Cardiovascular disease (CVD) continues to be the leading cause of death of Canadian women and while treatment for CVD has improved dramatically, women typically fare worse than men with regards to morbidity following cardiac event. Cardiac rehabilitation (CR) is well established as a key intervention in the treatment of coronary artery disease and has been shown to be effective in both men and women. CR remains largely underutilized, especially in women who comprise only 12 – 24% of contemporary CR programs, even though the prevalence of CVD in men and women is similar. The objectives of this pilot trial were to test the feasibility of all procedures, specifically to determine: 1) an estimate of patient recruitment rates, 2) acceptability and feasibility of the intervention and 3) barriers to CR attendance and resources required. Additionally, exploratory research questions were used to determine the effects of telephone coaching on women’s attendance at CR intake appointment, self-efficacy for cardiac exercise and self-efficacy to attend CR. A RCT design enrolled women with CVD referred for CR at a single site in Ontario. Patients were randomized, stratified for age, to either a usual care group or an intervention group. Participants allocated to usual care received a referral to CR. In addition to usual care, women assigned to the intervention group received individualized telephone coaching, designed to support self-management prior to CR intake. Eighty-three patients were approached and 70 consented to participate (usual care n = 36, intervention n = 34). Participants in the intervention group were significantly more likely to attend CR intake (p = 0.048). Participants were highly satisfied with their coaching experience; they found the information provided to be helpful with goal setting, action planning and assisted them in their interactions with their health care providers. Barriers to attendance identified included transportation, health concerns, timing and lack of physician endorsement. Most common resources identified included problem solving support, assistance with communication with physicians and information concerning CR. The evidence obtained from this pilot trial suggests that a telephone coaching intervention designed to enhance self-management is feasible and may improve attendance at CR intake for women following hospital discharge with a cardiac event.

Cardiovascular disease (CVD) continues to be the leading cause of death of Canadian women and while treatment for CVD has improved dramatically, women typically fare worse than men with regards to morbidity following cardiac event. Cardiac rehabilitation (CR) is well established as a key intervention in the treatment of coronary artery disease and has been shown to be effective in both men and women. CR remains largely underutilized, especially in women who comprise only 12 – 24% of contemporary CR programs, even though the prevalence of CVD in men and women is similar. The objectives of this pilot trial were to test the feasibility of all procedures, specifically to determine: 1) an estimate of patient recruitment rates, 2) acceptability and feasibility of the intervention and 3) barriers to CR attendance and resources required. Additionally, exploratory research questions were used to determine the effects of telephone coaching on women’s attendance at CR intake appointment, self-efficacy for cardiac exercise and self-efficacy to attend CR. A RCT design enrolled women with CVD referred for CR at a single site in Ontario. Patients were randomized, stratified for age, to either a usual care group or an intervention group. Participants allocated to usual care received a referral to CR. In addition to usual care, women assigned to the intervention group received individualized telephone coaching, designed to support self-management prior to CR intake. Eighty-three patients were approached and 70 consented to participate (usual care n = 36, intervention n = 34). Participants in the intervention group were significantly more likely to attend CR intake (p = 0.048). Participants were highly satisfied with their coaching experience; they found the information provided to be helpful with goal setting, action planning and assisted them in their interactions with their health care providers. Barriers to attendance identified included transportation, health concerns, timing and lack of physician endorsement. Most common resources identified included problem solving support, assistance with communication with physicians and information concerning CR. The evidence obtained from this pilot trial suggests that a telephone coaching intervention designed to enhance self-management is feasible and may improve attendance at CR intake for women following hospital discharge with a cardiac event.

As an effect of increased living standards and improved health care, life expectancy has risen in many parts of the world. At the same time, welfare diseases such as diabetes and obesity increases. As the number of elderly and long-term sick rises, so will the medical care needs. E-health applications are often presented as a way to meet future medical and doing so within the scope of existing resources. By facilitating health communication and widen access to health services by offering them online, e-health applications encourages people to become more engaged in their own health, thus working proactively towards a healthier population. However, e-health applications often fail to reach their full potential. The purpose of this study is to explore how health care providers and health care recipients perceives e-health applications and their usefulness and thus being able to identify factors significant for successful introduction and use of e-health services. Two e-health applications have been analysed and six important aspects have been identified and discussed. In order to be successful, an e-health application must facilitate behaviour change and be integrated in the everyday life of the user. Substantial and adequate evaluation is essential to make sure that the application meet the requirements from both health care providers and health care recipients. An understanding of the possibilities technology has to offer is needed in order to fully exploit the potential of e-health applications in health care. Instructions for health care providers on how to use the applications are essential not only to ensure their proper usage but also to make sure that applications are being presented to recipients in a satisfactory way and that care providers can offer the support and help recipients may need. Finally, when discussing e-health applications it is important to remember that there are people who does not want to get involved and that there is still a demand for face-to-face interaction in health care. Therefore, e-health services must be complemented with alternatives providing different types of interaction opportunities.

