Development and validation of the healthcare providers patient-activation scale

Patient Education and Counseling 102 (2019) 1550–1557

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Development and validation of the healthcare providers patient-activation scale Lyndel Shanda,b , Rosemary Higginsa,b,c , Barbara Murphya,b,d,* , Alun Jacksona,b,e a

Australian Centre for Heart Health, Melbourne, Victoria, Australia Faculty of Health, Deakin University, Burwood, Victoria, Australia Department of Physiotherapy, University of Melbourne, Victoria, Australia d Department of Psychology, University of Melbourne, Victoria, Australia e Centre on Behavioural Health, Hong Kong University, Hong Kong b c

A R T I C L E I N F O

A B S T R A C T

Article history: Received 26 July 2018 Received in revised form 20 February 2019 Accepted 7 March 2019

Objective: It has become increasingly important to assess healthcare providers’ role in chronic disease self-management (CDSM) and patient activation (PA). The present study extends previous work relating to patients’ behaviours by assessing healthcare providers’ own behaviours in supporting PA. Method: 50 items were generated: half assessed a PA approach; half reflected a non-patient-activation approach. 105 healthcare providers working in cardiac rehabilitation who were participants in a CDSM online training program completed the items pre- and post-training. Factor analysis determined the presence of higher order factors. Item responses pre- and post-training were compared to assess sensitivity to change. Results: Results indicated the presence of two factors: ‘patient-activation approach’ and ‘non-patientactivation approach’. While both demonstrated good internal consistency, the’ non-PA approach’ had superior discriminatory validity and sensitivity to change. Conclusion: Healthcare providers’ beliefs about the importance of patient-activation behaviours can be measured by 40-item Healthcare Provider-Patient Activation Scale (HP-PAS). The scale could be easily converted to measure healthcare providers’ actual PA behaviours. Practice implications: The HP-PAS could be used to assess the effectiveness of clinician training for healthcare providers working in cardiac rehabilitation and other areas of CDSM. Further reliability and validity testing within other healthcare provider samples is warranted. © 2019 Elsevier B.V. All rights reserved.

Keywords: Patient-centred care Patient activation Self-management Chronic disease Instrument development Disease management

1. Introduction Chronic disease prevention and management is a national health priority for many developed nations. In recent decades, chronic diseases have overtaken acute diseases as the major cause of death and disability globally [1–6]. The major chronic diseases cardiovascular disease, diabetes, cancer and chronic respiratory disease – cause over 29 million deaths annually worldwide [1], accounting for more than seven in 10 deaths in America [7,8], the European region [3], and Australia [9]. Chronic diseases also impact negatively on the quality of life of those with the disease as well as their families [8]. A large proportion of chronic disease burden is attributable to modifiable risk factors [1,7,9,10]. As such,

* Corresponding author at: Australian Centre for Heart Health, Box 2137 Royal Melbourne Hospital, Victoria, 3050, Australia. E-mail address: [email protected] (B. Murphy). https://doi.org/10.1016/j.pec.2019.03.005 0738-3991/© 2019 Elsevier B.V. All rights reserved.

for people living with a chronic disease, effective behaviour change strategies, including dietary change, increased physical activity and smoking cessation, are required to delay disease progression and improve quality of life [11]. For well over a decade, researchers and policy makers have recognised that people with chronic illness have a central role in determining their care outcomes through a process of chronic disease self-management (CDSM) [5,12–14]. CDSM requires that a person with a chronic disease adopts a set of attitudes, behaviours and skills to effectively self-manage their condition [12,13,15,16]. People with a chronic illness need to actively engage in shared decision-making with healthcare providers, including adopting a care plan that is agreed and negotiated in partnership with their health care team [13,17]. Central to the self-management process is patient-activation (PA), through supportive health care systems in which healthcare providers empower patients to actively participate in the management of their condition [18–23]. PA is defined as “the ability (of the healthcare provider) to activate the patient to

