Psychometric properties of two implementation measures: Normalization MeAsure Development questionnaire (NoMAD) and organizational readiness for implementing change (ORIC)

Background

Effective interventions need to be implemented successfully to achieve impact. Two theory-based measures exist for measuring the effectiveness of implementation strategies and monitor implementation progress. The Normalization MeAsure Development questionnaire (NoMAD) explores the four core concepts (Coherence, Cognitive Participation, Collective Action, Reflexive Monitoring) of the Normalization Process Theory. The Organizational Readiness for Implementing Change (ORIC) is based on the theory of Organizational Readiness for Change, measuring organization members' psychological and behavioral preparedness for implementing a change. We examined the measurement properties of the NoMAD and ORIC in a multi-national implementation effectiveness study.

Method

Twelve mental health organizations in nine countries implemented Internet-based cognitive behavioral therapy (iCBT) for common mental disorders. Staff involved in iCBT service delivery (n = 318) participated in the study. Both measures were translated into eight languages using a standardized forward-backward translation procedure. Correlations between measures and subscales were estimated to examine convergent validity. The theoretical factor structures of the scales were tested using confirmatory factor analysis (CFA). Test-retest reliability was based on the correlation between scores at two time points 3 months apart. Internal consistency was assessed using Cronbach's alpha. Floor and ceiling effects were quantified using the proportion of zero and maximum scores.

Results

NoMAD and ORIC measure related but distinct latent constructs. The CFA showed that the use of a total score for each measure is appropriate. The theoretical subscales of the NoMAD had adequate internal consistency. The total scale had high internal consistency. The total ORIC scale and subscales demonstrated high internal consistency. Test-retest reliability was suboptimal for both measures and floor and ceiling effects were absent.

Conclusions

This study confirmed the psychometric properties of the NoMAD and ORIC in multi-national mental health care settings. While measuring on different but related aspects of implementation processes, the NoMAD and ORIC prove to be valid and reliable across different language settings.

POS1560-HPR “MY GUT FEELING IS…”: IDENTIFYING HOW HEALTHCARE PROFESSIONALS COMMUNICATE ABOUT PAIN IN PAEDIATRIC RHEUMATOLOGY MULTI-DISCIPLINARY TEAM MEETINGS

Background

Multi-disciplinary teams (MDTs) are common in paediatric rheumatology where UK standards of care state that all children/young people should have access to a paediatric rheumatologist, nurse, physiotherapist, occupational therapist and a psychologist. MDTs in paediatric rheumatology regularly meet for the broader purpose of discussing the assessment of and future management plans for children/young people with a range of complex conditions in which chronic pain may feature. The content of these discussions has not been previously researched. Little is known about healthcare professional to healthcare professional communication and how this may influence the care of children/young people with chronic pain.

Objectives

The objective of the current study was to investigate healthcare professionals communication about children and young people with chronic musculoskeletal pain during MDT meetings in paediatric rheumatology.

Methods

This study was a non-participant ethnographic observation of virtual and face-to-face MDT meetings in three paediatric rheumatology centres in the UK. A structured observation checklist was used to capture and organise field notes which were analysed using an inductive thematic approach amongst research team members. Interpretation of field notes was guided by discussions with healthcare professionals from each of the teams involved.

Results

Forty-two healthcare professionals from across the three teams participated. Ten meetings from each team (n=30) were observed, with meetings ranging from 1-2 hours. Analysis was organised into three themes;

1)Describing the child/young person with pain: Healthcare professionals’ perceptions about personality characteristics (e.g. “He is mature”, “She is sensitive”) were frequently used to introduce a child/young person to the team. A child/young person description was always accompanied by a description of parents and perceptions about their behaviour (e.g. “Dad is very disengaged”, “Mum can shout”).

2)Interpreting the pain of the child/young person: A core component of interpretations was professional’s familiarity with the child/young person and parents (e.g., “I haven’t got a handle on them yet”). Professionals also discussed how their interpretations of pain were influenced by “gut feelings” or “vibes that something else is going on at home”.

3)

Managing the child/young person with pain: Healthcare professionals discussed the need for acceptance of pain and treatment from children/young people (e.g., “She wasn’t buying into that”; “He needs to get used to it”). Setting boundaries for children/young people and parents for accessing the team also featured in discussions (e.g., “We need to re-assure them but not always be available”).

Conclusion

This study highlights a range of healthcare professional approaches and processes to communicating about and discussing children/young people with pain at paediatric rheumatology MDT meetings. Findings suggest that healthcare professionals in paediatric rheumatology describe, interpret and manage the child/young person presenting with pain alongside the broader psychosocial (and less frequently the biological) context. These findings will inform the content and methods of a behaviour change intervention to improve pain communication in consultations with children/young people, parents and amongst the paediatric rheumatology team of healthcare professionals in the UK.