Contexte : Les interventions cliniques pour les patients avec multimorbidité sont complexes et l'effet du statut socioéconomique sur ces interventions est limité. Nous avons analyser l'effet d'une intervention multidisciplinaire chez des patients avec multimorbidité et l'effet du statut socioéconomique (SSÉ) sur les résultats de l'intervention. Méthodologie : Analyse secondaire de données d'une intervention multidisciplinaire pragmatique randomisée-contrôlée de patients avec maladies chroniques. Patients recrutés dans 8 cliniques médicales de première ligne. Les patients avec trois maladies chroniques et plus ou leurs facteurs de risques ont été analysés. Issu primaire : changement substantiel dans un des huit domaines du Health Education Impact Questionnaire (heiQ). Le statut socioéconomique (SSÉ) des participants a été mesuré au début de l'intervention. Une collecte de données additionnelles a été faite pour mesurer l'autoappréciation de la situation financière des participants. Des régressions logistiques univariées et multivariées ont été utilisées. Résultats : 281 participants ont été analysés, avec une moyenne de 5,5 maladies chroniques. 13.5% avaient un revenu annuel de moins de 20,000$ et 51% avaient un diplôme d'études secondaires ou moins. En analyses univariées, l'intervention a amélioré le heiQ dans 6 domaines (RC : 1.96-2.91, p<0,05). En contrôlant pour le SSÉ, le OR de quatre domaines a augmenté incluant un domaine qui est devenu statistiquement significatif (Positive and active engagement in life). Conclusion : L'intervention a été efficace pour améliorer les résultats du heiQ chez des patients avec multimorbidité. Après avoir corrigé pour le SSÉ, quatre domaines se sont améliorés, suggérant que le SSÉ avait un effet négatif sur les résultats. / Abstract : Background : Successful interventions for patients with multimorbidity are complex and the known impact of the socioeconomic status (SES) on these interventions is limited. We analyzed the effect of a multidisciplinary intervention on patients with multimorbidity and the effect of the SES on the results of the intervention. Methods : Secondary data analysis of a pragmatic randomized controlled trial relating to a multidisciplinary intervention on patients with chronic diseases in 8 primary care practices in Quebec, Canada. Participants with three or more chronic conditions or risk factors were included in the analysis. Primary outcome: self-management improvement assessed by a substantial change in one of the eight domains of the Health Education Impact Questionnaire (heiQ). Socioeconomic Status (SES) of participants was measured at baseline. Self-perceived financial status was also collected. Univariate and multivariate logistic regression were used. Results : 281 participants were included in the analysis, with a mean 5.5 chronic conditions or risk factors. 13.5% had an annual income <20,000$ and 51% had an high school degree or less. In the univariate analysis, the intervention improved 6 domains of the heiQ (RC : 1.96-2.91, p<0,05). After controlling for SES, the OR of 4 domains improved, including a domain that became statistically significant (Positive and active engagement in life). Interpretation : The intervention was effective at improving self-management of patients with multimorbidity. After correction for SES, the OR of domains improved, suggesting the SES had a negative effect on the results.