L. Shand et al. / Patient Education and Counseling 102 (2019) 1550–1557

take control in the consultation and/or in the management of their condition” [21] (p198). PA is one aspect of the broader concept of patient-centred care, which requires that clinicians focus on and attend to the needs, concerns, beliefs, values, goals and preferences of the patient [20,21,23,24]. However, the self-management paradigm presents considerable challenges for healthcare providers [14,18,23]. Indeed, the personal skill set that healthcare providers must possess is often overlooked [18,23]. To successfully support self-management and effective lifestyle change, healthcare providers require favourable attitudes, beliefs and skills regarding PA. This includes the ability to conduct a personalised approach to assessment; empower patient choice and practice collaborative goal setting; enhance patient skills to conduct specific health behaviours and self-monitor; encourage patients to enable resources that support their goals; and provide ongoing follow-up and support [14,25]. Healthcare providers need to be willing to adapt their practice to a style that embraces patients as active collaborators in their own care [17]. In many cases this must be done in the context of workforce shortages, and time and health system constraints [20]. As such, efforts to increase workforce capacity to effectively support patients in the self-management of their chronic conditions need to take into account the attitudes and behaviours of healthcare providers towards this model of care. This recognition of the importance of attitudes is reflected in the development, by Hibbard and colleagues, and validation of the Clinical Support for Patient Activation Measure (CS-PAM) [24,26]. The CS-PAM assesses clinicians’ beliefs about the importance of patients’ selfmanagement behaviours [24]. However, no such measure exists to assess healthcare providers’ beliefs about their own PA behaviours. The present study built on the work of Hibbard and colleagues by exploring healthcare providers’ beliefs about their own PA behaviours. The study focused on a sample of healthcare providers, predominantly nurses, working in cardiac rehabilitation. This paper describes the development and validation of the Healthcare Providers Patient-Activation Scale (HP- PAS) designed to assess healthcare providers’ beliefs about the importance of various PA behaviours in their own practice. 2. Method 2.1. Item generation for the HP-PAS Items were generated by the authors based on the ecological perspective of patient self-management proposed by Fisher and colleagues [25], which identifies the key resources and supports to successful self-management from the perspective of the individual’s needs – namely, individualised assessment; collaborative goalsetting; skills enhancement; follow-up and support; patient access to resources in daily life; and continuity of quality care. In addition, the capabilities for supporting prevention and chronic condition self-management outlined by Battersby and Lawn were used to construct items [17]. Twenty-five items that assessed perceived importance of various aspects of patient-centred care (e.g. ‘support the patient in identifying the lifestyle changes they are willing to make) were generated. Each item was paired with a statement that reflected an opposing action reflective of a non-patient centred care approach (e.g. ‘tell the patient what lifestyle changes they need to make’). The inclusion of the items to represent both the PA and non-PA approaches was deemed important in order to reduce the risk of an acquiescence response set - that is the endorsement of socially desirable items - if only the more desirable PA items were included. The importance of each statement was rated on a 5-point Likert scale (1 = not important; 5 = very important) [27]. Respondents were asked to “complete the following questions

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concerning aspects of your current work practice and rate the importance of each statement”. 2.2. Sampling and recruitment Participants were part of a broader program examining the effectiveness of an online training program to support CDSM. The online training is a translation of face-to-face training developed by the Australian Centre for Heart Health (ACHH) that has been shown to significantly increase the clinicians’ selfefficacy in CDSM practice [14]. The training was translated into an online format comprising five modules, including: Introduction to CDSM; Effective communication; Behavioural goalsetting; Cognitive strategies; and Motivational interviewing. The training has been completed by over 2000 healthcare providers to date and is endorsed by several peak professional bodies, including the Australian Cardiovascular Health and Rehabilitation Association, the Australian Practice Nurse Association, the Royal College of Nursing, the Lung Foundation, and Kidney Health Australia. A convenience sampling strategy was utilised to recruit participants. Invitations to participate in the online training were disseminated during face-to-face training programs run by the ACHH, which attracts mostly healthcare providers working in cardiac rehabilitation, the majority of whom are nurses and other allied health professionals. Email invitations were also sent to attendees of past ACHH training programs and to members of the peak state professional body for health professionals working in cardiac rehabilitation. Participants were also encouraged to disseminate information about the program to interested colleagues. 2.3. Procedure Participants completed the online survey prior to undertaking the first module of the online CDSM training program. The 50 HPPAS items were presented to participants in a random order. At completion of the final CDSM module, participants completed an online exit survey which included the 50 HP-PAS items, again presented in random order. Participants could only access the training after completing the pre-training questionnaire, and the certificate of training completion was issued only after completion of the post-training questionnaire. Ethics approval was granted by the University of Melbourne Human Research Ethics Committee and consent was obtained from all participants. 2.4. Data analysis Item responses pre-training were subjected to factor analysis using principal axis factor with promax rotation to determine the presence of higher order factors. Histograms for individual items were examined to determine the distribution of responses and to assess whether the items discriminated. To further examine the number of components present in the data set, Horn’s parallel analysis was used to identify the correct number of components to retain [28,29]. Eigenvalues in the current data set were compared to eigenvalues for a randomly generated data matrix of the same size (50 variables x 105 respondents). Values larger than the criterion value from parallel analysis were retained for the factor, and values less than this were rejected. Deletion of items and their corresponding pair occurred where an item did not load on any factor, where an item cross-loaded on another factor and the difference was <.2, or where an item loaded on a factor but lacked face-validity.

