Design, Delivery, Maintenance, and Outcomes of Peer-to-Peer Online Support Groups for People With Chronic Musculoskeletal Disorders: Systematic Review

Background: Online support groups (OSGs) are one way for people with chronic diseases, their family or friends, and health professionals to communicate, gain information, and provide social support. As the number of peer-to-peer OSGs for chronic musculoskeletal conditions grows, it is important to gain insight into the different designs of groups available, who is accessing them, if and how they may be effective, and what strategies are being used to implement or increase consumer engagement. Objective: The objectives of this systematic review of people with musculoskeletal conditions were to (1) describe the design features (functions, usage options, moderation, and expert input) of peer-to-peer OSGs, (2) describe the characteristics of the individuals using peer-to-peer OSGs, (3) synthesize the evidence on outcomes of participation, and (4) identify strategies used in the delivery and maintenance of OSGs. Methods: A search comprising terms related to the population (people with musculoskeletal disorders) and the intervention (peer-to-peer OSGs) was conducted in 6 databases. Results were filtered from 1990 (internet inception) to February 2019. Studies identified in the search were screened according to predefined eligibility criteria using a 2-step process. Quantitative studies were appraised by 2 reviewers using the Risk Of Bias In Non-Randomized Studies of Interventions tool. Qualitative studies were appraised by 2 different reviewers using the Critical Appraisal Skills Programme checklist. Extracted data were synthesized narratively. Results: We examined 21 studies with low to moderate risk of bias. Of these studies, 13 studies included OSGs hosted on public platforms, 11 studies examined OSGs that were conducted in English, and 6 studies used moderators or peer leaders to facilitate engagement. Studies either reported the number of OSG members (n=1985 across all studies) or the number of posts (range: 223-200,000). The majority of OSG members were females who were not full-time employees and with varied levels of education. There were no randomized controlled trials measuring the efficacy of OSGs. Qualitative and quantitative studies identified empowerment, social support, self-management behavior, and health literacy as primary constructs to measure OSG efficacy. Neutral or marginal improvement was reported in these constructs. Sharing experiences and a greater level of engagement appeared to have an important influence on OSGs efficacy. The extent to which members posted on the website influenced engagement. Conclusions: Across a diverse range of designs, languages, included features, and delivery platforms, peer-to-peer OSGs for chronic musculoskeletal conditions attract predominantly female participants of all ages and education levels. The level of participation of a member appears to be related to their perceived benefit, health literacy, and empowerment. Future studies are needed to identify which design and maintenance strategies have superior efficacy and whether there are concomitant improvements in health outcomes for people with chronic musculoskeletal conditions resulting from participation in OSGs

