Tailored patient therapeutic educational interventions: A patient‐centred communication model

Abstract Background Tailoring therapeutic education consists of adapting the intervention to patients' needs with the expectation that this individualization will improve the results of the intervention. Communication is the basis for any individualization process. To our knowledge, there is no guide or structured advice to help healthcare providers (HCPs) tailor patient education interventions. Objectives We used a data‐driven qualitative analysis to (1) investigate the reasons why HCPs tailor their educational interventions and (2) identify how this tailoring is effectively conducted. The perspective aimed to better understand how to individualize therapeutic patient education and to disentangle the different elements to set up studies to investigate the mechanisms and effects of individualization. Design Individual semistructured interviews with 28 HCPs involved in patient education were conducted. The present study complied with the COREQ criteria. Results Why individualization is necessary: participants outlined that the person must be thought of as unique and that therapeutic education should be adapted to the patient's personality and cognitive abilities. The first step in the individualization process was formalized by an initial patient assessment. Several informal practices were identified: if needed, giving an individual time or involving a specific professional; eliciting individual objectives; reinforcing the relationship by avoiding asymmetrical posture; focusing on patients' concerns; leading sessions in pairs; and making the patient the actor of decisions. Conclusion From our thematic data analysis, a model for tailoring patient education interventions based on the Haes and Bensing medical communication framework is proposed. The present work paves the way for evaluation, then generation of recommendations and finally implementation of training for individualization in educational interventions. Short Informative Tailoring in therapeutic education consists of an adaptation to patients' needs. Communication is the basis for any individualization process. There is no model of patient‐centred communication in educational interventions. From semistructured interviews with HCPs, we propose a patient‐centred communication model for tailoring patient education intervention.


| INTRODUCTION AND BACKGROUND
In 1998, the World Health Organization described therapeutic patient education (TPE) as 'educational activities essential to the management of pathological conditions, managed by healthcare providers (HCPs), duly trained in the education of patients and designed to help a patient (or a group of patients and their families) to manage their treatment and prevent avoidable complications, while keeping or improving their quality of life'. 1 TPE covers organized activities, including psychosocial support, designed to make patients fully aware of their disease and to inform them about care, hospital organization and procedures as well as health-and disease-related behaviours. 2 TPE can be a way to cope with change in self-identity and to plan, pace and prioritize. 3 Educational activities can include interventions based on health education, promotion of medical adherence, illness-related problems in everyday life, promotion of physical activities, psychological support and social counselling (see e.g., Meng et al. 4 ). Several meta-analyses showed that TPE interventions are beneficial for patients, but they are rarely described in detail. [5][6][7][8][9][10] In 2007, Conn even spoke about the 'black box', whereby no one can determine what actually happened during an intervention, 11 which is not appropriate from a strictly epistemological point of view.
A description of the intervention is essential to understand its mechanisms and to explain the obtained results. TPE interventions are complex by nature because they are based on multiple components such as the variability of individuals, HCPs, healthcare systems, economics, political factors and their interaction. [12][13][14] Adult patient education has its own particularities. Indeed, the people to whom it is addressed already have representations and experiences and have built up knowledge. TPE interventions often question their certainties. Although education includes a part of transmission of knowledge or know-how, it also aims at the appropriation of this knowledge and its transformation by the person to whom it is transmitted. TPE interventions place a strong emphasis on experiential learning. The patient's reflexivity is emphasized to define their own goals and action plans. It also aims to develop self-knowledge and critical thinking skills that contribute to the ability to make choices and to exist in a social environment. 15 The individualization process consists of adapting the intervention to a patient's needs, according to assessment on admission and subsequent re-evaluations. 16 To achieve this process in the context of TPE, several levers are already envisioned, for example, taking into account factors such as cultural context [17][18][19] or patients' health literacy level. 20,21 The importance of social workers or psychologists is also highlighted. 22,23 For individualization, professionals should have precise and up-to-date medical knowledge of the illness and high communication skills reinforced by training courses. [24][25][26] Patient initial assessment is the first step of TPE from which individualized education can be operationalized and deployed. 22,[26][27][28][29] More generally, for Hawkins et al. 30  The principles of using tailored communication states that by tailoring content, superfluous information is eliminated. People pay more attention to information that they perceive to be personally relevant, and this information process is more likely to have an effect.
Information that addresses the unique needs of a person will be useful in helping them become and stay motivated and will promote desired life-style changes. 32 Comprehension is expected to improve, and exchanges on the content and changes in behaviours and attitudes will be enhanced.
Hawkins et al. 30 39 In 2018, the COMFORT communication curriculum was developed for nurses and has become the first theoretically grounded and evidence-based curriculum for teaching palliative care communication. 40 Finally, there are few developments on patient-centred communication for women with breast cancer. 41 In addition, training in communication skills for nurses is emerging, 39,[42][43][44][45][46][47] which highlights needs in this domain.
We used a data-driven qualitative analysis to (1)