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Item responses pre-and post-training were analysed using matched-pairs Wilcoxon signed rank tests with list-wise case deletion to assess sensitivity to change across time. 3. Results 3.1. Participant characteristics 105 healthcare providers working in cardiac rehabilitation completed the pre- and post-training questionnaires. Completion of the pre- and post-training questionnaires was mandatory during the study period, hence the response rate was 100%. The majority of the participants were female (96%), aged over 45 years (53%), employed as nurses (71%) in part-time positions (57%) and held at least a bachelor-level tertiary qualification (70%). Table 1 presents the demographic characteristics of the participants. 3.2. Factor analysis Step 1. Inspection of the data indicated that it was suitable for factor analysis, with many coefficients .3 present in the correlation matrix. The Kaiser-Meyer-Olkin value was .83 and Bartlett’s Test of Sphericity reached statistical significance. Preliminary factor analysis revealed the presence of 6 factors with eigenvalues exceeding 1, explaining 32.47%, 15.49%, 3.60%, 2.69%, 2.43% and 2.13% of the variance respectively. The results of the parallel analysis also indicated a possible six-factor solution, with eigenvalues exceeding the corresponding criterion values for a randomly generated data matrix of the same size (50 variables x 105 respondents). However, an inspection of the scree plot indicated a plateauing after the second factor. Table 1 Participant characteristics. Characteristic Sex Female Male Age group (in years) 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55 or more Profession Nursing Physiotherapy Exercise physiology Occupational therapy Dietetics Social work Psychology Allied health assistant Qualifications Certificate Hospital-based training University degree Post-graduate certificate Masters Doctorate Employment status Full-time Part-time Two or more part-time positions Casual Self-employed N = 105.

n

%

101 4

96.2 3.8

1 9 14 16 10 16 21 18

1.0 8.6 13.3 15.2 9.5 15.2 20.0 17.1

75 10 5 1 7 3 2 2

71.4 9.5 4.8 1.0 6.7 2.9 1.9 1.9

8 25 52 52 20 1

7.6 23.8 49.5 49.5 19.0 1.0

33 60 10 1 1

31.4 57.1 9.5 1.0 1.0

Two, three, four, five and six factor solutions were generated to determine the most parsimonious solutions for the data. Each solution explained 47.34%, 50.71%, 53.38%, 55.76% and 57.91% of the total variance respectively. Inspection of the pattern matrix for each solution revealed the most parsimonious solution comprised two factors, and this solution was thus retained. Step 2. Both factors showed a number of strong loadings. One item was deleted as it cross-loaded on both factors with the difference between the two loadings <.2. Four items that were designed to assess non-patient centre care behaviours loaded on the patient-centred factor and were therefore deleted due to poor face validity. The matching pair of each of these items was also deleted. The interpretation of the two factors were ‘non patientactivation approach (non-PA)’ (factor 1, 20 items) vs. ‘patientactivation approach (PA)’ (factor 2, 20 items). Step 3. A second factor-analysis was performed with the 40 retained items. The solution explained 47.30% of the variance. The pattern and structure matrix for the two factors with initial items deleted and the communalities for all items are presented in Table 2. Step 4. The histograms for each item on both factors were inspected to determine the distribution of responses. A positive response bias was apparent for factor 2, PA, whereas there was a breadth of responses to items on factor 1, non-PA. Step 5. To determine the distribution of responses, the histograms, and mean and standard deviations for each item were inspected. In addition, the inter-item correlations on both factors were inspected to determine the distribution of responses. A positive response bias was again apparent for factor 2, PA, indicated by the skew of the histograms, the high means and restricted standard deviations. In comparison, there was a breadth of responses to items on factor 1, non-PA, indicated by the more normally distributed histograms and larger standard deviations. No negative inter-correlations were present for either factor indicating the items appeared to measure the intended construct. Step 6. As shown in Table 3, the results of the sensitivity to change analysis indicated a significant reduction on scores on factor 1, non-PA, pre- and post-program. The scores on factor 2, PA, also demonstrated a significant change pre- and post-program. However this was not in the expected direction, with perceived importance of this approach by health professionals decreasing post-program. Step. 7. Given that items on the non-PA factor appeared to better discriminate the behaviours endorsed by healthcare providers regarding a patient-activation approach and to assess change in the expected direction, it was decided that only this sub-scale be used for scoring the HP-PAS. A reliability analysis using these 20 non-PA items demonstrated very good internal consistency with Cronbach’s α = .95. All 20 items were retained in the non-PA scale as no improvement in internal consistency was demonstrated if items were deleted. Responses to the scale could range from 20 to 100. Lower scores indicate more patient-activation behaviours. The final full 40-item scale is shown in Box 1, with items to be scored highlighted. 4. Discussion and conclusion 4.1. Discussion The results of this study demonstrated that healthcare providers’ beliefs about behaviours reflective of a patientactivation approach to care were measured by a 20-item subscale reflecting a non-PA approach. This ‘non-PA’ scale was a better indicator of healthcare provider orientation than the ‘PA’ scale, with very good internal consistency, good face validity and discriminatory ability, and high sensitivity to change.