Quality of physiotherapy care for people with hip and/or knee osteoarthritis

© 2020 Pek Ling TeoPatients with hip and/or knee osteoarthritis (OA) desire high quality of care when managing their condition. Clinical guidelines advocate exercise, weight loss (for people who are overweight or have obesity), and education regarding self-management as first line treatments for OA. Physiotherapists are important providers of such non-surgical interventions. As such, they have a professional responsibility to ensure that the care they provide to people with OA is safe and aligns with best practice. Current quality indicators (QIs) for care of people with hip and knee OA are not designed to specifically assess physiotherapy care. Furthermore, little is known about the experiences of Australian physiotherapists and people delivering and receiving care for knee OA, and if their reported experiences align with the national Clinical Care Standard for knee OA (quality statements that describe the care Australian patients should be offered by health professionals and health services for OA in line with current best evidence). This thesis aims to build on the current understanding of the quality of care provided by physiotherapists to people with hip and/or knee OA, by developing QIs to evaluate such care and exploring the experiences of physiotherapists and patients delivering and receiving care for knee OA in Australia. Study One aimed to identify and prioritize the most important clinical guideline recommendations relevant to physiotherapy practice for hip and/or knee OA. A panel of 62 international physiotherapists was invited to first complete an online modified-Delphi survey, followed by a priority-ranking exercise. Recommendations were extracted from two high quality international clinical guidelines for OA. From an initial list of 70 potential recommendations (including seven new recommendations generated by the expert panel), 30 were included in the priority-ranking exercise. The final 30 recommendations were condensed and categorised by content area to convey high quality physiotherapy management for hip and/or knee OA. The top recommendations related to providing exercise, weight management, and education as core treatments; individualised OA management; and communication approaches. Study Two aimed to develop a patient-reported QI tool (the Quality Indicators for Physiotherapy Management of Hip and Knee Osteoarthritis (QUIPA) tool) and to assess its reliability and validity. A conceptual model based on the final 30 recommendations from Study One was used when developing the QUIPA tool, where the four main categories of the final recommendations were synthesized to establish the three subscales of the QUIPA tool. Patient focus groups were conducted to further refine the draft items. To evaluate test-retest reliability, construct validity (hypothesis testing) and criterion validity, patients with hip and/or knee OA (n= 65) were recruited to attend a single physiotherapy session and required to complete the QUIPA tool one, twelve- and thirteen-weeks following their session. Physiotherapists (n= 9) were expected to complete the tool immediately post-consultation. Patient test-retest reliability was assessed between twelve- and thirteen-weeks following their session. Construct validity was evaluated based on three predefined hypotheses. Criterion validity was assessed based on agreement between physiotherapists and participants at week one. The final QUIPA tool comprised 18 items (three subscales). The QUIPA tool demonstrated acceptable test-retest reliability for subscales and total score, but individual items showed inadequate reliability. Construct validity was adequate but criterion validity for individual items, subscales and the total score was poor. The QUIPA tool needs further refinement to improve its clinimetric properties before implementation into clinical practice. Study Three was a qualitative study that explored the experiences of Australian physiotherapists (n= 22, thirteen from major cities, five from inner regional, three from outer regional and one from remote areas) delivering care for people with knee OA and investigated the degree to which their reported experiences aligned with the Australian OA of the Knee Clinical Care Standard. Inductive thematic analysis was conducted, and the interview data were also deductively analysed according to the national Clinical Care Standard. Findings revealed that physiotherapists tended to focus on a biomedically-oriented assessment with little evaluation of psychosocial factors that may impact patients with knee OA. They perceived their primary role as providing goal-focused individualised exercise via short-term episodic care. Knee surgery was considered as a last option but for patients who chose surgery, physiotherapists ‘prepped’ them for the procedure. Patient comorbidity, poor patient adherence and patient desire for a ‘quick fix’ were perceived as clinical challenges. Physiotherapists also described a mismatch between what they know and what they do when it came to manual therapy, imaging, and weight loss advice. They saw weight management, medication, and surgical advice as outside of physiotherapy scope of practice. Overall, physiotherapists’ reported experiences with delivering care for people with knee OA were mostly consistent with the OA of the Knee Clinical Care Standard. Study Four was a qualitative study that explored the experiences of Australians (n= 24, from all six states and two territories of Australia) receiving physiotherapy care for knee OA. Participants generally presented to physiotherapists with a pre-existing OA diagnosis and were mostly comfortable with their existing knowledge about OA. They described accessing physiotherapy through various referral pathways, funding models and modes of delivery. They consulted physiotherapists for various reasons but most commonly for assistance with knee pain and functional impairments. Participants described physiotherapy management as primarily centred on exercise therapy, often supplemented by adjunctive treatments. Participants perceived advice about surgery, medications, and injections as outside of physiotherapists’ domain of care. Participants were generally happy and satisfied with their physiotherapy experiences and described valuing the personalised care they received. They also believed surgery was inevitable for their knee OA. Overall, these results provide evidence from the patients’ perspectives about the important role physiotherapists play in the care of Australians with knee OA. Findings from this thesis build on the current understanding of the quality of care provided by physiotherapists to people with hip and/or knee OA. The first two studies lay the groundwork for future design and evaluation of an international patient-reported QI tool for benchmarking quality of physiotherapy care in hip and/or knee OA. Overall, findings from the last two studies indicated that physiotherapy management of knee OA in Australia mostly aligned with the national clinical care standard and that patients were generally happy and satisfied with the physiotherapy care received. Suggested areas to improve care delivered by physiotherapists include increased consideration of psychosocial factors that may influence OA symptoms and prognosis, attention to the language used when discussing OA (i.e. avoid biomedical terms such as ‘wear and tear’ or ‘degenerative’) so that physiotherapists are not contributing to patient misinformation (i.e. joint surgery is inevitable; OA is a ‘degenerative’ or ‘wear and tear’ condition; imaging is required to diagnose OA), increased emphasis on advice and information about losing weight (for patients who need it), pain medications and knee surgery, and offering regular longer-term reviews. Findings also highlight the importance of appropriate funding mechanisms to support Australians to access physiotherapy care for their knee OA both in private and public sectors

