cultures where many activities are traditionally performed on the floor, wheelchairs and tricycles are often inappropriate solutions. In response to this, a novel mobility device has been designed for use by women with ambulatory disabilities living in rural and low-income areas of India. The device is intended to assist the user in performing activities of daily living which occur within and near the home, and at ground level. To this end, the device conceptually differs from traditional wheelchair designs in that it physically keeps the rider near to the floor. This paper describes the new device as well as the cross-cultural and cross-professional collaborative methodology used in its design.

The mobility needs of women with physical disabilities in India: a functional perspective

The purpose of this research was to explore the functional mobility needs of women with lower extremity disabilities in Gujarat state, India. Ten women participated in a Mobility Needs Assessment which used multiple data collection methods to gather quantitative and qualitative information in five main areas. The results indicated that the physical environment was diverse, at times unpredictable, and environmental barriers were commonly encountered. The women travelled relatively long distances to perform self-care activities such as bathing and toileting. Furthermore, the women had compensated for their disability by implementing different strategies, such as four methods of locomotion, ten sitting positions, and various methods for carrying objects. Activities of daily living were similar amongst the women, although some women required assistance to complete specific activities successfully. Although the women expressed different views on how they felt about their present level of mobility, all were able to identify activities they wished to perform if they could move more easily. The resulting information contributed towards an area where little has been documented previously.

Needs of people with disabilities used to determine clinical education

Western rehabilitation techniques were first introduced into China in the early 1980s. The predominantly 'medical model' of health care in China has resulted in a shortage of rehabilitation personnel and limited experience determining the needs of clients. Occupational therapy practitioners in China are learning their new roles and clients, having never had any contact with occupational therapy, are unaware what services can be offered. The purpose of this research was to determine the most frequently self-identified functional problems (in the ares of self-care productivity and leisure) identified by 113 in-patients in four different hospitals in China, in order to assist therapists to develop programmmes that are responsive to clients' needs. Using the Canadian Occupational Performance Measure, both males and females identified significantly more self-care than leisure or productivity problems (P = 0.01). Females identified more productivity problems than males (P = 0.01) while males appeared to consider leisure difficulties as a priority more frequently than women. The study was jointly undertaken by a Canadian and a Chinese researcher. To our knowledge, this is the first time that occupational therapy personnel in China have formally surveyed clients about their rehabilitation needs, in order to develop priorities for programming.