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Table 2 Pattern and structure coefficients of pattern matrix and communalities. Pattern coefficients

Communalities

Factor Item

1

Direct the patient on how to make lifestyle changes Direct the patient on how they should manage their symptoms Make sure the patient adheres to their treatment regime Direct the patient on how they should change their behaviour Inform the patient of what treatment options are best for them Direct the patient on how to cope with impact of their disease on their work or personal life Tell the patient what they need to know about managing their condition Tell the patient what lifestyle changes they need to make Direct the patient on how they should manage their emotions Advise the patient what they have to do to manage their symptoms Tell the patient about the barriers they are likely to face in making lifestyle changes Persuade the patient to follow your advice about managing their condition Provide the patient with a care plan for long term management of their condition Advise the patient on problems they are likely to encounter in managing their symptoms Share your knowledge with the patient about what works to change their lifestyle Emphasise to the patient why lifestyle change is important Share with the patient strategies that have helped others manage their chronic condition in the past Oversee the patient’s progress in making lifestyle changes Oversee the patient’s management of symptoms of their disease Set goals for the patient for lifestyle change Identify with the patient the skills they have to manage their symptoms Help the patient identify what works for them to change their lifestyle Support the patient in identifying lifestyle changes they are willing to make Identify with the patient their confidence to manage their symptoms Explore with the patient strategies for managing their symptoms Work with the patient to create goals for lifestyle change Identify with the patient the barriers they are likely to face in making lifestyle change Help the patient to monitor their progress in making lifestyle changes Tailor information about how to make lifestyle changes to the patient’s stage of change Explore with the patient their level of knowledge for managing their condition Explore the patient’s attitudes towards adhering to their treatment regime Explore with the patient strategies for changing their behaviour Explore with the patient strategies for managing their emotions Explore with the patient strategies that have helped them manage their chronic condition in the past Help the patient to monitor symptoms of their disease Identify with the patient their own reasons for why lifestyle change is important Support the patient to make decisions about what treatment options are best for them Encourage the patient to seek information about managing their condition Develop a care plan with the patient for long-term management of their condition Help the patient to manage any impact of their disease on work or personal life

.97 .88 .86 .85 .83 .82 .81 .79 .79 .78 .73 .67 .67 .62 .61 .54 .49 .43 .38 .37

2

Initial

Extraction

.77 .75 .73 .73 .70 .69 .68 .66 .66 .64 .63 .61 .61 .56 .55 .52 .52 .51 .48 .48

.71 .55 .72 .79 .75 .70 .83 .66 .85 .58 .69 .82 .60 .75 .64 .49 .60 .79 .90 .67 .74 .77 .66 .74 .61 .91 .78 .75 .80 .74 .72 .76 .67 .89 .86 .75 .80 .74 .71 .66

.51 .26 .19 .55 .46 .43 .59 .39 .67 .28 .55 .59 .29 .49 .37 .30 .25 .48 .60 .42 .53 .67 .40 .45 .31 .87 .56 .39 .60 .38 .49 .67 .39 .70 .76 .47 .54 .37 .32 .40

Note. Values <.3 suppressed.

Table 3 Pre-training and post-training mean scores on the Patient Activation and nonPatient Activation subscales. Pre-training

Non-PA subscale PA subscale

Post-training

Mean

SD

Mean

SD

77.38 94.24

16.03 6.33

61.16 89.81

20.98 8.9

Z

p 3.38 3.23

<.001 <.001

N = 105. PA = patient activation.

