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Research to assess the effect of interventions to improve the processes of shared decision making and self-management directed at health care professionals is limited. Using the protocol of Intervention Mapping, a Web-based intervention directed at health care professionals was developed to complement and optimize health services in patient-centered care.
The objective of the Web-based intervention was to increase health care professionals’ intention and encouraging behavior toward patient self-management, following cardiovascular risk management guidelines.
A randomized controlled trial was used to assess the effect of a theory-based intervention, using a pre-test and post-test design. The intervention website consisted of a module to help improve professionals’ behavior, a module to increase patients’ intention and risk-reduction behavior toward cardiovascular risk, and a parallel module with a support system for the health care professionals. Health care professionals (n=69) were recruited online and randomly allocated to the intervention group (n=26) or (waiting list) control group (n=43), and invited their patients to participate. The outcome was improved professional behavior toward health education, and was self-assessed through questionnaires based on the Theory of Planned Behavior. Social-cognitive determinants, intention and behavior were measured pre-intervention and at 1-year follow-up.
The module to improve professionals’ behavior was used by 45% (19/42) of the health care professionals in the intervention group. The module to support the health professional in encouraging behavior toward patients was used by 48% (20/42). The module to improve patients’ risk-reduction behavior was provided to 44% (24/54) of patients. In 1 of every 5 patients, the guideline for cardiovascular risk management was used. The Web-based intervention was poorly used. In the intervention group, no differences in social-cognitive determinants, intention and behavior were found for health care professionals, compared with the control group. We narrowed the intervention group and no significant differences were found in intention and behavior, except for barriers. Results showed a significant overall difference in barriers between the intervention and the control group (
The intervention was used by less than half of the participants and did not improve health care professionals’ and patients’ cardiovascular risk-reduction behavior. The website was not used intensively because of time and organizational constraints. Professionals in the intervention group experienced higher levels of barriers to encouraging patients, than professionals in the control group. No improvements were detected in the processes of shared decision making and patient self-management. Although participant education level was relatively high and the intervention was pre-tested, it is possible that the way the information was presented could be the reason for low participation and high dropout. Further research embedded in professionals’ regular consultations with patients is required with specific emphasis on the processes of dissemination and implementation of innovations in patient-centered care.
Netherlands Trial Register Number (NTR): NTR2584; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=2584 (Archived by WebCite at http://www.webcitation.org/6STirC66r).
In health care, the focus is on optimizing patient self-management. Patients should manage their own health with the support of health care professionals. For targeted and effective self-management, shared decision making is a prerequisite. Shared decision making to improve self-management is more than offering professional support or increasing knowledge about patients’ health problem(s). In patient-centered care, patients and health care professionals should cooperate, exchange their own relevant information, and work together optimizing self-management to achieve intended outcomes. It results in better patient outcomes when health care professionals encourage their patients to be involved in decision making. A review showed that professionals tend to misjudge patients’ ability to be involved in decision making [
To facilitate shared decision making with the objective of optimizing self-management, interventions directed at the health care professional is an option to explore. Intervention Mapping provides a framework to develop systematically planned, theory- and evidence-based interventions [
Information and communication technologies (ICT) in the health care domain (eHealth) can facilitate communication and improve the health of patients and the quality of health care [
Research to assess the effects of interventions to improve the processes of shared decision making and self-management directed at health care professionals is limited [
Participants were health care professionals with at least a bachelor’s degree in nursing or physiotherapy and who had regular consultations with patients with cardiovascular risk factors (ie, abdominal obesity, high blood pressure, low high-density lipoprotein cholesterol, elevated triglycerides, and elevated blood glucose levels) and low levels of physical activity [
A randomized controlled trial was performed using a pre-test (T1) and post-test (T2) design, to determine the effectiveness of a clinical decision support system used to optimize shared decision making and the self-management of patients. Health care professionals were the unit of randomization and were randomly allocated to the intervention versus the waiting list control group. Health care professionals invited their patients. The recommendation was to use the intervention for every patient that fit the intervention. Patients were informed about the study and gave informed consent. The study sample size was based on the outcome of improved professionals’ behavior toward patient-centered care. Power analysis estimated how many respondents were needed for the study to find a significant difference in health care professionals’ behavior. This analysis (power 0.80; alpha=.05, two-tailed) revealed that 62 professionals in each condition were needed. Randomization was based on a random number sequence, using a computer randomized number generator. The total group of 278 professionals was randomized and drop by drop assigned to the intervention versus the control group; 81 professionals were willing to participate (
Outcomes were self-assessed through a questionnaire based on the Theory of Planned Behavior [
We assessed
“Perceived behavioral control” (PBC) was assessed by: “Do you think that you have the skills and knowledge to encourage cardiovascular patients to become physically active?”, “Do you think you can rely on your skills and knowledge to encourage cardiovascular patients to become physically active?”, and third we asked, “Encouraging every cardiovascular patient to become physically active is very difficult (1) - very easy (7)”. PBC was further assessed by eight items that paralleled the eight items used for attitudes: “It is very difficult (1) - very easy (7) to: assess patients’ motivation, assess the pros and cons of physical activity, teach patients how to resist social pressure, teach patients specific skills pertaining to physical activity, teach patients how to handle barriers in regard to physical activity, formulate physical activity goals together with patients, teach patients how to handle relapses, and help patients understand the relationship between the specific health problem and physical inactivity?”. Once again, this scale score was calculated and combined with the previous three items as a measure of PBC (Cronbach alpha=.68). “Subjective norm” was measured by four items: “Most colleagues who are important to me think I should encourage cardiovascular patients to become physically active”, “Most colleagues value that I encourage cardiovascular patients to become physically active”, “Patients value that I encourage them to become physically active”, and “The organization I work for values that I encourage cardiovascular patients to become physically active” (Cronbach alpha=.73).