Acknowledgements

The authors would like to thank the healthcare professionals for kindly taking the time to take part in this study. The views expressed herein are those of the authors and not necessarily those of the National Health Service, the National Institute for Health Research, or the UK Department of Health. This work was supported by a Foundation Fellowship award from Versus Arthritis (Grant 22433). Aspects of this work were also supported by funding from the Centre for Epidemiology Versus Arthritis (Grant 20380) and the NIHR Manchester Biomedical Research Centre.

Disclosure of Interests

None declared

POS1510-HPR IDENTIFYING THEORY-DRIVEN THERAPEUTIC CONTENT FOR A SMARTPHONE APP FOR THE SELF-MANAGEMENT OF SJOGREN’S SYNDROME

Background

Technology-supported self-management of long-term conditions (e.g., through the use of smartphone apps) provides easily accessible support. However, currently there are no systematically developed, evidence-based smartphone apps for Sjogren’s Syndrome. We took an agile approach to developing such an app: instead of starting “from scratch” we deemed it more efficient and scientifically sound to digitalise relevant components from existing, evidence-based interventions for the symptoms of SS.

Objectives

The present study was desk research, which aimed to deconstruct interventions and resources down to units of theory-driven therapeutic content, to then select from, for the inclusion in an app for the self-management of SS.

Methods

We used deductive and inductive content analysis, to identify behaviour change techniques (BCTs)[1] and behaviour change methods (BCMs)[2]. The materials consisted of published fatigue, pain and sleep interventions (e.g. [3] and [4]), as well as private-facing clinician notes and public facing resources on self-management from Versus Arthritis and the UK NHS’s CRESTA fatigue clinic.

Results

We found 38 active ingredients from the BCT Taxonomy and the BCM intervention mapping approach frameworks, of which at least 14 were overlapping in function. Importantly we noted that BCTs and BCMs were formulated in various ways pertaining to how the interventions should be delivered (form of delivery-FoD) [5]. Further qualitative analysis revealed 6 themes relating to FoD. The theme Interactivity involved presenting information in ways that would involve the reader in actively responding to it in various ways. The theme Reflection was about engaging the recipient in in-depth consideration of their own experience with symptoms and self-management processes. The theme Validation encompassed all the ways in which the illness and management experience was socialised and normalised to remove stigma and sense of isolation. The theme Treatment Rationale was about providing an a-priory transparent, sound, and compelling justification for the self-management actions required from recipients. The theme Discourse pertained to how information was being communicated, e.g., with language that is warm, simple, assertive, etc. Finally, the theme Approaches was about the therapeutic origins of the active ingredients, e.g. Second and Third Wave CBT. These themes indicate that meaningful therapeutic content is missing from commonly used theoretical frameworks for the development of interventions.

Conclusion

Our findings indicate that meaningful therapeutic content is missing from commonly used theoretical frameworks for the development of interventions.

Interventions should not just include BCTs and methods, but also active ingredients pertaining to how these techniques and methods are delivered, i.e., active ingredients relating to FoD. Reflection deserves particular attention in self-management, as it is unclear empirically in apps what is the most effective way to produce the most useful psychological and behavioural insight, and for whom. FoD is a component of intervention development that requires systematising and the present findings can contribute to such efforts.

References

[1]S. Michie, et al. Annals of Behav Med 2013. 46:1

[2]G. Kok, et al. Health Psych Rev 2016. 10:3

[3]S. Hewlett, et al. Ann. Rheum. Dis 2019. 78: 4.

[4]S. D. Kyle, et al. Sleep Med Rev 2015. 23.

[5]S. U. Dombrowski, et al. Brit. J Health Psych 2016. 21: 4

Acknowledgements

I have no acknowledgments to declare.

Disclosure of Interests

None declared

FRI0625-HPR APPS TARGETING SYMPTOMS ASSOCIATED WITH SJÖGREN’S SYNDROME AND POTENTIAL USERS’ PERCEPTIONS OF THEIR FEATURES: CONTENT ANALYSIS AND THINK ALOUD STUDY

Background:

Sjögren’s syndrome (SS) is a rheumatic disease requiring self-management which may be delivered through smartphones. When developing digital interventions it is important to review what is already available (market segmentation)1to identify unique selling points and aid uptake and adoption. While there are no dedicated SS apps, many are publicly available for other rheumatic conditions2. Understanding user preferences for existing apps may help to design an engaging app for SS self-management.

Objectives:

To explore apps targeting SS symptoms of dryness, sleep disturbances, fatigue and pain. To explore views of people with SS on these app features.