While the ‘PA’ sub-scale also demonstrated good internal consistency, it exhibited a ceiling effect, did not accurately distinguish health professionals’ approach to care, and did not measure change in the expected direction. The unexpected decline in PA scores from pre- to post-training might reflect an increase in self-awareness amongst participants about what is actually required in using a PA approach, namely engagement in behaviours that support patients in their self-management rather than using a ‘clinician as expert’ approach. That the PA subscale exhibited a ceiling effect at pre-training supports the interpretation that participants may have over-rated their PA behaviours prior to undertaking the training without fully understanding what the PA approach entailed.

Alternatively, the high pre-training scores on the PA subscale might indicate that the patient-activation message is well established amongst the healthcare providers in our study. In contrast, in the development of the CS-PAM, Hibbard et al (2010) found that clinicians more often endorsed non-patient centred care rather than patient-centred care items in their measure [24], and this was a matter of concern to be addressed by health service managers. Perhaps our findings indicate an actual improvement over the past decade in healthcare providers’ beliefs about the importance of adopting a PA approach. If that is the case, then the decrease from pre- to post-training might reflect a regression towards the mean due to the ceiling effect at pre-training [30]. Importantly, the HP-PAS focuses on the behaviours of healthcare providers themselves. In this way, our work extends that of Hibbard et al. whose scale focuses on clinicians’ beliefs about patients’ self-management behaviours [24]. Given that patient centred care is a partnership [31], both patients and healthcare providers require favourable attitudes. Indeed, if healthcare providers do not possess favourable attitudes and beliefs towards the patient-activation approach, then they will be unable to adopt the behaviours required to activate patients to be involved in the self-management of their own conditions or to deliver behaviour change support in a way that takes into account the needs, preferences and values of the patient.

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The scale presented here could be easily adapted to measure healthcare providers’ actual behaviour. In its present form, the scale asks respondents to rate each aspect of their current work practice in terms of ‘How important is it to . . . ’, using a response scale from 1 ‘not important’ to 5 ‘very important’. By changing the question to ‘How often do you . . . ’’ and using a frequency response scale from 1 ‘never’ to 5 ‘always or routinely’, the scale would measure the frequency of actual behaviours. Hibbard and colleagues also note the importance of measuring clinician actual behaviour with regard to PCC [24]. Indeed, behaviour change requires that a person not only view a behaviour as important, but also possess the capability and opportunity to enact the desired behaviour [32]. Building a health workforce with a culture of patient-centred care requires that healthcare providers be equipped not only with knowledge of the paradigm but also the skills to implement this style of care. Healthcare providers need to be capable of adapting their practice to embrace patients as active collaborators in their own care, and to be open to adopting new ways of providing care by replacing previously learned behaviours with new ways of practicing [17,20]. They also require good communication skills, and the ability to deliver evidence-based behaviour change support in key areas relevant to health [17,20]. The current study had some limitations. First, the analysis was undertaken using responses from a single sample of cardiacoriented healthcare providers who had self-selected into an online training program to support CDSM. Moreover, nurses constitute almost three quarters of the study sample, the remainder being other allied health professionals, with no representation from physicians who have a central role in CDSM. This bias towards allied health professionals, together with the bias towards female participants, suggests that the findings cannot be generalised to other professionals or to male healthcare providers, particularly given that different disciplines work under different clinical conditions. Importantly though, a total of eight disciplines was represented. Second, the sample size is relatively small for instrument development, suggesting the need for further validation studies. Third, we did not include patients with chronic disease in the development of the original item pool: inclusion of patients might have optimised the face validity of the item pool and ensured that no relevant areas were overlooked. Unfortunately, as the item pool was initially developed to evaluate the online CDSM training program, the inclusion of patients was not seen as imperative at the time of item development. Fourth, pre-testing of the item pool would have been desirable, particularly in light of the ceiling effect found on the PA subscale. Pre-testing may have identified this issue earlier. Finally, a test-retest reliability analysis was not able to be conducted as the second data collection point was after training participation. These limitations could be addressed in future validation studies.