The evolution of education premiums in Vietnam : 1992-2006.

This paper evaluates the education premium since the Doi Moi reforms were implemented over the last two decades based on survey data from VLSS of 1992, 1998 and VHLSS of 2006. Our findings show that education premiums were relatively low when the reforms were just carried out. However, as progress was made, education premiums increased gradually. We also find that the rate of return to schooling in the public sector is higher compared to the private sector for both men and women.Bachelor of Art

Patient-reported quality indicators to evaluate physiotherapy care for hip and/or knee osteoarthritis- development and evaluation of the QUIPA tool

BACKGROUND: There is no physiotherapy-specific quality indicator tool available to evaluate physiotherapy care for people with hip and/or knee osteoarthritis (OA). This study aimed to develop a patient-reported quality indicator tool (QUIPA) for physiotherapy management of hip and knee OA and to assess its reliability and validity. METHODS: To develop the QUIPA tool, quality indicators were initially developed based on clinical guideline recommendations most relevant to physiotherapy practice and those of an existing generic OA quality indicator tool. Draft items were then further refined using patient focus groups. Test-retest reliability, construct validity (hypothesis testing) and criterion validity were then evaluated. Sixty-five people with hip and/or knee OA attended a single physiotherapy consultation and completed the QUIPA tool one, twelve- and thirteen-weeks after. Physiotherapists (n = 9) completed the tool post-consultation. Patient test-retest reliability was assessed between weeks twelve and thirteen. Construct validity was assessed with three predefined hypotheses and criterion validity was based on agreement between physiotherapists and participants at week one. RESULTS: A draft list of 23 clinical guideline recommendations most relevant to physiotherapy was developed. Following feedback from three patient focus groups, the final QUIPA tool contained 18 items (three subscales) expressed in lay language. The test-retest reliability estimates (Cohen's Kappa) for single items ranged from 0.30-0.83 with observed agreement of 64-94%. The intraclass correlation coefficient (ICC) and 95% confidence interval (CI) for the Assessment and Management Planning subscale was 0.70 (0.54, 0.81), Core Recommended Treatments subscale was 0.84 (0.75, 0.90), Adjunctive Treatments subscale was 0.70 (0.39, 0.87) and for the total QUIPA score was 0.80 (0.69, 0.88). All predefined hypotheses regarding construct validity were confirmed. However, agreement between physiotherapists and participants for single items showed large measurement error (Cohen's Kappa estimates ranged from - 0.04-0.59) with the ICC (95% CI) for the total score being 0.11 (- 0.14, 0.34). CONCLUSIONS: The QUIPA tool showed acceptable test-retest reliability for subscales and total score but inadequate reliability for individual items. Construct validity was confirmed but criterion validity for individual items, subscales and the total score was inadequate. Further research is needed to refine the QUIPA tool to improve its clinimetric properties before implementation

Development of a miniaturized Ti-plasmid and helper plasmid system for Agrobacterium-mediated plant transformation