Methods:

Apple Store apps were retrieved on 04 March 2019 using the following search terms:dry, dry eye, sleep, insomnia, fatigue, tirednessandpain. Included apps were English and in Medical or Health & Fitness genres. Exclusion criteria were; duplicates, additional external devices required and apps targeting alcohol reduction or children.

Included apps were grouped by symptom. App descriptions were open-coded to generate a thematic coding framework (i.e. full list of features) for each symptom which was then applied to all app descriptions. To obtain views of people with SS, several of the reviewed apps for each symptom covering the full list of features were given to 13 focus group participants to use in ‘think aloud’ sessions (n=4). Audio data was recorded, transcribed and deductively analysed using the framework to gather opinions relating to each feature.

Results:

Of 914 apps retrieved, 542 were included. Features within apps targeting dryness (n=15) provided dry eye information, self-assessment and reminders to blink or look away from screens. Apps targeting sleep (n=310) included features to support sleep restriction, sleep hygiene, sleep tracking (sleep onset and wake up times, time in bed, overall sleep quality), relaxing sounds, guided meditation, sleep stories, snore recording and alarms. Fatigue apps (n=79) included features to detect current physical and mental fatigue levels, support pacing (i.e. track fatigue, label tasks as ‘high energy’, prioritise tasks), and self-massage instructions. Apps targeting pain (n=138) featured pain tracking (of severity, affected body areas), guided exercises, and mindfulness.

Dryness apps prompted participants to reflect on its impact on daily activities, but further dryness features were desired relating to: using a humidifier; eye drop reminders; and dryness tips for other body areas e.g. vaginal dryness. Sleep restriction features were believed to be irrelevant but viewing and selecting sleep hygiene tips to “try” were considered useful. Beyond entering sleep onset and wake up times, participants wished to track “when and why I woke up”, to understand night awakenings in relation to other symptoms. Fatigue detection features were felt to be more useful for those recently diagnosed, as experienced participants could easy identify when they were fatigued (“I don’t need an app to tell me!”). Participants valued pacing features but found them difficult to use. Daily pain tracking was considered demotivating, but useful for remembering and explaining issues to healthcare professionals. Participants believed that a dedicated app for SS would support self-management and raise SS awareness.

Conclusion:

Existing apps targeting SS symptoms do not meet the needs of those with SS. App features should be tailored to SS by supporting dryness management in body areas beyond eyes, and night-awakenings. Pacing features must be easy to use. The ability to track pain should be optional and tracking prompts should be limited. Design considerations should be implemented alongside evidence-based behaviour change techniques to support self-management.

References:

[1] Araújo-Soares, V. et al (2019).European Psychologist,24(1), 7

[2] Knitza, J., et al (2019).JMIR mHealth and uHealth,7(8), e14991

Acknowledgments:

Versus Arthritis (Grant 22026)

Disclosure of Interests:

None declared

SAT0614-HPR IDENTIFYING AND OPTIMISING MULTIPLE INTERVENTION COMPONENTS AND THEIR DELIVERY WITHIN A SELF-MANAGEMENT SMARTPHONE APP FOR PEOPLE WITH SJÖGREN’S SYNDROME: A QUALITATIVE STUDY

Background:

Sjögren’s syndrome (SS) is an autoimmune rheumatic disease with diverse symptoms including mental and physical fatigue, dryness, pain and sleep disturbances. These symptoms are interconnected and rarely occur in isolation. Improving symptoms and quality of life requires people with SS to navigate multiple interventions and engage in self-management. Smartphone applications (apps) can deliver multiple cognitive and behaviour-based interventions in users’ everyday daily lives and are readily accessible. However, delivering several therapeutic interventions together within a single coherent self-management app requires systematic and evidence-based selection of intervention components, and an understanding of existing self-management approaches and their associated challenges for those living with SS.

Objectives:

To identify theory-based intervention components for inclusion in a SS self-management app. To understand the self-management approaches and challenges of those living with SS to inform in-app component delivery.

Methods:

First, to identify intervention components within the app, existing interventions that target each symptom of fatigue, dryness, pain, sleep disturbance were identified through a literature search. Their content was coded by the research team using behaviour change techniques and the Theoretical Domains Framework1. The content was grouped to form five intervention components which target multiple symptoms.

Second, to understand SS self-management approaches and challenges, 13 people living with SS took part in a series of qualitative focus groups (n=6) and design workshops (n=7). Focus groups involved participants discussing their own self-management experiences and approaches (e.g. when and how they employed a variety of techniques). In design workshops participants sketched metaphors to explain these experiences and used craft materials to create “Magic Machines”2addressing their self-management challenges. Focus groups and design workshops were audio-recorded, transcribed, thematically analysed as a single data set, and findings mapped to the self-determination theory3dimensions of capability, autonomy, and relatedness.

