Barriers to implementing motivational interviewing in addiction treatment: A nominal group technique process evaluation

The successful implementation of evidence-based practices (EBPs) in real-world settings requires an adaptive approach and ongoing process evaluation and tailoring. Although conducting a needs assessment during the preparation phase of implementation is beneficial, it is challenging to predict all barriers to EBP implementation that may arise over the course of implementation and sustainment. This article describes a process evaluation that identified emergent and persistent barriers that impacted the implementation of an EBP across multiple behavioral health organizations and clinics. This study was conducted during the first cohort of a cluster randomized controlled trial testing the effectiveness of the Leadership and Organizational Change for Implementation (LOCI) strategy to implement motivational interviewing (MI) in substance use disorder treatment agencies and clinics. We used a modified nominal group technique (NGT) in which clinic leaders identified barriers faced during the implementation process. Barriers were categorized, then ranked and rated according to leaders' perceptions of each barrier's influence on implementation. The barriers were then contextualized through individual qualitative interviews. Fifteen barriers were identified, grouped into staff-level barriers, management-level barriers, and implementation program barriers. Time and resistance to MI were rated as the most influential staff-level barriers. Among management-level barriers, time was also rated highest, followed by turnover and external contractual constraints. The most influential implementation barrier was client apprehension of recording for fidelity assessment and feedback. Individual interviews supported these findings and provided suggested adaptations for future implementation efforts. EBP implementation is an ongoing process whereby implementation strategies must be proactively and strategically tailored to address emergent barriers. This research described a process evaluation that was used to identify 15 emergent and/or persistent barriers related to staff, management, and the implementation program. Using implementation strategies that can be tailored and/or adapted to such emergent barriers is critical to implementation effectiveness

Conceptualizations of occupation in relation to health: A conversation between theory and experience-near data

Current occupational science theory describes a positive link between occupation and human health. This theory asserts that an essential unit of analysis for understanding health is in every-day human actions (Wilcock, 2006). Indeed, extant literature has identified occupation as a powerful facilitator of health and wellbeing. Consequently, basic theory in occupational science has favored positive implications for health based on engagement in occupations. However, experience-near accounts reveal that engaging in occupation has both positive and negative implications. Recent scholarship in occupational science has recognized this conflict and asserts that further understanding of the occupation-health link is necessary (Durocher, Rappolt, & Gibson, 2014). This panel will advance the discussion between experience-near accounts and basic theory by employing case examples from interdisciplinary research. Presentation #1 will frame the discourse by providing a conceptual map (Feyerabend, 2011) of how occupational science has described the relationship between occupation and health, and identify opportunities for theoretical expansion. We will argue for adopting a dialectic perspective on the occupation-health link. To illustrate the need for expanded theory, a case example will be given employing data from a large mixed-methods ethnographic study (‘Autism in urban context: linking heterogeneity with health and service disparities’, NIMH, R01MH089474, 09/30/2009 - 08/31/2012, Solomon, O., P.I.). These data capture the experiences of a child with ASD and his family related to ways in which his medical and developmental conditions make participation in physical play both transformative and detrimental. Presentation #2 extends this dialogue to the clinical care setting by challenging notions of the health-promoting effects of healthcare providers’ recommendations within chronic disease management. This presenter will provide one exemplar case from a study on diabetes as a lens into the experiences of making agentic choices between maintaining the intensive requirements of diabetes management and engaging in developmentally normative, though potentially risky activities. These choices are further examined using theoretical tools from medical sociology and anthropology combined with concepts introduced within occupational science literature. Presentation #3 will describe the activities of a Latino gang. Drawing from a transactionalism framework and understanding the interrelatedness of contextual conditions to occupation (Dickie, Cutchin & Humphry, 2006). The presenter will discuss the affordances and constraints typical of a gang-inhabited neighborhood, and evaluate both the positive and negative health-related aspects of gangs. Additional excerpts from memoirs and first-hand accounts of former gang members (Rodriguez, 2005) will be analyzed to describe the occupational activities of gangs from a participant perspective. This presentation will critically appraise the limitations of a health-promoting view of occupation by framing culturally grounded information as necessary when describing possible impacts on health. As these presentations will illustrate, occupations lead to flourishing for some aspects of health, but may also lead to some negative impact. The panel will demonstrate the importance of including both the positive and the negative impact into conceptualizations of occupation to better understand how it is linked to human health, wellness and participation. Key Words: Health Promotion, Critical Occupational Science, Experience-Near Research Presenter information Mark E. Hardison, MS, OTR/L¹ Kristine M. Carandang, MS, OTR/L¹ Lucía I. Floríndez, MA¹ Elizabeth A. Pyatak, PhD, OTR/L, CDE² Olga Solomon, PhD² Ruth Zemke, PhD, OTR(Retired), FAOTA³ 1 = Presenter and author, 2 = Author only, 3 = Moderator Affiliation University of Southern California, Mrs. T. H. Chan Division of Occupational Science and Occupational Therapy Acknowledgements Autism in Urban Context: Linking Heterogeneity with Health and Service Disparities (NIMH, R01 MH089474, 2009-2012, O. Solomon, P.I.) Objectives for the Discussion Period 1. Participants will ask questions of the panel to clarify or expand the presentation. 2. Participants will share other experiential examples critically appraising the health-promoting view of occupation. 3. Participants and panel members will explore reconciliation of these observations with basic theory of occupation