Bakgrund: Antalet patienter med kroniska sjukdomar ökar i världen, vilket ställer krav på sjuksköterskans stödjande roll i form av patientundervisning. Sjuksköterskan kan vägleda patienten till ett hälsosamt samt reflektivt förhållningssätt som ger utrymme för dennes lärande och egenvård. En del av egenvård är att hitta en vardag som bringar känsla av kontroll och hälsa. Syfte: Belysa sjuksköterskors erfarenheter av patientundervisning vid kroniska sjukdomar. Metod: En litteraturöversikt över vetenskapliga artiklar. Resultat: Resultatet visar att förståelse och att se patientens livsvärld upplevs som betydelsefullt. Stöd och vägledning möjliggör både en god hälsa samt egenvårdsförmåga. Faktorer som begränsar eller försvårar patientundervisningen kan vara bristande följsamhet, patientens ekonomiska situation, anhöriga samt tidsbrist i arbetet. Konklusion: Patientundervisning för att stärka patientens egenvårdsförmåga visar sig vara ett omfattande område. Sjuksköterskor belyser flera aspekter i patientundervisningen som bidrar till en god egenvårdsförmåga hos patienten. En personcentrerad vård skapar ett samarbete mellan sjuksköterska och patient där fokus ligger på gemensamma mål och förståelse för patientens livsvärld. Sjuksköterskan behöver i arbetet med patientundervisning vara medveten om eventuella barriärer som kan förekomma där ett lösningsorienterat och inlyssnande arbetssätt måste beaktas. / Background: The number of patients with chronic diseases is increasing worldwide, which increases the demand for the nurse's supportive role in the form of patient education. The nurse can guide the patient to a healthy and reflective approach that provides space for the patient's learning and self-management. A part of self-care is to find an everyday life that brings a sense of control and health. Aim: Explore nurse’s experience of patient education in case of chronic disease. Method: The study is a literature review of scientific articles. Findings: The results show that understanding and seeing the patient's world as important. Support and guidance enable good health and self-management ability. Factors that limit or complicate patient education can be lack of compliance, the patient's financial situation, relatives and lack of time at work. Conclusion: Patient education to strengthen the patient's self-management ability turns out to be an extensive area. Nurses highlight several aspects that help the patient's self-management. A person-centered care creates a collaboration between nurse and patient where the focus is on common goal and understanding of the patient's world. Nurse’s need to be aware of barriers, where a solution-oriented and listening approach must be considered.

Background: Over the last decade, diabetes health coaching, also referred to as diabetes coaching, has emerged as a patient-centered intervention to assist individuals with type 2 diabetes mellitus (T2DM) in acquiring independence with self-management. The structure and delivery of such interventions have varied greatly while showing improvements in glycemic control. However, literature continues to show a gap around the patient experience of receiving diabetes coaching support. Objective: To explore the perceived experience of receiving telephone-based diabetes health coaching among community-based adults with T2DM within the Canadian context. Methods: A qualitative exploration with an interpretive descriptive design was carried out. Participants from the intervention group of a larger randomized controlled trial who had received a telephone-based diabetes coaching intervention over one year were invited to participate in a telephone interview with open-ended questioning. Findings: A total of 12 participants were interviewed and four major themes were identified. (1) Adapting to life with T2DM reflects how coaching helped individuals to integrate diabetes into their lives by addressing misconceptions, providing knowledge, encouraging awareness, and easing transition onto insulin. (2) Heightened mindfulness of diabetes-related wellness captured the greater attention participants’ gave to their overall well-being and self-management behaviours. (3) Behaviour change guided by the participant highlights the differences in participants’ motivation, readiness to make changes, external factors that influenced their ability to make self-management behaviour changes. (4) Lastly, valuing a supportive relationship illustrates that participants felt the unique coach-client relationship was reliable, holistic, non-judgmental, and encouraging. Conclusion: Overall, participants found diabetes coaching to be positive and highlighted the various ways it was able to support their ability to more effectively self-manage their diabetes. / Thesis / Master of Science in Nursing (MSN)

Background Type 2 diabetes demands self-management over time, to maintain health and reduce the risk for diabetes complications. However, despite efforts, many persons with type 2 diabetes are not reaching the treatment targets. In diabetes, person-centred care and group education are recommended. Diabetes specialist nurses (DSNs) working in primary healthcare have an important role in supporting patients with type 2 diabetes in their self-management to adapt to the demands of the disease in everyday life. Therefore, it is important to explore the DSNs’ professional role and their experiences of practising person-centred care. The overall aim of the thesis was to explore the professional role of DSNs in primary healthcare, and to describe their experiences of person-centred diabetes care. Methods The thesis includes three studies with qualitative, and one with a quantitative, approach. Data collection consisted of focus group interviews, individual interviews, observations, and questionnaires. Qualitative content analysis and statistics were used in the analysis. In studies I and II, 29 and 31 DSNs participated, respectively. In study III, 10 DSNs and 44 persons with type 2 diabetes participated. Lastly, in study IV, 10 DSNs participated. Results The results in the thesis showed that DSNs have a complex and multifaceted professional role that entails striving to be an expert, a fosterer, a leader, an executive, and a role model, which they found challenging. The DSNs perceived high job demands, such as decision-making and learning. The thesis also showed that the interaction between DSNs and persons with type 2 diabetes shifted from empowerment to authority struggles during group support sessions based on person-centred care. The experience of person-centred care was described as enriching, but DSNs also expressed ambivalence, related to an altered professional role. Conclusion There is a desire by DSNs to be close to persons with type 2 diabetes, although they have several challenges to fulfil, which makes it difficult to uphold a relation with proximity; thus, distance is also present. Even though person-centred care is recommended in healthcare, and despite DSNs’ efforts to practise PCC, the result of this thesis shows that it also implies an altered professional role for DSNs that has to be addressed. / Diabetes intervention in Västerbotten, DIVA 2

