Health‐care professionals’ assessment of a person‐centred intervention to empower self‐management and health across chronic illness: Qualitative findings from a process evaluation study

Abstract Background Person‐centred care (PCC) empowers patients to manage their chronic illness and promote their health in accordance with their own beliefs, values and preferences. Drawing on health‐care professional's (HCP’s) experiences implementing an empowerment‐focused, person‐centred intervention called the Bodyknowledging Program (BKP), we undertook a process evaluation that aimed to assess the impact on patient health and well‐being. Methods We used individual in‐depth interviews and semi‐structured focus groups comprising n = 8 interprofessional HCP who facilitated intervention sessions with n = 58 patients situated in Norwegian specialist care sites. Content analysis was used to analyse the data and summarize major themes. Results Health‐care professional interviews revealed four main ways in which the intervention operated in support of health‐related patient outcomes: (i) addressing the whole person; (ii) hope and affirmation; (iii) expanding recovery; and (iv) social support and revitalized relationships. The intervention provided new tools for patients to understand the social, emotional and physical impact of their illness. Health‐care professional reported new insights to facilitate patient engagement and to promote patients’ health. Conclusions The Bodyknowledging Program facilitated patient engagement through the promotion of patient‐centred care while developing the patients’ ability to exploit their own resources for effectively managing their health within illness. The process evaluation supported the underlying theoretical basis of the intervention and was suggestive of its potential transferability elsewhere.


| INTRODUC TI ON
The global ambition of 'leaving no one behind' has been adopted by all member states of the United Nations and is grounded in 17 sustainable development goals (SDGs), which together form an urgent call for all countries to take action in critical areas, including the global burden of disease. An important target is to reduce the number of persons who die prematurely of chronic illness. 1 Beyond efficient treatment and care, health promotion interventions have been offered to prevent secondary conditions, increase opportunities to participate in activities of daily living and attain optimal health. 2 Empowerment is a key dimension in health promotion and is defined as a process through which individuals gain broader control over the decisions and actions that affect their health. Empowerment is fostered by participation and requires the legitimization of lay knowledge and active patient participation in their health-care encounter. 3 Although empowerment could offer a path to enhance clinical practice in order to improve the health and well-being of patients diagnosed with chronic illness, there is a lack of interventions that utilize patients' lay knowledge of their health and a lack of interventions that may be applied across diagnoses. [4][5][6] Moreover, the World Health Organization 7 emphasizes the importance of person-centred care (PCC) to promote better health outcomes and improve wellbeing. The purpose of PCC is to empower patients to improve and manage their own health in accordance with their beliefs, values and preferences. 8 In this study, the aim was to explore health-care professional's (HCP's) assessment of patients' experience of engaging in an empowerment-based, person-centred intervention for patients with a variety of chronic illness in order to improve the delivery of the intervention.

| Theoretical background
The Bodyknowledging Program (BKP) is an example of PCC. 9 BKP is grounded in Bodyknowledging theory, 10,11 which asserts that people living with chronic illness possess bodily knowledge regarding their limits of tolerance concerning the type and magnitude of activity and factors in their physical (ie food or air quality) and psychosocial environment (ie significant others) that constitute an important resource for coping, recovery and health. [11][12][13] This theory draws on Merleau-Ponty´s phenomenological theory 14 of the body as a foundation for knowledge and existence and Antonovsky´s 15 theory of health as a dynamic continuum. In keeping with Paulo Freire's 16 'pedagogy of the oppressed' in which dialogue serves as the main method for helping people to understand their situations and to act in new ways, the essence of the BKP is to present patient-centred expertise to be interpreted and applied by new patients. The BKP intervention aims to support the person's understanding of how they can utilize their inherent resources to handle the consequences of chronic illness, prevent deterioration and facilitate recovery and health within their specific life situation. Two main conceptions of recovery can be distinguished in the literature: 'medical' or 'clinical' recovery, referring to cure of an illness; and 'personal' or 'life' recovery, referring to a process of personal growth and health-related change. In the context of chronic illness, personal recovery is not the same as being cured and/or having no further symptoms. Instead, it includes a 'return to a state of wellness' (eg following a relapse). [17][18][19] This aligns with an understanding of health as a dynamic continuum as described by Antonovsky. 15 In his theory, health is constituted by the sense of coherence (SOC), consisting of the dimensions; understanding, handling and meaning. 15 The three dimensions in SOC are attended to in the BKP intervention.
In prior work, the intervention was piloted in both specialist and community health-care settings in the south-eastern region of Norway. Studies found that patients with a variety of chronic illness diagnoses reported that the programme allowed them to work systematically on their health as a process and enabled them to renew their participation in different areas of life, that is family life, working life and social life. 20 In a separate study of the feasibility and outcomes in community care, participants reported that their engagement in the intervention improved perceived control of illnessrelated stress and circumstances when HCP challenged patients to get to know their bodies and utilize their knowledge of health and illness. 21 Another study investigating the efficiency of BKP in community care reported significant changes in recovery. 22 A comparative study of BKP participants in specialist and community care showed that SOC improved at programme completion in both groups. 23 Overall, there is promising evidence related to patient experiences and outcomes; however, the views and experiences of the participating HCP require further attention to further improve the process of implementation.