Examining relationships between participation, glycemic control, and quality of life

Title: Examining relationships between participation, glycemic control, and quality of life Type of submission: Research paper Purpose: Persons with chronic medical conditions are prescribed self-management regimens with the goal of maintaining physical health, often measured through biological markers. However, self-management regimens are complex and time-consuming; as such, they may interfere with or limit participation in meaningful occupations, which in turn may negatively influence quality of life (e.g. Pyatak, 2011). Therefore, using an occupational science lens (Wilcock, 2007; Durocher, Rappolt, & Gibson, 2014), we examined the relationship between occupational engagement and multiple domains of health using baseline data from the Resilient, Empowered, Active Living with Diabetes (REAL Diabetes) study, a randomized controlled trial of an occupation-based diabetes management intervention. Our presentation focuses on young adults with diabetes and the associations between participation, glycemic control, and quality of life. Methods: The REAL Diabetes study included 81 young adults diagnosed with type 1 or type 2 diabetes from low socioeconomic status and minority backgrounds (Pyatak et al., 2016). We assessed the following: (1) objective participation: frequency of participation across five domains of activities: household activities, productive activities, transportation, leisure, and social activities and (2) subjective participation, calculated by multiplying participants’ ratings of personal importance of individual activities by satisfaction with their frequency of participation in those activities, both measured by the Participation Objective, Participation Subjective scale (POPS) (Brown et al., 2004); (3) glycemic control, as measured by Hemoglobin A1c (HbA1c); and (4) diabetes-related quality of life, as measured by the Audit of Diabetes Dependent Quality of Life. We examined the associations of both domains of participation with HbA1c and diabetes-related quality of life using nonparametric statistical methods, then examined these associations for potential effect modification. Results: Subjective participation was negatively associated with HbA1c (r=-0.23, p=0.04). Diabetes type was an effect modifier for this association (p for interaction=0.03); subjective participation was associated with lower HbA1c in people with type 1 diabetes (p=0.004) but not type 2 diabetes (p=0.22). In addition, subjective participation was positively associated with diabetes-related quality of life among all participants (r=0.24, p=0.03). There were no significant associations between objective participation and HbA1c or diabetes-related quality of life. Implications for Occupational Science: Our findings suggest that satisfaction with, but not frequency of, participation is associated with both physical health and disease-related quality of life. These findings substantiate the link between occupation and health and provide insight that different dimensions of participation (objective versus subjective) make different contributions to well-being. Discussion Questions/Objectives for Discussion: How can healthcare providers and systems incorporate knowledge about subjective participation within approaches to chronic disease management? How does occupational science incorporate objective and subjective domains of participation when examining the relationship between occupation and health? How can occupational scientists engage with other communities to translate research findings about the link between occupation and health into practical applications for health promotion? Three key words: Chronic disease, Self-management, Participatio