Intervention flow chart.
Participants had access to the website [
Intervention screenshot.
Intervention screenshot.
Intervention screenshot.
Descriptive statistics were calculated and chi-square analyses were used to characterize the study groups at baseline and to determine the use of the website. We used paired
The module with background information on how to coach the patient with the aim of supporting the health professional in his or her encouraging behavior toward patients was used by 48% (20/42) of the professionals; 17% (7/42) of the professionals used all seven screens; 45% (19/42) used the screen how to encourage a patient to think about his/her personal risk; 33% (14/42) used the screen how to list pros and cons with a patient; 26% (11/42) used the screen how to seek support; and 21% (9/42) how to practice the sub-skills needed. The last screens in this module (planning the encouraging behavior, putting the behavior change into practice, and maintaining the behavior) were used by 19% (8/42) of the health care professionals. The forum directed at improving social support was used by 4 health care professionals.
Health care professionals invited 54 patients in the intervention: 56% (30/54) male, mean age 50.9 years (SD 11.8), with differing educational degrees. Health care professionals assessed cardiovascular risk and 19% (10/54) of the patients had two or more cardiovascular risk factors, and/or a heart disease and/or diabetes; 13% (7/54) were physically active for at least 30 minutes, for 5 days per week. In 82% (44/54) of the patients, the guidelines to assess cardiovascular risk were not used by the health professional. The module to improve patients’ intention and risk-reduction behavior, with the purpose of increasing the processes of shared decision making and self-management, was provided to 44% (24/54) of the patients by a health professional (
When we narrowed the intervention group (n=26) by transferring the professionals who did not use the website to the waiting list control group (n=43), no significant differences between the intervention and control group were found in social-cognitive determinants, intention and behavior, except for perceived behavior control and barriers (
Baseline demographics of study participants
|
Intervention group (n=42) |
Control group (n=27) |
|
Gender, female | 29 (69%) | 21 (78%) |
|
Age, years, mean (SD) | 38.6 (11.3) | 39.7 (8.4) | .062 |
Education, bachelor’s degree | 26 (79%) | 13 (68%) | .406 |
Education, degree above bachelor’s | 7 (21%) | 6 (32%) | N/A |
Professional experience, years, |
9.76 (8.5) | 9.58 (9.1) | .910 |
Working as a soloist, or with 1 or 2 colleagues | 16 (44%) | 5 (21%) | .060 |
Working with 3 or more colleagues | 20 (56%) | 19 (79%) | N/A |
Consultation time devoted to health education | 36 (59%) | 23 (54%) | .508 |
Paired differences between intervention group and control group, measured at T1 and T2.a
|
|
Intervention group (n=42) |
Control group (n=27) |
|
|
||||
|
T1 | 4.54 (1.02) | 4.83 (0.69) |
|
|
T2 | 4.63 (0.85) | 4.79 (0.82) |
|
|
||||
|
T1 | 6.25 (1.00) | 5.87 (1.15) |
|
|
T2 | 6.06 (1.11) | 6.02 (0.91) |
|
|
||||
|
T1 | 6.30 (0.44) | 6.23 (0.69) |
|
|
T2 | 6.30 (0.56) | 6.31 (0.68) |
|
|
||||
|
T1 | 4.65 (0.79) | 4.90 (0.87) |
|
T2 | 5.04 (0.73) | 5.28 (0.80) |
|
|
|
||||
|
T1 | 5.48 (0.55) | 5.58 (0.93) |
|
T2 | 5.57 (0.63) | 5.74 (0.76) |
|
|
|
||||
|
T1 | 6.04 (0.63) | 6.20 (0.59) |
|
|
T2 | 6.19 (0.70) | 6.30 (0.55) |
|
|
||||
|
T1 | 3.11 (1.17) | 2.78 (1.01) |
|
|
T2 | 3.18 (1.12) | 2.63 (0.96) |
|
asocial-cognitive variables range 1-7.