| The intervention
The Bodyknowledging Program (BKP) is designed to be broadly applied across diagnosis, age, gender and clinical settings and is organized into seven sessions and held in individual or group formats. 9 Individual sessions lasted 1.5 hours. Group sessions last for 3 hours with a 30-minute break and include 8-10 individuals per group managing various health conditions (Table 1). Nurses, occupational therapists and physical therapists who had completed 80 hours of training (Table 2) lead the intervention groups. A poster, a flip-over chart and a booklet/diary serve as pedagogical tools. Studying materials and sharing reflections on their health-related challenges facilitate exploration, by the patient, of their recovery strategies while engaging in a supportive group process. In this way, patients' own life situations, coping strategies and health-promoting abilities form the core of the programme's content. In addition, patients were asked to choose a routine physical activity to complete at home twice a week in order to strengthen their physical capacity and facilitate reflection on their range of tolerance. Details on the development of the intervention and each intervention component have been published The present analysis was part of a larger study in which the BKP was piloted in different clinical sites. 20,23 In line with the recommendations for the development of complex interventions, 24 a qualitative process evaluation 25 was undertaken to identify key intervention components and the connections between intervention activities and outcomes. The method also served to examine the applicability of the theory underpinning intervention design. 26 Qualitative data were collected using focus-group and individual indepth interviews with HCP. 25,27 The Ethics Committee of the Southeastern Regional Health Authorities in Norway approved the study.

| Recruitment
The participating HCP discovered the Bodyknowledging model when attending a health conference in Norway and requested further training. Nine group facilitators were purposively selected in order to ensure interdisciplinary participation from a variety of health professions. All the facilitators were invited to participate in evaluation interviews. One participant was unable to complete the training, and pre-training data were excluded from the analysis. Patients were interviewed from the same groups run by the facilitators. Results from patient interviews have been published elsewhere. 20,22,23 TA B L E 1 Structure, aims and tools of the Bodyknowledging Program-a person-centred intervention for facilitating empowerment, selfmanagement and health in chronic illness

Structure
Intervention aims and tools

| Data collection
The first author conducted four focus groups and two individual interviews with the HCP lasting 60-90 minutes in duration, 1-2 weeks after the intervention was completed. Two focus-group interviews (n = 8) were conducted with all participants from all three sites together. One focus group (n = 5) was conducted at the rehabilitation unit, and one was conducted at the centre for patient education (n = 2). Finally, two individual interviews were conducted with one nurse who worked TA B L E 2 Training programme for health-care professionals (HCPs) leading the Bodyknowledging Program (BKP)

Course 1. Health promotion processes
Course 1 has two 3-day meetings (1 in-person and 1 online) Method of work: Resource lectures are arranged based on the central topics. Written report 1 for study group with oral presentation during videoconference. Written report 2, individually, with guidance from supervisor.

