A monitoring and feedback tool embedded in a counselling protocol to increase physical activity of patients with COPD or type 2 diabetes in primary care: study protocol of a three-arm cluster randomised controlled trial

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A monitoring and feedback tool embedded in a counselling protocol to increase physical activity of patients with COPD or type 2 diabetes in primary care: study protocol of a three-arm cluster randomised controlled trial

BACKGROUND: Physical activity is important for a healthy lifestyle. Although physical activity can delay complications and decrease the burden of the disease, the level of activity of patients with chronic obstructive pulmonary disease (COPD) or type 2 Diabetes Mellitus (DM2) is often far from optimal. To stimulate physical activity, a monitoring and feedback tool, consisting of an accelerometer linked to a smart phone and webserver (It’s LiFe! tool), and a counselling protocol for practice nurses in primary care was developed (the Self-management Support Program). The main objective of this study is to measure the longitudinal effects of this counselling protocol and the added value of using the tool. METHODS/DESIGN: This three-armed cluster randomised controlled trial with 120 participants with COPD and 120 participants with DM2 (aged 40–70), compares the counselling protocol with and without the use of the tool (group 1 and 2) with usual care (group 3). Recruitment takes place at GP practices in the southern regions of the Netherlands. Randomisation takes place at the practice level. The intended sample (three arms of 8 practices) powers the study to detect a 10-minute difference of moderate and intense physical activity per day between groups 1 and 3. Participants in the intervention groups have to visit the practice nurse 3–4 times for physical activity counselling, in a 4-6-month period. Specific activity goals tailored to the individual patient's preferences and needs will be set. In addition, participants in group 1 will be instructed to use the tool in daily life. The primary outcome, physical activity, will be measured in all groups with a physical activity monitor (PAM). Secondary outcomes are quality of life, general - and exercise - self-efficacy, and health status. Follow-up will take place after 6 and 9 months. Separately, a process evaluation will be conducted to explore reasons for trial non-participation, and the intervention’s acceptability for participating patients and nurses. DISCUSSION: Results of this study will give insight into the effects of the It’s LiFe! monitoring and feedback tool combined with care from a practice nurse for people with COPD or DM2 on physical activity. TRIAL REGISTRATION: ClinicalTrials.gov: NCT0186797

Evaluating the impact of physical activity apps and wearables: interdisciplinary review

Background: Although many smartphone apps and wearables have been designed to improve physical activity, their rapidly evolving nature and complexity present challenges for evaluating their impact. Traditional methodologies, such as randomized controlled trials (RCTs), can be slow. To keep pace with rapid technological development, evaluations of mobile health technologies must be efficient. Rapid alternative research designs have been proposed, and efficient in-app data collection methods, including in-device sensors and device-generated logs, are available. Along with effectiveness, it is important to measure engagement (ie, users’ interaction and usage behavior) and acceptability (ie, users’ subjective perceptions and experiences) to help explain how and why apps and wearables work. Objectives: This study aimed to (1) explore the extent to which evaluations of physical activity apps and wearables: employ rapid research designs; assess engagement, acceptability, as well as effectiveness; use efficient data collection methods; and (2) describe which dimensions of engagement and acceptability are assessed. Method: An interdisciplinary scoping review using 8 databases from health and computing sciences. Included studies measured physical activity, and evaluated physical activity apps or wearables that provided sensor-based feedback. Results were analyzed using descriptive numerical summaries, chi-square testing, and qualitative thematic analysis. Results: A total of 1829 abstracts were screened, and 858 articles read in full. Of 111 included studies, 61 (55.0%) were published between 2015 and 2017. Most (55.0%, 61/111) were RCTs, and only 2 studies (1.8%) used rapid research designs: 1 single-case design and 1 multiphase optimization strategy. Other research designs included 23 (22.5%) repeated measures designs, 11 (9.9%) nonrandomized group designs, 10 (9.0%) case studies, and 4 (3.6%) observational studies. Less than one-third of the studies (32.0%, 35/111) investigated effectiveness, engagement, and acceptability together. To measure physical activity, most studies (90.1%, 101/111) employed sensors (either in-device [67.6%, 75/111] or external [23.4%, 26/111]). RCTs were more likely to employ external sensors (accelerometers: P=.005). Studies that assessed engagement (52.3%, 58/111) mostly used device-generated logs (91%, 53/58) to measure the frequency, depth, and length of engagement. Studies that assessed acceptability (57.7%, 64/111) most often used questionnaires (64%, 42/64) and/or qualitative methods (53%, 34/64) to explore appreciation, perceived effectiveness and usefulness, satisfaction, intention to continue use, and social acceptability. Some studies (14.4%, 16/111) assessed dimensions more closely related to usability (ie, burden of sensor wear and use, interface complexity, and perceived technical performance). Conclusions: The rapid increase of research into the impact of physical activity apps and wearables means that evaluation guidelines are urgently needed to promote efficiency through the use of rapid research designs, in-device sensors and user-logs to assess effectiveness, engagement, and acceptability. Screening articles was time-consuming because reporting across health and computing sciences lacked standardization. Reporting guidelines are therefore needed to facilitate the synthesis of evidence across disciplines