| Programme selection
Programmes were chosen among Lorraine Regional Health Agenciesauthorized programmes from their updated list. After eliminating 23 programmes for children, spleen diseases and psychiatric disorders, 113 programmes remained. We selected 12 programmes in the Lorraine region and two outside the region: one in Paris (Île-de-France Region) and one in Grenoble (Auvergne Rhone Alpes Region).
Sample heterogeneity is considered essential to capture in depth a large and diverse content. To construct a maximum variation sampling, 49,50 we identified three key dimensions of variations of the programmes: 51,52 diseases; hospital or nonhospital programmes; and urban or rural programmes.
The list of the Regional Health Agencies included the name and contact information of the programme manager (public data).
L. R. and J. K. phoned the programme manager to explain details and ask them to participate in the CONCErTO project. No manager refused programme participation.

| Participants
Interviews were conducted where programmes took place by an We interviewed all HCPs involved in each programme who were present on the day of the interview. The researchers did not have any relationship with HCPs before the start of the study. All solicited HCPs agreed to participate after a short presentation of the CONCErTO project. The interview duration was about 1 h. Interviews were integrally audio-recorded and transcribed.

| Protocol development and data collection
During three meetings in the first quarter of 2016, an interview guide was designed with a clinician/epidemiologist (also coordinator of a TPE programme), a psychologist and a sociologist (also coordinator of a transversal TPE unit of a teaching hospital). The key research questions for discussion were to describe the TPE practices and identify elements that may affect the outcome, participation and sustainability of the intervention.
Probing questions for in-depth exploration were organized based on May's normalization process theory, 53 with three levels: macro (institutional elements), meso (elements linked to the TPE organization) and micro (elements linked to the patient and the HCP-patient relationship). Probing questions were defined to identify HCPs' perception of TPE (see Box 1) and to investigate the institutional (macro), organizational (meso) and pedagogical, medical and psychosocial (micro) components of a TPE programme affecting outcomes such as participation and sustainability of the programme. The key aim was to encourage HCPs to speak freely about factors of success or difficulty in TPE.
Individualization was addressed with the probing question 5 on 'methods, facilitation, HCP-patient relationship, pedagogical tools used, and customization'.
We collected demographic information of the participants (i.e., specific profession, age class and number of years of experience in TPE). For each included programme, we also collected the mode of delivery of sessions (one-to-one, in groups, both) and whether a specific strategy for composition of the participant groups was applied.

| Analysis and rigour
We followed a general inductive approach 54  Therefore, we chose to focus specifically on exploring individualization. A document specifying the content of the themes (elements to be included/excluded in each theme) was created and revised progressively to stabilize the coding grid. All themes and subthemes were defined and discussed during the meeting to triangulate the perspectives of psychology, sociology and clinical and public health.
In this type of triangulation, researchers provide different insights for a deeper and broader understanding of findings. 55,56 L. R. and J. K. are experts in qualitative research, A. C. R. is also a coordinator of a TPE programme and J. K. is also a coordinator of a transversal TPE unit of a teaching hospital. The variety of expertise ensured rich data interpretation. 57 In 2018, J. V. was trained in the coding grid. Six interviews were double-coded by L. R. and J. V. (21% of the qualitative material). All coding disagreements between the two coders were resolved by discussion. In case of persistent disagreement, resolution was obtained by discussion with a third researcher (A. C. R.). Then, we measured the level of agreement between the two coders using Cohen's Κ coefficient. This calculation provided an overview about the process of achieving coder consensus. 58 After reaching a κ value of 0.89, J. V. encoded the remaining data. Throughout the coding process, difficulties and queries were regularly discussed by the whole team.
The recruitment process ended after data saturation, that is, on obtaining sufficient data to report on all aspects of the phenomenon. 59,60 Data saturation is achieved when concepts and subconcepts cannot be further specified with additional data.
To achieve data saturation, L. R. conducted interviews with HCPs until the information redundancy point was reached (no emergence of new idea from data). J. K. then conducted three more interviews to ensure data saturation (one with an allied health professional and two with a nurse). In other words, we continued data collection for three more interviews to confirm that no new relevant themes emerged from supplementary interviews. 61 Data analysis was performed using NVivo v11.