Results:

Intervention components identified were: i) SS psychoeducation, ii) relaxation techniques, iii) activity pacing and goal setting, iv) assertiveness and communication skills, and v) sleep and dryness tips. Participants tackled complex symptom patterns (i.e. symptom interrelatedness and flares) using different self-management approaches; reactively (focusing on the most severe symptom) or systematically (one symptom at a time). Knowing which intervention techniques to choose was felt to be challenging; however the availability of multiple interventions techniques provided a sense of optimism and motivation. Participants were enthusiastic about accessing several intervention techniques via an app, but warned that smartphones and technology can exacerbate mental fatigue and eye dryness. The invisible nature of symptoms, and highly visible nature of management techniques (e.g. applying eye drops), presented further self-management challenges relating to their interactions with other people.

Conclusion:

Promising components to include in an SS app were identified but should be tested in an optimisation trial. The in-app delivery of component modules should be designed to support diverse self-management approaches, choice and autonomy, yet provide module recommendations and guidance when needed, and be simple to use to reduce mental fatigue and dry eye symptoms. A self-management app should also be designed to enable users to share information about SS with other people.

References:

[1] Cane J, et al. (2012)Implementation science,7(1), 37.

[2]Andersen K, & Wakkary R. (2019)CHI Conference on Human Factors in Computing Systems(p. 1-13).

[3]Deci E, & Ryan R (2008)Canadian psychology, 49(3), 182.

Acknowledgments:

Versus Arthritis (Grant 22026)

Disclosure of Interests:

None declared

How well do services for young people with long term conditions deliver features proposed to improve transition?

BACKGROUND

For young people with long-term conditions, transition from child to adult-oriented health services is a critical period which, if not managed well, may lead to poor outcomes. There are features of transition services which guidance and research suggest improve outcomes. We studied nine such features, calling them 'proposed beneficial features': age-banded clinic; meet adult team before transfer; promotion of health self-efficacy; written transition plan; appropriate parent involvement; key worker; coordinated team; holistic life-skills training; transition manager for clinical team. We aimed to describe the extent to which service providers offer these nine features, and to compare this with young people's reported experience of them.

METHODS

A longitudinal, mixed methods study followed 374 young people as their care moved from child to adult health services. Participants had type 1 diabetes, cerebral palsy or autism spectrum disorder with additional mental health difficulties. Data are reported from the first two visits, one year apart.

RESULTS

Three hundred four (81.3%) of the young people took part in the second visit (128 with diabetes, 91 with autism, 85 with cerebral palsy). Overall, the nine proposed beneficial features of transition services were poorly provided. Fewer than half of services stated they provided an age-banded clinic, written transition plan, transition manager for clinical team, a protocol for promotion of health self-efficacy, or holistic life-skills training. To varying degrees, young people reported that they had not experienced the features which services said they provided. For instance, the agreement for written transition plan, holistic life-skills training and key worker, was 30, 43 and 49% respectively. Agreement was better for appropriate parent involvement, age-banded clinic, promotion of health self-efficacy and coordinated team at 77, 77, 80 and 69% respectively. Variation in the meaning of the features as experienced by young people and families was evident from qualitative interviews and observations.

CONCLUSIONS

UK services provide only some of the nine proposed beneficial features for supporting healthcare transition of young people with long term conditions. Observational studies or trials which examine the influence of features of transition services on outcomes should ensure that the experiences of young people and families are captured, and not rely on service specifications.

Qualitative methods in a randomised controlled trial: the role of an integrated qualitative process evaluation in providing evidence to discontinue the intervention in one arm of a trial of a decision support tool

OBJECTIVE

To understand participants' experiences and understandings of the interventions in the trial of a computerised decision support tool in patients with atrial fibrillation being considered for anti-coagulation treatment.

DESIGN

Qualitative process evaluation carried out alongside the trial: non-participant observation and semistructured interviews.

PARTICIPANTS

30 participants aged >60 years taking part in the trial of a computerised decision support tool.

RESULTS

Qualitative evidence provided the rationale to undertake a decision to discontinue one arm of the trial on the basis that the intervention in that arm, a standard gamble values elicitation exercise was causing confusion and was unlikely to produce valid data on participant values.

CONCLUSIONS

Qualitative methods used alongside a trial allow an understanding of the process and progress of a trial, and provide evidence to intervene in the trial if necessary, including evidence for the rationale to discontinue an intervention arm of the trial.

"We saw human guinea pigs explode"

L Stobbart and colleagues examine newspaper coverage of adverse events in the TGN1412 trial