Toward Integration of mHealth in Primary Care in the Netherlands: A Qualitative Analysis of Stakeholder Perspectives

Background: There is a growing need to structurally change the way chronic illness care is organized as health systems struggle to meet the demand for chronic care. mHealth technologies can alter traditional approaches to health care provision by stimulating self-management of chronically ill patients. The aim of this study was to understand the complex environment related to the introduction of mHealth solutions into primary care for chronic disease management while considering health system functioning and stakeholder views. Methods: A transdisciplinary approach was used informed by the Interactive Learning and Action (ILA) methodology. Exploratory interviews (n = 5) were held with representatives of stakeholder groups to identify and position key stakeholders. Subsequently, professionals and chronically ill patients were consulted separately to elaborate on the barriers and facilitators in integration, using semi-structured interviews (n = 17) and a focus group (n = 6). Follow-up interviews (n = 5) were conducted to discuss initial findings of the stakeholder analysis. Results: Most stakeholders, in particular primary care practitioners and patients, seem to have a supporting or mixed attitude toward integration of mHealth. On the other hand, several powerful stakeholders, including primary care information system developers and medical specialists are likely to show resistance or a lack of initiative toward mHealth integration. Main barriers to mHealth integration were a lack of interoperability with existing information systems; difficulties in financing mHealth implementation; and limited readiness in general practices to change. Potential enablers of integration included co-design of mHealth solutions and incentives for pioneers. Conclusion: Stakeholders acknowledge the benefits of integrating mHealth in primary care. However, important barriers perceived by end-users prevent them to fully adopt and use mHealth. This study shows that the complexity of introducing mHealth into primary care calls for strategies encouraging collaboration between multiple stakeholders to enhance successful implementation

Older Adult Caregivers’ Lived Experiences With Debilitated Chronically Ill Relatives in a Rural Southern County

By 2030, the last of the baby boomer generation will reach the age of 65, which will expand the older adult population to more than 70 million in the United States. Based on the inflated numbers of the older adult population and the noted decreased birth rate in the younger population, fewer health-care providers will be available to teach, prepare, train, and assist caregivers in the ongoing care of their ill relatives. The problem investigated in the study involved the present upsurge of the older adult population living longer and contributing to a shortage of health-care providers for older adults. Baby boomers account for 40% of active registered nurses entering into retirement. This qualitative study aimed to identify older adult caregivers’ lived experiences with debilitated chronically ill relatives in a rural southern county, as well as to explore the trend of elderly caring for the elderly and the possible unfortunate outcomes and challenges related to the reduction in health professionals for family caregiving. The findings of this study indicated the lived experience of elderly caregivers for elderly patients is characterized by stress, resentment, and frustration. Caregiver participants spend the majority of their days providing care for others, with little time left for themselves. There is a sense of constantly feeling overwhelmed by circumstances but with no good alternative solution. Compounding this was the feeling that they had to take the verbal abuse and sometimes physical aggression that their husbands and brothers displayed toward them, which was how these men expressed their resentment and frustration. Receiving such aggression made participants resentful of their patients and frustrated with the patients and the circumstances of providing care

Factors affect the social engagement among community dwelling older person: community nurses perspective.

INTRODUCTION: Remaining involved in activities that are meaningful and purposeful and maintaining chose relationship. METHOD: Descriptive qualitative research approach. CONCLUSION: Promoting a considerate cultures in all levels of society is fundamental to create friendly and conducive environment for all people

Systematic Review of Practice Facilitation and Evaluation of a Chronic Illness Care Management Tailored Outreach Facilitation Intervention for Rural Primary Care Physicians