| RESULTS
Saturation was achieved with 28 interviews (20 nurses, 6 dieticians, 1 physiotherapist and 1 psychologist). Table 1 shows that sampling was varied to collect a large diversity of perceptions concerning TPE.
The average education experience was 7 years. Table 2 shows that among the 14 programmes, most (n = 10) If the patient wants to go slower, we will go slower.
(Participant, 1) In one other programme for hepatitis, individual sessions were proposed for confidentiality reasons because the target population was often former drug users.
One single programme included both individual and group sessions.
In one programme, significant others were systematically invited to participate in the last group session. In three other programmes, significant others' participation for group sessions was left to the discretion of the patients. The HCPs' perceived interest was 'to have a better understanding of each other' (Participant, 12). Table 3 presents an overview of why and how an educational programme is tailored in an individual education configuration or To take care of a patient not just a disease 'We take the person as a whole, with his/her environment, disease (s), desires, needs, tastes, and then we adapt the TPE' (p. 23).
To adapt to personal functioning 'With the patient profile it's difficult and it's up to me to adapt, but this very rigorous patient, it's absolutely not possible for me to tell him you can move forward or backward 24 hours because he won't be well ' (p. 20).
To adapt to cognitive and language abilities 'We use a vocabulary that is not the same for everyone and approach things in different ways' (p. 16).
How? Take time 'To get there, the key is to take time' (p. 20).

Organization of the programme
Conduct an initial assessment 'Initial assessment allows us to find the most appropriate program to their needs. If you have a person who is physically hyperactive, it's not the most urgent to make him meet the group workshops with the physiotherapist' (p. 22).
Systematically add an individual session 'We tell them: you measure your breath for a month, you send us the results and then we meet again for a last session, for crisis management' (p. 14).

Add alternative or complementary individual sessions if needed
'Because he has questions that are too personal and it doesn't concern the theme of the day's workshops… we let the group go and then we resume in a somewhat informal way for some questions' (p. 9).

Content of the programme
Define objectives along the sessions' progression 'Patients always leave [the session] with an objective' (p. 12).
Consider the patient's lifestyle 'If the person gets up at 9 am, they will not be asked to measure their blood sugar at 7 am' (p. 26).
Adapt content and activities 'This involves adapting the content to age and age-related concerns' (p. 12).
Take into account pedagogical assessment 'Not to continue the sessions if there are things that have not been understood, to be able to readjust before continuing the session' (p. 14).
Individualized follow-up between sessions 'For the most vulnerable people, I also do telephone follow-up' (p. 4).

Relationship with the patient
Allow for a deeper relationship than in routine practice 'I'm not here as a care prescriber (…) saying you have to, you have to, you have to' (p. 28).
Built over time It is important that patients 'always deal with the same professional' (p. 5).

Communication style with patients
Avoid asymmetric positions 'We are no more with the image of the nurse who is there for her knowledge, who bombard patients with things to do' (p. 9).
Concentrate on patients' interests 'We have to focus communication on the patients' interests and not unpack everything we know' (p. 4).

How to facilitate group sessions
Know the participants beforehand 'As I know them well, when I animate I know very well who I have to look at, who I have to tell, why I am going to ask such a patient to give an example or how he feels' (p. 4).
Facilitate sessions in pairs 'In pairs, better listening to the group where sometimes someone will take the floor, the floor will be cut. We have trouble hearing the two people, and it is true that the second person can therefore reformulate what has been said next door to take up etc. Uh, all alone, I think there might be more forgotten remarks (…) that you don't necessarily hear alone when you are in a conversation' (p. 2).

Patient actor of the individualization process
The patient can choose to address 'questions or problems that have not been perceived' (p. 17).

RICCI ET AL.
| 281 in a group intervention without any strategy concerning group composition.

| TPE takes care of a patient, not just a disease
HCPs emphasized the holistic approach of TPE, which takes into account the whole person in their environment at a given time. All study participants outlined that, in TPE, the person must be thought of as unique.

| Need to adjust to the patient's cognitive abilities and to language barriers
The notion of speech-language disorders (aphasia, dysarthria) was never addressed in our data. Cognitive abilities (i.e., the patient's level of understanding of educational contents as perceived by the HCPs) were seen as a prerequisite for improving an understanding of the disease and its management and being autonomous in healthcare.
When HCPs perceived poor cognitive abilities, they usually reduced the content or adapted the intervention: • There are people with whom we will not go into as much detail because we will realize that they will not necessarily understand everything. (Participant, 11) • We help them, but without denigrating. (Participant, 9) • We go to the essential. (Participant, 15) • We take time… and respect them with their limits.
(Participant, 25) One programme even proposed individual rather than group sessions for patients who 'may not understand everything' (Participant,14).
Language barriers (i.e., when patients are not fluent in French) also require accommodations (e.g., practical demonstrations or accompaniment by a relative able to translate).