Using Patient Experiences of Health Management Occupations to Guide Research on Medical Adherence

Title: Using Patient Experiences of Health Management Occupations to Guide Research on Medical Adherence Topic: Examining the construct of medical adherence through the lens of occupational science Purpose/Aims: Adherence originates from medical science literature and is a revision of the earlier concept of compliance. Modern conceptualization of adherence integrates feedback from patients and expands the patient’s role in directing care. Yet still, medical advice is privileged above patient perspectives maintaining providers in the role of expert. Little is known about how patients’ lived experiences of adherence fit within their occupational experience of health management. In this panel, we will explore the dialogue between the medical perspective of adherence and the lived occupational experiences of patients seeking to heal from an injury or manage a chronic disease. Presentation #1 Methods: Using a review of the literature, Presenter 1 compares the constructs of adherence, compliance, patient-provider communication, and partnership. Result: Evidence in this area remains sparse. We argue that the transactionalism (Cutchin & Dickie, 2012) framework within occupational science is poised to assist in improving patient and provider relationships, and support the occupation of health management through research. Presentation #2 Methods: Presenter 2 reports on emergent qualitative findings from a multi-phase, mixed methods study that explored the impact of rheumatic disease on young adults’ occupational engagement. Young adults (n=12) were individually interviewed using a semi-structured guide. Based on iterative analysis, three participants were then purposively recruited to each complete a series of four additional follow-up narrative interviews. Result: Data revealed diverse experiences when young adults collaborated with rheumatologists to find tailored medication regimens while also exploring strategies to maintain a normal life. Presentation #3 Methods: A mixed-methods, case series was completed with 16 patients receiving care at an outpatient hand therapy clinic. Qualitative data was collected via individual, semi-structured interviews across the patients’ episodes of care, and quantitative survey data was collected after each therapy visit. Result: Quantitative data revealed that therapists rated patients as highly adherent and engaged with little variation. However, patients’ perspectives revealed disparate amounts of engagement in therapy because of the interaction between home life and assigned home exercise. Argument/Importance to Occupational Science: Experience-near accounts of patients provide a contextualized perspective of medical treatment. This reveals how adherence fits as a component of the occupation of health management, and expands current understandings of adherence in order to support patients in future applied occupational science research. (397 Words) Key Words: Transactionalism, Health Management Occupations, Adherence, Engagement Objectives for Discussion: Does the current literature as discussed in presentation 1 on adherence accurately describe the construct as patients experience it as seen in presentations 2 and 3? How so? How do the results of presentation 2 and 3 fit with or contradict frameworks in Occupational Science (e.g. Transactionalism, Systems Theory)? What is the opportunity for applied Occupational Science in reframing the medical research on adherence? What are the next steps with this line of work (e.g., development of a model, development of outcome measures for engagement or adherence)

Pediatric to Adult Transition Literature: Scoping Review and Rheumatology Research Prioritization Survey Results

The transition from pediatric to adult care is the focus of growing research. It is important to identify how to direct future research efforts for maximum impact. Our goals were to perform a scoping review of the transition literature, highlight gaps in transition research, and offer stakeholder guidance on the importance and feasibility of research questions designed to fill identified gaps.The transition literature on rheumatic diseases and other common pediatric-onset chronic diseases was grouped and summarized. Based on the findings, a survey was developed and disseminated to pediatric rheumatologists and young adults with rheumatic diseases as well as their caregivers.The transitional care needs of patients, healthcare teams, and caregivers is well-described in the literature. While various transition readiness scales exist, no longitudinal post-transfer study confirms their predictive validity. Multiple outcome measures are used alone or in combination to define a successful transition or intervention. Multimodal interventions are most effective at improving transition-related outcomes. How broader health policy affects transition is poorly studied.Research questions ranked highest for importance and feasibility included those related to identifying and tracking persons with psychosocial vulnerabilities or other risk factors for poor outcomes. Interventions surrounding improving self-efficacy and health literacy were also ranked highly. In contrast to healthcare teams (n=107), young adults/caregivers (n=23) prioritized research surrounding improved work, school or social function.The relevant transition literature is summarized and future research questions prioritized, including the creation of processes to identify and support young adults vulnerable to poor outcomes

