Planning & Implementing a Planning & Implementing a Patient-Centered Intervention Patient-Centered Intervention

for Health Promotionfor Health Promotion

Diane Ruth Lauver, PhD APRN BC FAAN

Professor

Primary Care Conference 11-15-06

Objectives Objectives

• Introduce theory guiding a program of research

• Present findings from descriptive study of patients’ goals

• Share the design for & preliminary findings from feasibility study re: health promotion in primary care

Health-related Goals Among Health-related Goals Among Primary Care PatientsPrimary Care Patients

*Diane Ruth Lauver, PhD APRN BC FAAN

+Chiraporn Worawong, MSN, RN

#Christine Olsen, MSN RN WHNP

*University of Wisconsin-Madison School of Nursing

+Srimahasarakham Nursing College, Thailand

#Reproductive Health Center of Madison, Wisconsin

AcknowledgementsAcknowledgements

• Grant: UW-Madison, School of Nursing Research Committee

• Recruitment: Ann Baggot, MS WH NP, Carol Glassroth, MS APRN FNP, Kelly Kruse Nelles MS NP, Elaine Rosenblatt, MSN, APRN, BC, & Jean Marie Sharp, MS WHNP;

• Content Analyses: Kim Ehlers, BS RN; Sheryl Krause, MS, RN; Jennifer Ohlendorf, MS, RN

Health-related BehaviorsHealth-related Behaviors

• Associated with reduced risk of diseases

• Difficult/challenging to initiate & maintain

• Intriguing

Interventions to promote Interventions to promote health behaviorshealth behaviors

• Have not often been individualized on characteristics salient to participants

• Have focused rarely on behaviors chosen by participants

Conceptual Conceptual backgroundbackground

• Patient-centered interventions (PCIs) may be more effective than one-size-fits-all interventions

• Individualizing on participants’ health goals would be promising

Self-determination theorySelf-determination theory

• Autonomy vs. Control

–Motivation• Competence

• Relatedness

–Respecting autonomy or not

Study 1: AimsStudy 1: Aims

• Identify health-related goals in primary care patients

• Describe patients’ preferences about how to reach such goals

• Summarize implications for a PCI involving goals

MethodMethod

• Design: Descriptive

• Settings: Outpatient clinics

–Family practice– Internal medicine–Obstetric/gynecology –Women’s health

Sampling CriteriaSampling Criteria

• Patients seeking non-emergent care

• 18-75 years old

• Scheduled with nurse practitioners

• Able to communicate in English

Sample Sample NN = 60 = 60

• 75% women

• Mean age = 34.6; sd = 12

• Mean years education = 16

• Race & Ethnicity

– 86.2% Caucasian/White – 5.2% Asian/Pacific Islander – 3.4% Latino; 3.4% Multi-racial – 1.7% Native American

InstrumentsInstrumentsQuestions re: health

• Values - future states desired

• Long-term goals - in next 2 months

• Short-term goal - in next week

• Preferences • with whom &• how to address goals & get information • payment for services

Clinical, Social & Clinical, Social & Demographic MeasuresDemographic Measures

• Physical symptoms

– Symptom checklist w/ PRIME MD• Health status

– Overall health & function w/ EuroQOL

– Perceived health w/ Visual Analogue

• Social & Demographic factors

ProcedureProcedure

Questionnaires were

–Anonymous–Provided by clinic staff–Returned

•On leaving clinic •Mailed with SSAE

Data reductionData reduction

Content analyses

–Themes–Categories–Codes

ResultsResults

• Mean physical symptoms = 5.5 /15

• Health status

– Little disability– Perceived health - very good

Common reasons for visitCommon reasons for visit

• Have a preventive visit 35%

• Have screening tests 32%

• Treat symptoms 12%

Goal IdentificationGoal Identification

• 92% - primary goal

• 35% - additional primary goal

• 52% - secondary goal

• 50% - primary & secondary goals

Primary GoalsPrimary Goals

• Get in better shape 40%

• Lose weight 30%

• Change consumption habits 7%

• Manage stress 7%

• Manage disease/illness 5%

Secondary goalsSecondary goals

• Change consumption habits 17%

• Get in better shape 13%

• Lose weight 7%

• Manage stress 7%

• Manage disease/illness 7%

How could NP be of How could NP be of help?help?

