- Top of page
- PATIENTS AND METHODS
- Appendix A
Self-management programs promote patient responsibility for managing daily health in conjunction with traditional health care (1). By building behavioral skills that promote self efficacy and self management, these programs may ultimately improve patients' health status. The Arthritis Self-Management Program (ASMP) epitomizes a successful strategy that has consistently improved health outcomes and reduced health care utilization among patients with various rheumatic conditions (2–5). Given the prevalence and costs associated with acute low back pain in the US (6), particularly among socioeconomically vulnerable persons (7), we sought to tailor the ASMP to low-income, inner-city patients with acute low back pain (ALBP). We designed our program to be sensitive to potential recruitment difficulties, protocol delivery, attendance, and adherence goals.
Interventions seeking to instill behavioral change typically recruit highly motivated subjects using strategies such as newspaper advertisements and organizational mailing lists (8, 9). Although these strategies may increase attendance and adherence to program goals, using volunteers introduces selection bias (e.g., those who are interested in exercise are more likely to join and follow a physical activity program). These methods also tend to attract well-educated, middle-upper class whites (10, 11). As a consequence, programs using such strategies would generalize to highly selected volunteers, rather than the majority of patients with medical conditions.
Protocol delivery strategies represent another critical consideration in designing the program. ASMP uses group sessions for 6 weeks or longer (4). However, our focus groups suggested that having 6 group sessions would not be pragmatic for socioeconomically vulnerable populations. Other programs for this population have reported barriers of lack of time, transportation, and flexibility with work schedules or childcare (12). Thus, efficacious programs may be ineffective among vulnerable populations with such barriers.
This article describes how we implemented and revised strategies for patient recruitment, protocol delivery, and attendance patterns for a randomized, controlled trial of a self-management intervention among low-income, inner-city primary care patients with ALBP. In addition, we identified baseline patient predictors of program attendance to elucidate correlates of program acceptance among this population.
- Top of page
- PATIENTS AND METHODS
- Appendix A
The traditional self-management programs (e.g., ASMP) usually include at least 6 weekly group meetings that are typically held in the community and are facilitated by volunteer lay leaders. We presented a modified self-management program for inner-city primary care patients with ALBP. Unlike the ASMP, the patients in our program presented with acute pain of the low back rather than chronic arthritis pain, attended 3 group meetings compared with the usual 6, attended in smaller groups, and the groups were facilitated by staff rather than volunteer lay leaders. In addition, we actively recruited patients from primary care practices rather than by passive methods in the community.
Recruiting from a defined, clinical population enabled us to determine our eligibility and participation rates. After screening, 39% of all eligible patients were randomized into our study, a rate almost 4 times greater than that reported in a study of a low back pain self-management program conducted in a suburban, middle-class white population (5). However, the group session participation rate in that study was much higher than our study. Thus, although we reached a greater portion of the eligible patients, the group session mode did not meet the needs of all interested patients. Future analyses will provide some indication of the extent to which the different modes yield different patient outcomes. The only other self-management program that targeted alternative populations was the Spanish Arthritis Self-Management Program (24). However, this randomized trial recruited volunteers from the community, therefore eligibility and comparison rates of class attendance are not available.
Another benefit of our ALBPSMP is the involvement of patients' primary care physicians in the process of patient recruitment. Implementing a computer alert program to notify physicians of potential patients greatly improved the efficiency of the patient screening process. It also enabled the physician to screen patients as required by the institutional review board. Future work may investigate the importance of physician referral to patient involvement.
We faced several challenges in implementing a self-management program in a low-income population. First, patients often expressed difficulty with transportation, a concern unique to a socioeconomically vulnerable population. Therefore, it became difficult to hold large group sessions in central locations. Patients expressed a preference for attending sessions at their neighborhood health center rather than other centers, even when the distance was <10 miles. Despite the transportation difficulties, however, our data suggest that a significant portion of low-income patients were interested in self-management in conjunction with traditional medical care.
To identify those patients attracted to our program, we analyzed baseline patient characteristics associated with program attendance. We reported that older, poorer, and unemployed patients were more likely to attend at least 1 intervention class. Thus, our program appeared to reach patients with little financial resources and more free time. These patients were more likely to take advantage of the extra program offered free of charge for their back pain. It is possible that younger, employed patients with greater financial resources may have greater access to other resources for their back pain (i.e., over-the-counter products, coworkers' experiences) and may perceive our program as less essential. Employed patients may also have trouble getting time off to attend the classes, or the classes may compete with their time after work. The “working poor” may be particularly vulnerable, having neither the time for interventions such as ours nor the financial resources for more traditional health care interventions. Given that this population has often been underserved regarding health behavioral programs (25), additional research is needed to understand program acceptance.
The second, not unique, challenge is motivating patients to attend nonpharmaceutical treatment programs. With only one-third of our intervention group attending class sessions, alternative methods were required to deliver the intervention. We chose to audiotape class sessions and provide hand-held cassette players with batteries as an inexpensive alternative to group sessions. Although this method increased the intervention exposure to an additional 30% of the self-management group, approximately 40% of the self-management group was unavailable for telephone followup after receiving the tapes. Exposure to the first class also increased when we offered individual sessions at the convenience of the patient's schedule and clinic preference. However, individual sessions limited the group dynamics (i.e., social modeling) that may assist in behavioral change.
Offering different delivery modes of educational programs may be important for increasing patient participation in behavioral interventions, and the mode may depend on the symptom severity (acute versus chronic). Patients experiencing greater pain or disability from their medical condition may be more motivated to attend behavioral interventions.
We recognize the limitations of alternative intervention delivery methods; however, traditional self-management efforts reached only one-third of the eligible patients. As our next step, we plan to evaluate the effectiveness of our intervention. Because we are not powered to evaluate 3 separate intervention groups, we will evaluate group differences and adjust our analyses based on those differences. The results presented in this article provide a foundation that can be used to build alternative intervention programs while avoiding ineffective methods for a low-income population. Developing effective, minimal-contact behavioral interventions remains an objective for future research.