Nearly two decades of research on translating evidence-based care guidelines into practice has resulted in a considerable body of primary and secondary evidence about guideline implementation strategies and the individual, organizational and environmental challenges associated with closing the evidence to practice gap in primary care. Interventions to improve professional performance are complex and a disentangling of the various independent, intervening and constraining variables is required in order to be able to design and implement interventions that can improve primary care practice performance. The PRECEDE-PROCEED planning model (Green & Kreuter, 1999) provides a step-wise theoretical framework for understanding the complexity of causal relationships among the variables that affect the adoption of evidence-based practice and may assist in the design and implementation of practice-based interventions. Knowledge of an evidence-based practice guideline is important, but a consensus has emerged that having knowledge is rarely sufficient to change practice behaviour. Didactic education or passive dissemination strategies are ineffective, whereas interactive education, reminder systems and multifaceted interventions tailored to the needs of the practice are effective. Outreach or practice facilitation is a proven effective multifaceted approach that involves skilled individuals who enable others, through a range of tailored interventions, to address the challenges in implementing evidence-based care guidelines within the primary care setting. The challenges to implementing evidence-based chronic illness care practice guidelines are thought to be similar to the other contextual, organizational and individual behavioural challenges associated with the uptake of research findings into practice. A multifaceted guideline implementation strategy such as practice facilitation may be well-suited to improving the adoption of these guidelines within rural primary care settings. However, research has not systematically reviewed, through meta-analysis, the published practice facilitation trials to determine overall effects and an implementation research study of practice facilitation that has considered fidelity of implementation within the rural Ontario setting for a complex practice guideline such as chronic illness management has not been done. The systematic review in the thesis incorporated an exploratory meta-analysis of randomized and non-randomized controlled trials of interventions targeted towards implementing evidence-based practice guidelines through practice facilitation, and was conducted to gain an understanding of the overall effect of practice facilitation and the factors that moderate implementation success. The results were the identification of an improvement overtime in the methodological rigour of practice facilitation implementation research based on a critical appraisal of methods, a significant moderate overall effect size of 0.54 (95% CI 0.43 – 0.65) for 19 good quality practice facilitation intervention studies and several significant effect size modifiers; notably, tailoring to the needs of the practice, using multiple intervention components, extending duration, and increasing the intensity of practice facilitation were associated with larger effect sizes. As more practices were assigned to the practice facilitator, the effect diminished. A significant positive association between the number of PRECEDE predisposing, enabling and reinforcing strategies employed by the facilitator and the effect size was detected. The implementation research study utilized mixed methods for data collection as part of an embedded case study of four rural primary care practices to determine the implementation fidelity of the practice facilitation of chronic illness care planning and the factors that impeded and contributed to implementation success. The feasibility of and potential cost savings of practice facilitation via videoconferencing was also implemented for two of the practices. For those practices that successfully implemented care planning, fidelity was achieved for the implementation of care plans. On the other hand, the dosage, duration, component delivery of the practice facilitation intervention was low in comparison to other published studies, and tailoring of the intervention to the practice was inconsistent. Based on the qualitative analysis of physician interviews, the moderating factors for successful implementation were categorized into the broad themes of pessimism and tempered optimism. Pessimistic physicians were unsuccessful at implementation, lacked a willingness to engage and were uncomfortable with the patient-centred approach to chronic illness care. Optimists were positive about the psychosocial, patient-centred assessment aspects of the chronic illness care protocol and provided anecdotes of success in resolving patient problems. However, this was tempered as both pessimists and optimists reflected on the time intensive aspect of the protocol and the unlikelihood of widespread implementation without additional supports. Participating physicians were satisfied with the facilitator and the videoconferencing experience, and the intervention cost analysis revealed opportunities for cost saving via the use of videoconferenced facilitation. Improvements to the intervention suggested by participants included integrating chronic illness management with medical information systems, involving other health disciplines, and forming networks of community health resources and support services for health providers and patients. This work has demonstrated that although practice facilitation can successfully result in moderate significant improvements in practice behaviour, it is not necessarily singularly effective in all contexts or for all targeted behaviours. A complex practice guideline such as the chronic illness care management model is unlikely to be adopted in the current context of primary care in rural Ontario and as a consequence to have any impact on the health of chronically ill patients without further intervention supports, adaptation, and implementation research undertaken to demonstrate successful execution of chronic illness care management. Alternative care delivery models are required to address barriers and improve the delivery of chronic illness care management

Improving the quality of care for older adults:Towards person-centred integrated care supported by digital health technology

Healthy ageing is a global priority as people worldwide are living longer. With longer lifespans, older adults are at increased risk of chronic conditions. Service provision based on disease-specific guidelines can be inappropriate for people with multiple health conditions; care can become duplicative and inefficient due to poor coordination. Person-centred integrated care is seen as a promising approach to delivering care that is proactive, coordinated and centred around people’s needs. In addition, digital health technology has the potential to involve patients better in their care process and could, therefore, support person-centred integrated care. The aim of the research presented in this thesis was to improve the quality of care for older adults by studying person-centred integrated care supported by digital health technology