2021 American College of Rheumatology Guideline for the Treatment of Rheumatoid Arthritis

ObjectiveTo develop updated guidelines for the pharmacologic management of rheumatoid arthritis.MethodsWe developed clinically relevant population, intervention, comparator, and outcomes (PICO) questions. After conducting a systematic literature review, the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to rate the certainty of evidence. A voting panel comprising clinicians and patients achieved consensus on the direction (for or against) and strength (strong or conditional) of recommendations.ResultsThe guideline addresses treatment with disease-modifying antirheumatic drugs (DMARDs), including conventional synthetic DMARDs, biologic DMARDs, and targeted synthetic DMARDs, use of glucocorticoids, and use of DMARDs in certain high-risk populations (i.e., those with liver disease, heart failure, lymphoproliferative disorders, previous serious infections, and nontuberculous mycobacterial lung disease). The guideline includes 44 recommendations (7 strong and 37 conditional).ConclusionThis clinical practice guideline is intended to serve as a tool to support clinician and patient decision-making. Recommendations are not prescriptive, and individual treatment decisions should be made through a shared decision-making process based on patients' values, goals, preferences, and comorbidities

2021 American College of Rheumatology Guideline for the Treatment of Rheumatoid Arthritis

Guidelines and recommendations developed and/or endorsed by the American College of Rheumatology (ACR) are intended to provide general guidance for commonly encountered clinical scenarios. The recommendations do not dictate the care for an individual patient. The ACR considers adherence to the recommendations described in this guideline to be voluntary, with the ultimate determination regarding their application to be made by the clinicians in light of each patient’s individual circumstances. Guidelines and recommendations are intended to promote beneficial or desirable outcomes but cannot guarantee any specific outcome. Guidelines and recommendations developed and endorsed by the ACR are subject to periodic revision as warranted by the evolution of medical knowledge, technology, and practice. ACR recommendations are not intended to dictate payment or insurance decisions, or drug formularies or other third-party analyses. Third parties that cite ACR guidelines should state that these recommendations are not meant for this purpose. These recommendations cannot adequately convey all uncertainties and nuances of patient care. The American College of Rheumatology is an independent, professional, medical and scientific society that does not guarantee, warrant, or endorse any commercial product or service. OBJECTIVE. To develop updated guidelines for the pharmacologic management of rheumatoid arthritis. METHODS. We developed clinically relevant population, intervention, comparator, and outcomes (PICO) questions. After conducting a systematic literature review, the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to rate the certainty of evidence. A voting panel comprising clinicians and patients achieved consensus on the direction (for or against) and strength (strong or conditional) of recommendations. RESULTS. The guideline addresses treatment with disease-modifying antirheumatic drugs (DMARDs), including conventional synthetic DMARDs, biologic DMARDs, and targeted synthetic DMARDs, use of glucocorticoids, and use of DMARDs in certain high-risk populations (i.e., those with liver disease, heart failure, lymphoproliferative disorders, previous serious infections, and nontuberculous mycobacterial lung disease). The guideline includes 44 recommendations (7 strong and 37 conditional). CONCLUSION. This clinical practice guideline is intended to serve as a tool to support clinician and patient decision-making. Recommendations are not prescriptive, and individual treatment decisions should be made through a shared decision-making process based on patients’ values, goals, preferences, and comorbidities