Background: People with intellectual disabilities (ID) remain at high risk of developing type 2 diabetes (T2D) due to lifestyle associated risk factors such poor diets and low physical activity levels. Interventions have been adapted which target ongoing T2D self-management. However, there are no adapted programmes which prevent T2D through reducing risk factors. The present research project addresses this gap through a three-phase study on the existing literature, theoretical basis, and process evaluation of a T2D prevention programme. Methods: Phase 1: The literature reviews identified that the support needs of people with ID with T2D are currently not being met. Appropriate training needs to be delivered so that people with ID can self-manage or reduce the risk of T2D effectively. Given the early onset of T2D in people with ID and their often shorter lifespan, there is rationale for a preventative agenda in T2D education. Four potential mainstream intervention programmes were identified, and the self-efficacy model was found to be the most prevalent successfully implemented theoretical model. Phase 2: Nine sub-themes were identified following analysis of the data: 1) "Mastery through knowledge"; 2) "Mastery through tools and strategies"; 3) "Mastery through autonomy"; 4) "Influence of social setting"; 5) "Positive social comparisons"; 6) "Positive and negative self-statements"; 7) "Feedback from Caregivers"; 8) "Adjustment experiences"; 9) "Symptom awareness". These were mapped onto Bandura's (1977) Four Sources of efficacy enhancement model and were consistentwith its proposed mechanisms. The Four Sources model serves as a useful mode of enquiry for exploring people with ID's experiences and perceptions of self-managing diabetes. It also confirms the appropriateness of ssself-efficacy as a potential intervention component for this population. However, additional support may be required for people with ID to reflect meaningfully on their experiences and thus have a sense of self-efficacy. Phase3: 96% of invited students agreed to participate. The Walking Away programme was positively received, and some short-term impact was described, yet there were limitations to accessibility of the program due to the complexity of the language and materials. Suggestions for further adaptations regarding materials and content were provided, and there was perceived scope for a long-term implementation built into college curriculum. Results: Phase One: The literature reviews identified that the support needs of people with ID with T2D are currently not being met. Appropriate training needs to be delivered so that people with ID can self-manage or reduce the risk of T2D effectively. Given the early onset of T2D in people with ID and their often shorter lifespan, there is rationale for a preventative agenda in T2D education. Four potential mainstream intervention programmes were identified, and the self-efficacy model was found to be the most prevalent successfully implemented theoretical model. Phase Two: Nine sub-themes were identified following analysis of the data: 1) "Mastery through knowledge"; 2) "Mastery through tools and strategies"; 3) "Masterythrough autonomy"; 4) "Influence of social setting"; 5) "Positive social comparisons"; 6) "Positive and negative self-statements"; 7) "Feedback from Caregivers"; 8) "Adjustment experiences"; 9) "Symptom awareness". These were mapped onto Bandura's (1977) Four Sources of efficacy enhancement model and were consistent with its proposed mechanisms. The Four Sources model serves as a useful mode of enquiry for exploring people with ID's experiences and perceptions of self-managing diabetes. It also confirms the appropriateness of self-efficacy as a potential intervention component for this population. However, additional support may be required for people with ID to reflect meaningfully on their experiences and thus have a sense of self-efficacy. Phase Three: 96% of invited students agreed to participate. The Walking Away programme was positively received, and some short-term impact was described, yet there were limitations to accessibility of the program due to the complexity of the language and materials. Suggestions for further adaptations regarding materials and content were provided, and there was perceived scope for a long-term implementation built into college curriculum. Phase Three: 96% of invited students agreed to participate. The Walking Away programme was positively received, and some short-term impact was described, yet there were limitations to accessibility of the program due to the complexity of the language and materials. Suggestions for further adaptations regarding materials and content were provided, and there was perceived scope for a long-term implementation built into college curriculum. Conclusions: The findings provide basis for a further trial incorporating the suggested adaptations. A self-efficacy informed prevention programme was highly acceptability to students and teaching staff. Further education colleges provided a supportive setting and yielded a rich sample.