aspects of patient-centred care, reflecting their own professional roles and interests [33], future research should focus on validation of the scale in more diverse sample of healthcare providers. Conversion of the scale to measure healthcare providers’ actual behaviours is also warranted. 4.3. Practice implications The HP-PAS has several potential applications. It could be used to assess the effectiveness of clinician training or education, as demonstrated here, or to monitor change in healthcare providers’ orientation to PA over time as new policies and practices emerge. Understanding and measuring healthcare providers’ beliefs about the practice of patient-activation will allow educators and managers to adopt a multifaceted approach to supporting the health workforce to deliver this aspect of patient-centred care through focused education efforts. Author contributions All authors contributed to the conception and design, acquisition of data, analysis and interpretation of data. LS led the drafting of the paper with all authors contributing to the writing. All authors have given approval of the submitted manuscript. Funding and conflict of interest The development of the CDSM online training was funded by the Australian Department of Health and Ageing as an Interprofessional Learning grant. No conflict of interest has been declared by the authors Data statement The datasets used and analysed during the current study are available from the corresponding author on reasonable request. Acknowledgements We thank the healthcare providers who participated in this research. We thank staff from the Australian Centre for Heart Health, including Michael Le Grande for assistance with the online survey and Emma Llewelyn for administrative support. Appendix A. The 40-item HP-PAS The Healthcare Providers Patient-Activation Scale Please complete the following questions concerning aspects of your current work practice and rate the importance of each statement. How important is it to

4.2. Conclusion Challenges to the adoption of patient-centred approaches, including patient-activation, still remain. The ongoing dominance of the biomedical paradigm and the lack of emphasis on individual clinical skills in formal education remain barriers to patientcentred care [20,23,33]. Nonetheless, the present study has built on previous work in this area by providing a scale to assess healthcare providers’ beliefs about the PA approach to care. The study has demonstrated that healthcare providers’ beliefs about their PA behaviours can be measured using a ‘non-PA’ sub-scale. We recommend that the entire 40-item scale be administered to provide a balance of ‘positive’ and ‘negative’ items, but that only the 20 non-PA items be used for scoring. Given that previous research has shown that different groups tend to focus on different

Not Slightly Moderately important important importantly 1

2

3

1 Tell the patient what lifestyle changes they need to make Explore with 1 the patient strategies for managing their symptoms Emphasise to 1 the patient why lifestyle

Very Extremely important important

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(Continued) Not Slightly Moderately important important importantly change is important 4 Identify with the patient the barriers they are likely to face in making lifestyle change Support the 5 patient to make decisions about what treatment options are best for them Set goals for 6 the patient for lifestyle change Share your 7 knowledge with the patient about what works to change their lifestyle Help the 8 patient to manage any impacts of their disease on their work or personal life Support the 9 patient in identifying lifestyle changes they are willing to make 10 Provide the patient with a care plan for long-term management of their condition 11 Identify with the patient the skills they have to manage their symptoms 12 Advise the patient what they have to do to manage their symptoms 13 Explore with the patient their level of knowledge for managing their condition 14 Work with the patient to create goals for lifestyle change 15

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Very Extremely important important

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Tell the patient what they need to know about managing their condition Persuade the patient to follow your advice about managing their condition Explore with the patient strategies for managing their emotions Advise the patient on problems they are likely to encounter in managing their symptoms Develop a care plan with the patient for long-term management of their condition Help the patient monitor their progress in making lifestyle change Direct the patient on how they should manage their emotions Direct the patient on how they should manage their symptoms Tailor information about how to make lifestyle changes to the patient’s stage of change Oversee the patient’s progress in making lifestyle changes Explore the patient’s attitudes towards adhering to their

Not Slightly Moderately important important importantly

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(Continued) Not Slightly Moderately important important importantly

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treatment regime Identify with the patient their own reasons for why lifestyle change is important Oversee the patient’s management of symptoms of their disease Tell the patient about the barriers they are likely to face in making lifestyle changes Encourage the patient to seek information about managing their condition Identify with the patient their confidence to about managing their condition Direct the patient on how to make lifestyle changes Direct the patient on how they should change their behaviour Explore with the patient strategies that have helped them manage their chronic condition in the past Help the patient identify what works for them to change their lifestyle Help the patient to monitor symptoms of their disease Share with the patient strategies that have helped others

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5 37

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38 1

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manage their chronic condition in the past Direct the patient on how to cope with the impacts of their disease on their work and personal life Explore with the patient strategies for changing behaviour Make sure the patient adheres to their treatment regime Inform the patient of what treatment options are best for them

Not Slightly Moderately important important importantly

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For scoring purposes, include items 1, 3, 6, 7, 10, 12, 15, 16, 18, 21, 22, 24, 27, 28, 31, 32, 36, 37, 39, 40. Total score range from 20 to 100. References 1

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