Tumor-inducing (Ti) plasmid is the requisite for Agrobacterium-mediated plant transformation. Over decades, continuous efforts have been made to improve the efficiency of Agrobacterium-mediated plant transformation and most of them focused on the binary vector system. A binary vector system comprises of a binary vector of which transferred DNA (T-DNA) resided on and a Ti plasmid to carry those essential virulence genes. In this study, we constructed a miniaturized helper Ti plasmid, designated as pYL102, with the aim to enhance the overall Agrobacterium-mediated transformation rate. The size of pYL102 was reduced to ~60% of the original plasmid pCAMBIA5105. Subsequently, pYL102 was coupled with the broad host range (BHR) bacterial expression vector, pYL101C, of which the key regulatory virulence gene, virG-N54D, was cloned in and expressed under the control of a strong constitutive PINTc promoter. To test the functionality of the constructed vector system, A. tumefaciens C58C1 carrying pYL102, pYL101C::virG-N54D and the transformation vector pGWB2::e35S-sfGFP was used to transform Nicotiana benthamiana leaves by agroinfiltration. Green fluorescence was observed in spots infiltrated with Agrobacterium carrying the test plasmids. The fluorescence intensity from the test agroinfiltrated leaves was significantly higher than those of the mock-infiltrated leaves (p<0.01), indicating the vector system can be used for plant transformation

Exploring the characteristics and preferences for online support groups: mixed method study

Osteoarthritis (OA) is a chronic, disabling, and prevalent disorder. As there is no cure for OA, long-term self-management is paramount. Support groups (SGs) can facilitate self-management among people living with OA. Understanding preferences in design and features of SGs, including online SGs (OSGs), among people with OA can inform future development of SG interventions for this condition.The objective of this study was to investigate health care- and health information-seeking behavior, digital literacy, and preferences for the design of SGs in people with OA. The study also explored the perceived barriers and enablers to being involved in OSGs.An online survey study was conducted with a mixed method design (quantitative and qualitative). Individuals aged ≥45 years with knee, hip, or back pain for ≥3 months were recruited from an extant patient database of the Institute of Bone and Joint Research via email invitations. Quantitative elements of the survey included questions about sociodemographic background; health care- and health information-seeking behavior; digital literacy; and previous participation in, and preferences for, SGs and OSGs. Respondents were classified into 2 groups (Yes-SG and No-SG) based on previous participation or interest in an SG. Group differences were assessed with Chi-square tests (significance level set at 5%). Responses to free-text questions relating to preferences regarding OSG engagement were analyzed qualitatively using an inductive thematic analysis.A total of 415 people with OA completed the survey (300/415, 72.3% females; 252/415, 61.0% lived in a major city). The Yes-SG group included 307 (307/415, 73.9%) participants. Between the Yes-SG and No-SG groups, there were no differences in sociodemographic characteristics, health care- and health information-seeking behavior, and digital literacy. An online format was preferred by 126/259 (48.7%) of the Yes-SG group. Trained peer facilitators were preferred, and trustworthiness of advice and information were highly prioritized by the respondents. Qualitative analysis for OSG participation revealed 5 main themes. Lack of time and motivation were the main barriers identified. The main enablers were related to accessibility, enjoyment of the experience, and the content of the discussed information.These findings highlight the preferences in design features and content of SGs and OSGs and may assist in the further development of such groups

Developing item banks to measure three important domains of health-related quality of life (HRQOL) in Singapore