Fundamental perspectives in health promotion work
The resource perspective in meeting with people who live with health problems or who are at risk of being afflicted. Salutogenic theory, theory of coping and the application of the theory in practice.
Health promotion processes Recovery research on long-term illness within somatics and psychiatry. The health promotion process: Bodyknowledging and patients/users experiences with health promotion processes.
Empowerment and user participation.
Patients as experts on their health and how to handle health problems. Tools and making accommodations for user participation in practice.
The significance of social relations for coping and health. Social networks and social context; inclusion and social interaction that promotes healing.
Health education Dialogue as a fundamental approach in health promotion work. Narrative method, storytelling and writing as a method in health education. Group methods and group processes.

| Analysis
The interviews were audiotaped and transcribed verbatim. The first author and a research assistant analysed the data from each site independently and discussed the preliminary findings. The data were then analysed across sites. In order to ensure confirmability and dependability, 28 findings were discussed in co-operation with the whole research team. The evaluation focused on the HCP's assessment of patient outcomes in relation to intervention activities. Patton`s 25 description of 'structure', 'process' and 'results' served as the main headings for the analytic process. Each interview was read through several times to obtain a sense of the whole. Content analysis 29,30 was used for interpreting the data through a systematic process of coding and identification of themes. The parts of the text that described the HCP's assessment of patient outcomes were extracted, and the text was divided into meaning units that described similar content. These were abstracted into themes and subthemes and labelled with a code. Themes, subthemes and codes were sorted, discussed and studied again in order to develop and report on general themes.

| RE SULTS
Health-care professional assessments of BKP and patient-reported outcomes were captured in four major themes: (i) addressing the whole person and individual needs; (ii) hope and affirmation; (iii) expanding recovery; and (iv) social support and revitalized relationships.

| Addressing the whole person and individual needs
Health-care professional reported that the new BKP approach

| Hope and affirmation
Health-care professional reported that the phased approach to the intervention, reflecting a progression in the patients' understanding of their illness, created hope and empowered patients to be taken seriously as the expert on their own illness experience.
The program allowed for a focus on coping which is founded on knowledge of different phases one naturally has to go through and the fact that it is possible to live with the condition, that there is hope. That it is possible to gain power and resources from within oneself and in the social network (RN). The nurse argued that the patient had received affirmation that his thoughts and feelings were valued inputs to his own recovery and this had made him less angry and more co-operative with his family.
She added that this clarified her practice of the intervention as a novel treatment in her encounters with patients diagnosed with chronic illness.

| Expanding recovery
In BKP, former patient's experience of recovery and health within illness is described in the pedagogical tools. Therefore, patients were invited to review content in between sessions and were en- Health-care professional also observed that some patients were able to ascertain expanded comfort zones for their bodies, beyond their initial (pre-intervention) understanding of their own physical limits. They (HCP) reported that one patient who experienced symptoms but had no diagnosis recognized himself within examples of other patient experiences described in the intervention booklet.
After programme completion, he had realized that he could live with the condition, and he started to go to the grocery store, something he had been unwilling to do given his uncertainty about his body's limit of tolerance. Health-care professional expressed that the intervention was useful even for patients who had lived with the illness for a long time without expanded physical capability because they were able to achieve some empathy for themselves, and to realize that they were allowed to be sad and that there was a grieving phase that may be complex and on-going. In addition, Health-care professional described how the intervention facilitated peer support; that is, when someone was describing their grief, others reacted with empathy.
We saw the effect of having people who described themselves as being healthy in spite of their illness, how they were able to support others who were dom- However, HCP reported that some participants who had been socially isolated for a long time due to their illness attained a better outcome when engaging in individual sessions as this allowed for more openness to specific challenges and in-depth work on their health.
Health-care professional emphasized the importance of holding on to the recovery perspective in patient encounters: I think that it is very important that HCP do not put restrictions on the patient's recovery, because we hear about this on and on again, that patients have got the message that they will not recover and that this (the illness and the consequences) is something they have to accept (RN).

