Planning & Implementing a Patient-Centered Intervention for Health Promotion

1. Planning & Implementing a Patient-Centered Intervention for Health Promotion Diane Ruth Lauver, PhD APRN BC FAAN Professor Primary Care Conference 11-15-06

2. 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

3. Health-related Goals Among Primary 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

4. Acknowledgements • 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

5. Health-related Behaviors • Associated with reduced risk of diseases • Difficult/challenging to initiate & maintain • Intriguing

6. Interventions to promote health behaviors • Have not often been individualized on characteristics salient to participants • Have focused rarely on behaviors chosen by participants

7. Conceptual background • Patient-centered interventions (PCIs) may be more effective than one-size-fits-all interventions • Individualizing on participants’ health goals would be promising

8. Self-determination theory • Autonomy vs. Control • Motivation • Competence • Relatedness • Respecting autonomy or not

9. Study 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

10. Method • Design: Descriptive • Settings: Outpatient clinics • Family practice • Internal medicine • Obstetric/gynecology • Women’s health

11. Sampling Criteria • Patients seeking non-emergent care • 18-75 years old • Scheduled with nurse practitioners • Able to communicate in English

12. Sample N = 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

13. Instruments Questions 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

14. Clinical, Social & Demographic Measures • Physical symptoms • Symptom checklist w/ PRIME MD • Health status • Overall health & function w/ EuroQOL • Perceived health w/ Visual Analogue • Social & Demographic factors

15. Procedure Questionnaires were • Anonymous • Provided by clinic staff • Returned • On leaving clinic • Mailed with SSAE

16. Data reduction Content analyses • Themes • Categories • Codes

17. Results • Mean physical symptoms = 5.5 /15 • Health status • Little disability • Perceived health - very good

18. Common reasons for visit • Have a preventive visit 35% • Have screening tests 32% • Treat symptoms 12%

19. Goal Identification • 92% - primary goal • 35% - additional primary goal • 52% - secondary goal • 50% - primary & secondary goals

20. Primary Goals • Get in better shape 40% • Lose weight 30% • Change consumption habits 7% • Manage stress 7% • Manage disease/illness 5%

21. Secondary goals • Change consumption habits 17% • Get in better shape 13% • Lose weight 7% • Manage stress 7% • Manage disease/illness 7%

22. How could NP be of 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%

23. What method of interaction preferred initially? • Face to face 25% • Email 22% • Phone 10% • Website 3%

24. With whom prefer working? • On own 56% • With peers in pairs 22% • In group 13%

25. Discussion • 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

26. Participants’ goals • Reflect current public health policies & concerns • Consistent with practice initiatives • Nursing • Medicine • Health education

27. Limitations • Lack of diversity • Education • Gender • Race & Ethnicity • Findings most applicable to samples similar to ours

28. Implications for practice Clinicians can: • Recognize many patients have health goals • Assess patients’ goals • Prepare to address common goals • Getting in shape • Controlling weight

29. Implications for Theory & Research • Test ideas from self-determination theory • Autonomy re: goals • Perceived competence re: goal progress • Respectful interpersonal context re: how

30. Proposed study An 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

31. Assessing the feasibility of a patient-centered, goal-focused intervention Diane Lauver PhD AP RN BC Professor University of Wisconsin-Madison School of Nursing Funding: NIH P20 Patient-Centered Interventions

32. Acknowledgements • 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

33. Study 2: 1st 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

34. Study 2: 2nd Aim • Explore intervention effects --to estimate effect sizes & power for future -- on • Recommended health behaviors • Goal attainment • Perceived competence

35. Self-determination theory • Autonomy vs. Control • Motivation • Competence • Relatedness • Respecting autonomy or not

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

37. Method Design: • One group, pre- post-intervention • based on SDT • focused on goals re: physical activity or diet • 1 month post-intervention interview

38. Setting • Mid-west, USA • Recruitment sites • Primary care clinics • Statewide program providing support for screening for those who cannot afford it

39. Sample 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

40. Intervention: 1st 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)

41. Intervention: Follow-up 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

42. APN 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

43. Measures: Pre- & Post-Intervention • Brief measures of physical activity, fruit/vegetable & fat intake • Perceived competence in engaging in desired health behavior

44. Assessments: During the intervention • APNs rated feasibility of intervention delivery • Research team reviewed audio-tapes of APNs intervention delivery to assess validity

45. Measures: Post-intervention • Participants’ acceptability ratings • Procedures • Where, when, how, with whom • Behavioral tools, from NIH • Physical activity - 7-day recall • Diet- Block’s fruit/veg & fat

46. Procedures • 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

47. Preliminary Findings re: Feasibility • 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

48. Findings: Participants’ Acceptability • Ratings - high (4.2-4.8/5 point scale) • study met their needs • nurse-intervener was helpful & • knowledgeable .

49. Findings: Participants’ ratings • Perceived competence w/ health behaviors improved over time • Perceived autonomy support from APNs rated highly

50. Findings: Participants’ Feedback Suggested • lengthen intervention > 6 weeks • revise the goals work sheet • decrease length of questionnaires