Background: Changes in reimbursement have been compelling for Dutch primary care practices to apply a disease management approach for patients with chronic obstructive pulmonary disease (COPD). This approach includes individual patient consultations with a practice nurse, who coaches patients in COPD management. The aim of this study was to gauge the feasibility of adding a web-based patient self-management support application, by assessing patients’ self-management, patients’ health status, the impact on the organization of care, and the level of application use and appreciation. Methods: The study employed a mixed methods design. Six practice nurses recruited COPD patients during a consultation. The e-Health application included a questionnaire that captured information on demographics, self-management related behaviors (smoking cessation, physical activity and medication adherence) and their determinants, and nurse recommendations. The application provided tailored feedback messages to patients and provided the nurse with reports. Data were collected through questionnaires and medical record abstractions at baseline and one year later. Semi-structured interviews with patients and nurses were conducted. Descriptive statistics were calculated for quantitative data and content analysis was used to analyze the qualitative data. Results: Eleven patients, recruited by three nurses, used the application 1 to 7 times (median 4). Most patients thought that the application supported self-management, but their interest diminished after multiple uses. Impact on patients’ health could not be determined due to the small sample size. Nurses reported benefits for the organization of care and made suggestions to optimize the use of the reports. Conclusion: Results suggest that it is possible to integrate a web-based COPD self-management application into the current primary care disease management process. The pilot study also revealed opportunities to improve the application and reports, in order to increase technology use and appreciation.
BackgroundTrials studying Motivational Interviewing (MI) to improve medication adherence in patients with schizophrenia showed mixed results. Moreover, it is unknown which active MI-ingredients are associated with mechanisms of change in patients with schizophrenia. To enhance the effect of MI for patients with schizophrenia, we studied MI's active ingredients and its working mechanisms.MethodsFirst, based on MI literature, we developed a model of potential active ingredients and mechanisms of change of MI in patients with schizophrenia. We used this model in a qualitative multiple case study to analyze the application of the active ingredients and the occurrence of mechanisms of change. We studied the cases of fourteen patients with schizophrenia who participated in a study on the effect of MI on medication adherence. Second, we used the Generalized Sequential Querier (GSEQ 5.1) to perform a sequential analysis of the MI-conversations aiming to assess the transitional probabilities between therapist use of MI-techniques and subsequent patient reactions in terms of change talk and sustain talk.ResultsWe found the therapist factor “a trusting relationship and empathy” important to enable sufficient depth in the conversation to allow for the opportunity of triggering mechanisms of change. The most important conversational techniques we observed that shape the hypothesized active ingredients are reflections and questions addressing medication adherent behavior or intentions, which approximately 70% of the time was followed by “patient change talk”. Surprisingly, sequential MI-consistent therapist behavior like “affirmation” and “emphasizing control” was only about 6% of the time followed by patient change talk. If the active ingredients were embedded in more comprehensive MI-strategies they had more impact on the mechanisms of change.ConclusionsMechanisms of change mostly occurred after an interaction of active ingredients contributed by both therapist and patient. Our model of active ingredients and mechanisms of change enabled us to see “MI at work” in the MI-sessions under study, and this model may help practitioners to shape their MI-strategies to a potentially more effective MI.
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Results: We observed a variation of factors which seemed to contribute to the active ingredients. Most prevalent was (eliciting) ‘change talk’, but also factors such as ‘experiencing competency’ and ‘changing sense making’. Since mechanisms of change refer to psychological processes within the patient’s mind, it is impossible to observe these. But we recognised clues for mechanisms of change, the most prevalent mechanism was ‘arguing oneself into change’. The most important conversational techniques are reflections and questions addressing medication adherent behaviour or intentions, which was often (in 74% and 69% of the time respectively) followed by change talk. Conclusions: Active ingredients of MI seem to consist of a sufficient combination of factors, to which both patient and therapist contribute. This combination may act as an active ingredient and can trigger mechanisms of change. Our study suggests that in particular the patient factors are a pool of factors from which, after proper activation by therapist factors, different combinations can form active ingredients.