bIntervention group: Cohen’s
Differences between narrowed intervention group and control group, measured at T1 and T2.a
|
|
Intervention group (n=26) |
Control group (n=43) |
|
|
||||
|
T1 | 4.38 (1.04) | 4.91 (0.67) |
|
|
T2 | 4.45 (0.81) | 4.89 (0.81) |
|
|
||||
|
T1 | 6.10 (1.06) | 6.08 (1.10) |
|
|
T2 | 5.93 (1.21) | 6.13 (0.85) |
|
|
||||
|
T1 | 6.28 (0.47) | 6.26 (0.63) |
|
|
T2 | 6.29 (0.56) | 6.31 (0.64) |
|
|
||||
|
T1 | 4.63 (0.82) | 4.85 (0.83) |
|
T2 | 5.01 (0.76) | 5.23 (0.77) |
|
|
|
||||
|
T1 | 5.46 (0.59) | 5.57 (0.84) |
|
T2 | 5.60 (0.63) | 5.68 (0.73) |
|
|
|
||||
|
T1 | 5.88 (0.60) | 6.28 (0.58) |
|
|
T2 | 6.08 (0.73) | 6.35 (0.53) |
|
|
||||
|
T1 | 3.09 (1.11) | 2.78 (1.11) |
|
|
T2 | 3.40 (1.09) | 2.59 (0.94) |
|
asocial-cognitive variables range 1-7.
bIntervention group: Cohen’s
Use of the intervention website modules.
In this paper, we report on the results of a randomized controlled trial testing the effectiveness of a Web-based intervention in the clinical practice of patient-centered care. The intervention was developed to optimize processes of shared decision making and self-management, following the protocol of Intervention Mapping. The objective was to increase health care professionals’ intention and behavior toward encouraging patient self-management.
Results indicated no intervention effect on the outcome measure of our study: the encouraging behavior of health care professionals. Results indicated no overall differences for social-cognitive determinants, intention and behavior, when the intervention group was compared with the control group. We narrowed the intervention group and took a closer look at the health care professionals that used the Web-based intervention. Results showed that these professionals experienced higher levels of barriers, meaning that time and organizational constraints withheld them and obstructed the planned behavior to encourage patients, compared with the professionals in the control group. Next to the overall results of the intervention, we took a closer look at possible effects in the (initial) intervention group. Results indicated a medium-size effect for perceived behavioral control, with no effect for the other social-cognitive determinants, intention and behavior. Professionals in the intervention group increased their perceived behavioral control and reported that they had more control over their skills necessary to encourage patients. The same effect was seen in the control group, which means that there was no overall effect when we compared the intervention group with the control group.
Our study showed that health care professionals had high intentions and planned their encouraging behavior. It also showed that health care professionals had positive attitudes and described more pros than cons toward encouraging patients. Further, the study showed a positive moral norm to be an encouraging professional. But scores on behavior were modest in comparison, and though health care professionals did plan the encouraging behavior, they did not practice the encouraging behavior. Also scores on subjective norm (meaning that colleagues, patients, and the organization value their encouragement) and scores on perceived behavior control as the skills needed, were modest. Attendance on the Web-based intervention and use of the website was sub-optimal. Less than half of the health care professionals used the module to change their professional behavior, and/or used the module to get support in their encouraging behavior toward patients, and/or used the module to improve patients’ intention and risk-reduction behavior. The module to improve patients’ intention and risk-reduction behavior was used most, followed by the module to support the health professional. The module to change professional behavior was the least used. Only in 1 of every 5 patients was the guideline following cardiovascular risk management used. We hypothesized that in the clinical practice of patient-centered care, shared decision making can optimize self-management using an eHealth-application, but we were not able to detect improvements in the processes of shared decision making and self-management of the patient.
Systematic reviews showed a clear relationship between the intentions of health care professionals and their subsequent behavior; these were found to be appropriate to predict their behavior, and can be used to improve behavior change interventions targeting health care professionals [
The application of evidence-based behavior change techniques used in our intervention should offer insight regarding how an intervention may change intention and behavior. When intention and perceived behavioral control are targeted in an intervention, clinician behavior can be improved [
In a review by Légare, it was concluded that sufficient enrollment of health care professionals and patients is often a problem and needs attention in research designs [
An online intervention can support health care professionals but training should be an important part of implementation. A total of 12 health care professionals attended a demonstration meeting, including professionals in the waiting list control group. It may be that training on the job can improve the use of the Web-based intervention. Training may increase professionals’ perception of perceived behavioral control, because professionals need to learn to use the specific clinical decision support tool [
The intervention was used by less than half of the participants and did not improve health care professionals’ and patients’ cardiovascular risk-reduction behavior. Health care professionals did not use the website intensively because of time and organizational constraints. Professionals in the intervention group experienced higher levels of barriers to encouraging patients, than professionals in the control group. We were not able to detect improvements in the processes of shared decision making and patient self-management. Although participant education level was relatively high and the intervention was pre-tested, it is possible that the way the information was presented could be the reason for low participation and high dropout. Further research embedded in professionals’ regular consultations with patients is required with specific emphasis on the processes of dissemination and implementation of innovations in patient-centered care.
CONSORT-EHEALTH checklist V1.6.2 [
Consolidated Standards of Reporting Trials
information and communication technology
perceived behavioral control
The authors would like to thank Ir Lex Verheesen for his contribution in the development of the intervention website.
None declared.