| Social support and revitalized relationships
One of the aims of BKP is to prepare people living with illness to reencounter social relations and to re-engage in the social world. The that is family and friends. Health-care professional observed that participants ability to communicate had been strengthened, especially when it came to complicated feelings of grief and anger connected to their reduced capabilities relative to the period prior to their illness. This example was given by a nurse regarding a male participant who self-described as modest: … he dared to tell how he was and to talk with the other group members. And then, he told that he was struggling with the communication with his wife because he was afraid of getting negative feedback. I challenged him to talk to his wife because the feeling he had inside did not contribute to his recovery, and then he talked to his wife and he did not get the negative answer that he was prepared for…He got the affirmation that he was able to express his thoughts and feelings (RN).
Another HCP reported that a male participant who engaged in individual sessions expressed that the experience was clarifying for him in relation to the amount of work he could do while remaining well.
Health-care professional also reported that some patients revealed that their partner or daughter had read the intervention booklet, which resulted in mutual reflection on key questions related to recovery, and that this had a positive impact on their relationship. These findings suggested that the intervention assisted with strengthening the social support network by developing new insights that were communicated effectively within the group and beyond.

| D ISCUSS I ON AND CON CLUS I ON
We have presented an evaluation of the process of implementing an empowerment-focused, person-centred intervention called the Bodyknowledging Program (BKP) by assessing the impact on patients according to qualitative observations by HCP drawn from nursing, physical therapy and occupational therapy professionals.
We found that HCP assessed that this intervention approach em- Health-care professional's assessment of patients' experience, including hope, affirmation, extended recovery, social support and revitalized relationships, aligns with previously reported patient outcomes. 20,22 Prior findings in Norwegian rehabilitation and outpatient clinical settings found significant improvements in patients' ability to manage their chronic illness. 20,21,23 The patient-reported outcomes were supported in this study by means of data on HCP's assessment of patient experience following implementation of BKP. According to HCP, the intervention offered a space for patients to discover and take advantage of their inherent and often under-utilized health resources such as their bodily knowledge on what makes their illness better or worse. [11][12][13]35 Individuals reflected and explored their individual strengths, resources and knowledge of their disease, which are necessary skills for self-care management. 21 to focus on recovery and health instead of merely on disease and to relinquish the power embedded in their professional expertise that is at odds with the patient-centred approach. [43][44][45] Overall, these findings suggest that the BKP may be a broadly applicable tool for HCP to incorporate PCC and an empowermentbased approach to health promotion in chronic illness. 34

| The study's strengths and limitations
Key strengths of this study include the focused aim, the use of theory to inform the intervention and the rich data set collected from key informants that were analysed across formats and clinical sites. 46 Health-care professional participating in this study took

| CON CLUS ION
The study assessed HCP's report of the patients' experience after facilitation of the Bodyknowledging Program (BKP), a personcentred, empowerment-focused intervention that aimed to supporting individuals in managing their chronic illness towards advancing the promotion of health and well-being. Analysis of interviews with HCP suggested that the programme facilitated patients' ability to explore their internal and external resources for health that are critical in their ability to manage their own care. Health-care professional reflections in this work demonstrate their use, in practice, of a demedicalized framework that enabled their focus to land on the whole patient, their values and context. These findings suggest that evaluating the intervention elsewhere using robust study design and with careful attention to local settings and contexts is feasible and will provide benefits for the clinical practice of HCPs.

| PATIENT OR PUB LI C CONTRIBUTI ON
Health-care professionals (HCPs) were involved in the development, implementation and evaluation of the intervention, in discussions and in dissemination of the findings. Patients were involved in evaluation of the intervention.

ACK N OWLED G EM ENTS
We thank the interdisciplinary health-care professionals for their participation in the study.

CO N FLI C T O F I NTE R E S T
No conflict of interest.

AUTH O R CO NTR I B UTI O N
KH originally conceived the study, collected and analysed the data and prepared the first draft of the manuscript. JBM, NS, BFO and MHL contributed to revising it critically for important intellectual content.

DATA AVA I L A B I L I T Y S TAT E M E N T
The data that support the findings of this study are available from the corresponding author upon reasonable request.