• Provide information & resources 32%

• Monitor progress, status; Encourage, Support, Help in gen’l 32%

• Advise, Suggest in particular 22%

• Help plan, Discuss routine,

Collaboratively set goals 17%

What method of What method of interaction preferred interaction preferred

initially?initially?• Face to face 25%

• Email 22%

• Phone 10%

• Website 3%

With whom prefer working?With whom prefer working?

• On own 56%

• With peers in pairs 22%

• In group 13%

DiscussionDiscussion

• New information re: patients’ goals

• Nearly all had health goals

• Most common goals•Get in better shape •Lose weight

• Preferences re: how to address goals

Participants’ goalsParticipants’ goals

• Reflect current public health policies & concerns

• Consistent with practice initiatives

–Nursing–Medicine–Health education

LimitationsLimitations

• Lack of diversity– Education– Gender– Race & Ethnicity

• Findings most applicable to samples similar to ours

Implications for Implications for practicepractice

Clinicians can:

–Recognize many patients have health goals

–Assess patients’ goals–Prepare to address common goals •Getting in shape •Controlling weight

Implications for Theory & Implications for Theory & ResearchResearch

• Test ideas from self-determination theory

– Autonomy re: goals– Perceived competence re: goal

progress– Respectful interpersonal context re:

how

Proposed studyProposed studyAn advanced practice nurse with MS (ex, NP)

• Collaborates 1:1 with participants

• Elicits & refines goals re: physical activity or diet

• Shares relevant information

• Monitors progress

• Offers encouragement & suggestions

• In autonomy respecting relationship

Assessing the feasibility of a Assessing the feasibility of a patient-centered, goal-focused patient-centered, goal-focused

interventionintervention

Diane Lauver PhD AP RN BC

Professor

University of Wisconsin-Madison

School of Nursing

Funding: NIH P20

Patient-Centered Interventions

AcknowledgementsAcknowledgements

• Recruitment: Julie Setzkorn-Brown w/ Funneling Project, Julia Greenleaf

• Interveners: Karen Cooper, RN MS; MaryJo Borden, RN MS

• Research team: Chiraporn Worawong, Colleen Foley, Rebecca West, Joseph Howell

Study 2: 1Study 2: 1stst Aim Aim• To assess feasibility of a patient-

centered intervention focused on participants’ health goals & based on SDT re:

– Recruitment &– Retention of participants– Delivery & – Acceptability of intervention

Study 2: 2Study 2: 2ndnd Aim Aim

• Explore intervention effects --to estimate effect sizes & power for future -- on

– Recommended health behaviors– Goal attainment– Perceived competence

Self-determination Self-determination theorytheory

• Autonomy vs. Control

– Motivation• Competence

• Relatedness

–Respecting autonomy or not

SDT applied to Patient-centered SDT applied to Patient-centered Interventions re: Health behavior GoalsInterventions re: Health behavior Goals

Individualized behavioral goals & practical plans to attain goals & feedback on goal attainment

Improved health outcomes

Autonomy re behavior change

Perceived competence for behavior change

Initial & maintained behavior change

Intervention

Mediator

Outcomes

MethodMethod

Design:

– One group, pre- post-intervention

– based on SDT

– focused on goals re: physical activity or diet

– 1 month post-intervention interview

SettingSetting

• Mid-west, USA

• Recruitment sites

– Primary care clinics

– Statewide program providing support for screening for those who cannot afford it

SampleSample

Sought 40 community-dwelling adults

18- 65

w/o new, untreated or unstable conditions

Able to read, write English

Obtained 54 participants, typically

– Caucasian– Women– Well-educated

Intervention: 1Intervention: 1stst Contact Contact

• APN provided autonomy--supportive relationship

• Assessed values, long term goals, sub-goals (choice/autonomy)

• Collaboratively refined goals to be reasonable, safe &

• Attainable (goals chosen, challenging, not too difficult; characteristics for goal attainment)

• Elicited reasons (motivation)

• Identified obstacles & problem-solved ways to overcome obstacles (perceived competence)