Objectives: To develop separate item banks for three health domains of health-related quality of life (HRQOL) ranked as important by Singaporeans - physical functioning, social relationships, and positive mindset. Methods: We adapted the Patient Reported Outcomes Measurement Information System Qualitative Item Review protocol, with input and endorsement from laymen and experts from various relevant fields. Items were generated from 3 sources: 1) thematic analysis of focus groups and in-depth interviews for framework (n= 134 participants) and item (n= 52 participants) development, 2) instruments identified from a literature search (PubMed) of studies that developed or validated a HRQOL instrument among adults in Singapore, 3) a priori identified instruments of particular relevance. Items from these three sources were “binned” and “winnowed” by two independent reviewers, blinded to the source of the items, who harmonized their selections to generate a list of candidate items (each item representing a subdomain). Panels with lay and expert representation, convened separately for each domain, reviewed the face and content validity of these candidate items and provided inputs for item revision. The revised items were further refined in cognitive interviews. Results: Items from our qualitative studies (51 physical functioning, 44 social relationships, and 38 positive mindset), the literature review (36 instruments from 161 citations), and three a priori identified instruments, underwent binning, winnowing, expert panel review, and cognitive interview. This resulted in 160 candidate items (61 physical functioning, 51 social relationships, and 48 positive mindset). Conclusions: We developed item banks for three important health domains in Singapore using inputs from potential end-users and the published literature. The next steps are to calibrate the item banks, develop computerized adaptive tests (CATs) using the calibrated items, and evaluate the validity of test scores when these item banks are administered adaptively.National Medical Research Council (NMRC)Published versionThis study was funded by grant HSRG/0034/2013 from the National Medical Research Council of Singapore

Trans-interaction of risk loci 6p24.1 and 10q11.21 is associated with endothelial damage in coronary artery disease

Background and aims: Single nucleotide polymorphism rs6903956 has been identified as one of the genetic risk factors for coronary artery disease (CAD). However, rs6903956 lies in a non-coding locus on chromosome 6p24.1. We aim to interrogate the molecular basis of 6p24.1 containing rs6903956 risk alleles in endothelial disease biology. Methods and Results: We generated induced pluripotent stem cells (iPSCs) from CAD patients (AA risk genotype at rs6903956) and non-CAD subjects (GG non-risk genotype at rs6903956). CRISPR-Cas9-based deletions (Δ63- 89bp) on 6p24.1, including both rs6903956 and a short tandem repeat variant rs140361069 in linkage disequilibrium, were performed to generate isogenic iPSC-derived endothelial cells. Edited CAD endothelial cells, with removal of ‘A’ risk alleles, exhibited a global transcriptional downregulation of pathways relating to abnormal vascular physiology and activated endothelial processes. A CXC chemokine ligand on chromosome 10q11.21, CXCL12, was uncovered as a potential effector gene in CAD endothelial cells. Underlying this effect was the preferential inter-chromosomal interaction of 6p24.1 risk locus to a weak promoter of CXCL12, confirmed by chromatin conformation capture assays on our iPSC-derived endothelial cells. Functionally, risk genotypes AA/AG at rs6903956 were associated significantly with elevated levels of circulating damaged endothelial cells in CAD patients. Circulating endothelial cells isolated from patients with risk genotypes AA/AG were also found to have 10 folds higher CXCL12 transcript copies/cell than those with non-risk genotype GG. Conclusions: Our study reveals the trans-acting impact of 6p24.1 with another CAD locus on 10q11.21 and is associated with intensified endothelial injury.Ministry of Education (MOE)Nanyang Technological UniversityNational Research Foundation (NRF)Published versionThe National Research Foundation, Singapore (Project Number 370062002) funded the Singapore Coronary Artery Disease Genetics Study (SCADGENS) and genotyping of the participants. The team from Nanyang Technological University Singapore was funded by an Academic Research Fund Tier 1 grant (2018-T1-001-030) from the Ministry of Education, Singapore, Human Frontier Science Program Research Grant (RGY0069/2019), and the Nanyang Assistant Professorship. K.Y. T. is supported by NTU Research Scholarship. H.H.L. is supported by the Institute of Molecular and Cell Biology (IMCB) Scientific Staff Development Award (SSDA) for her part-time Ph.D. A.K.K.T. is supported by IMCB, A*STAR, Precision Medicine and Personalised Therapeutics Joint Research Grant 2019, the 2nd A*STAR-AMED Joint Grant Call 192B9002 and NUHSRO/2021/035/NUSMed/04/NUS-IMCB Joint Lab/LOA