| How to individualize TPE
Leading a group session differed from leading an individual session: the way in which the different topics are discussed tends to be guided by the patient in individual sessions, whereas in a group, discussions remain focused on the topic of the session to avoid tangents and special discussions outside the group.
In individual sessions, of course, we are more focused on the patient and therefore we will go more in the direction of the patient, whereas when we are in a group, we will work more on a theme. (Participant, 7) Therefore, the underlying fundamental and practical question is how to individualize in a group session: It's individual in collective. (Participant, 25)

| Time
If the aims of TPE programmes are to work on intrapersonal change processes and targets, sessions can be delivered in groups, even if individualization seems less natural than in face-to-face interviews.
Knowing the patient and entering into an individualization process in collective sessions require time.

| Organization of the programme
The organization of the programme can help customize the inter-

| Initial assessment
Initial assessment is the keystone of patient education from which individualization of education can proceed. Aspects addressed during the initial assessment go far beyond the strict framework of the disease, its treatments or health practices to integrate psychological, social, economic or daily life aspects (e.g., dealing with elevators, domestic animals, working hours). Except for particular safety skills learning, which cannot be individualized, initial assessment may be used to generate individualized objectives.
In two programmes, patients could choose the sessions in which they participated: They don't have to join the full program. They can choose sessions that appeal to them more than others.

If needed, involvement of an HCP not systematically solicited
According to patients' needs, professionals who do not intervene in the TPE programme may be solicited (e.g., social workers, psychologists, physicians or professionals specializing in the support, longterm follow-up and retention of disabled people in employment). Proposals should also take into account local opportunities of living space (e.g., for the practice of a sport).

Content and activities of the sessions
In the asthma programme, support tools were individually tailored with individual follow-up booklets that included treatments, measures and warning signs. Tools for parenteral nutrition could be as follows: Quickly recreated for the patient when we look at the initial assessment, (…) The patient can say to himself: it was created for me, I am not a patient among 100 others. (Participant, 1) The physical activities are adapted to the difficulties encountered by patients.

Pedagogical assessment
Pedagogical assessment is an evaluation realized by an HCP with a specific tool or simply by observation to check the participants' understanding. The objective is to know to what extent the patient has understood and retained content addressed in the programme to adjust the programme continuation. This position is even more pronounced for 'safety' skills teaching for parenteral nutrition in digestive cancers and for injections in multiple sclerosis. In contrast, an HCP considered pedagogical assessment not really appropriate because it was like being at school.

Individualized follow-up
Two programmes offered patients the opportunity to call if necessary between sessions, particularly for reinsurance.

Relationship is deeper than in routine practice
The patient-HCP relationship is deeper in TPE than in usual consultation because the person is considered as a whole, with their environment, disease(s), desires, needs and tastes. Trust is built over time. The quality of the relationship is based on a bottom-up communication from the HCPs and is centred on the patient's concerns and not on predefined contents.

Patient relationships are built over time
A trust and listening relationship particular to TPE is considered to be built as the sessions progress. Three nurses clearly expressed it.

Not to have a masterful position in knowledge transmission
The central element in communication style with patients in TPE is not to have a masterful position in knowledge transmission and to enable patients to find appropriate solutions for themselves: We are trying to say as little as possible. We propose a subject but we will wait for them to bring us their knowledge. (Participant, 5)

Focus on patients' interests
Communication should also be centred on the patient's interests: • Not lecturing, we are not at school, even if sometimes we are forced to get into technicality, we try, • You have to talk to them about the things that concern them. (Participant, 4)

| How to facilitate group sessions
Knowing the participants beforehand HCPs' communication tricks are used to tailor the TPE intervention during group sessions particularly to focus the patient's attention on the right message at the right time. With the initial assessment or knowledge of the patient, group sessions are conducted differently depending on the composition of the group.

Facilitating sessions in pairs increases HCPs' attentional capacity
In groups, leading sessions in pairs increases HCPs' attentional capacity and therefore their propensity to adapt their communication to provide appropriate answers to patients.
• I admit that I will hear some things, my colleague will hear it differently, she will relaunch it differently and I am delighted because I did not hear it the same way she did and it allows even more   Individualized objectives are defined during the progression of sessions, and patients are invited to be proactive and to find appropriate solutions for themselves.
Our study produced suggestions to elicit tailoring in TPE interventions. 30 We propose a graphical representation of an adapted six-function model for individualization in TPE.

| Strengths and limitations
Qualitative data were generated and analysed according to COREQ criteria; 28 of the 32 items of the COREQ checklist were fulfilled.
Hence, findings were a synthesis of HCP views and experiences based on a robust qualitative study. However, no generalizable result can be provided using maximum variation sampling. 64 Moreover, findings could have been strengthened by further adding session observations to capture some aspects of individualization implemented without HCPs' conscious knowledge. Participants did not provide feedback on findings, which would have been interesting.

| Conclusion
The present work has paved the way for evaluation, then generation of recommendations and finally implementation of training for individualization in educational interventions. We provide a description of 'how' tailoring can be implemented in practice in TPE interventions.
It is a prerequisite to develop further studies to answer the following