• Set realistic, challenging sub-goals for week (support goal progress & perceived competence)

Intervention: Follow-up Intervention: Follow-up contacts contacts

• Weekly x 5

• In autonomy-supportive relationship, assess & discuss

– Goals (choice, autonomy)– Goal progress – Obstacles & dealing with them

• Refine goals to be attainable

• Support perceived competence

APN IntervenerAPN Intervener

• Selected for experience with

– Respecting others’ decisions, autonomy– Counseling for behavior change– Community-dwelling clients

• Trained by PI & team

– Discussed SDT, research, proposal & protocols

– Role played intervention w/ team & friends

– Meetings every 1-2 weeks

Measures: Pre- & Post-InterventionMeasures: Pre- & Post-Intervention

• Brief measures of physical activity, fruit/vegetable & fat intake

• Perceived competence in engaging in desired health behavior

Assessments: During the Assessments: During the interventionintervention

• APNs rated feasibility of intervention delivery

• Research team reviewed audio-tapes of APNs intervention delivery to assess validity

Measures: Post-Measures: Post-interventionintervention

• Participants’ acceptability ratings

– Procedures•Where, when, how, with whom

• Behavioral tools, from NIH

– Physical activity - 7-day recall– Diet- Block’s fruit/veg & fat

ProceduresProcedures

• Volunteers called office

• RN – screened callers, – obtained pre-intervention measures, – scheduled eligible participants with APN

• APN provided patient-directed, nurse facilitated discussion

• 1 month later RN obtained post-intervention measures

Preliminary Findings re: Preliminary Findings re: FeasibilityFeasibility

• Recruitment– More volunteers than expected; ~ 80%

eligible– Not from diverse populations

• Retention– Good ~ 83%

• Delivery

APNs rated feasibility highly; (3.7-3.9/4 pts)

Ratings of APN delivery for rigor - high

Findings: Participants’ Findings: Participants’ AcceptabilityAcceptability

• Ratings - high (4.2-4.8/5 point scale)

– study met their needs– nurse-intervener was helpful & – knowledgeable.

Findings: Participants’ Findings: Participants’ ratingsratings

• Perceived competence w/ health behaviors improved over time

• Perceived autonomy support from APNs rated highly

Findings: Participants’ Findings: Participants’ Feedback Feedback

Suggested

– lengthen intervention > 6 weeks

–revise the goals work sheet–decrease length of questionnaires

Goals & attainmentGoals & attainment

• Type of goals

--About ½ physical activity, about ½ diet

• 53% made some progress on program goals

• 1/4 achieved program goals

• 1/5 did not make progress on goals

Exploring Pre- Post- Exploring Pre- Post- Behaviors Behaviors

• Brief Behavior Measures - shift from little to more behavioral engagement

– Fruit/vegetable intake increased– fat intake decreased– aerobic physical activity improved, among participants with

corresponding goals

Preliminary ConclusionsPreliminary Conclusions

• Feasible to

– Recruit – Retaining participants– Deliver intervention by APNs– Acceptability of process to

participants

Findings lend support to Findings lend support to ideasideas

PCI could improve

health goal attainment

recommended health behavior

perceived competence &

influence perceived autonomy support

Future researchFuture research

• Design experimental 2 group study

• Longer longitudinal study

• Based on SDT & goal theories

• Test efficacy of goal-focused PCI on health behavior & bio-markers

• Seek a larger, more diverse sample

Future researchFuture research

• Test mechanisms of perceived

autonomy

competence

congruence

• Examine role of social desirability

Fidelity of interventionFidelity of intervention

Met weekly

Assessed APN intervener’s interactions on audiotapes & reviewed written documents

Assessed participants’ perceptions

autonomy-support

congruence of values, goals, subgoals

Preliminary findings re: Preliminary findings re: ValidityValidity

• Participants’ autonomy-support ratings were high (4.6-4.9/5 point scale)

• Perceived competence improved

• Participants’ ratings of concordance increased

Preliminary findingsPreliminary findings

• Type of reasons– Gives me sense of control– I’ll feel better– Decreases cravings for food

• Type of obstacles– Lack of time– Lack of knowledge– Social gatherings interfere