The Uptake and Use of Telemonitoring in Chronic Care Between 2014 and 2019: Nationwide Survey Among Patients and Health Care Professionals in the Netherlands.

BACKGROUND: Telemonitoring could offer solutions to the mounting challenges for health care and could improve patient self-management. Studies have addressed the benefits and challenges of telemonitoring for certain patient groups. OBJECTIVE: This paper will examine the nationwide uptake of telemonitoring in chronic care in the Netherlands from 2014 to 2019 by means of an annual representative survey among patients and health care professionals. METHODS: Between 2014 and 2019, approximately 2900 patients with chronic diseases, 700 nurses, and 500 general practitioners (GPs) and medical specialists received a questionnaire. About 30 questions addressed topics about the use of eHealth and experiences with it, including data about telemonitoring. RESULTS: Between 2014 and 2019, the use of telemonitoring remained stable for all groups except medical specialists. In medical specialist departments, the use of telemonitoring increased from 11.2% (18/161) in 2014 to 19.6% (36/184) in 2019 (χ24=12.3; P=.02). In 2019, telemonitoring was used by 5.8% (28/485) of people with chronic disease. This was 18.2% (41/225) in GP organizations and 40.4% (44/109), 38.0% (78/205), and 8.9% (29/325) in the organizations of nurses working in primary, secondary, and elderly care, respectively. Up to 10% of the targeted patient group such as diabetics were regarded by health care professionals as suitable for using telemonitoring. The main benefits mentioned by the patients were "comfort" (421/1043, 40.4%) and "living at home for longer/more comfortably" (334/1047, 31.9%). Health care professionals added "improvement of self-management" (63/176, 35.8% to 57/71, 80.3%), "better understanding of the patient's condition" (47/176, 26.7% to 42/71, 59.2%), "reduction of workload" (53/134, 39.6% of nurses in elderly care), "better tailoring of care plan to the patient's situation" (95/225, 42.2% of GPs), and "saves time for patients/caregivers" (61/176, 34.7% of medical specialists). Disadvantages mentioned by professionals were that "it takes time to monitor data" (13/130, 10% to 108/225, 48.0%), "it takes time to follow up alerts" (15/130, 11.5% to 117/225, 52.0%), and "it is difficult to estimate which patients can work with telemonitoring" (22/113, 19.5% to 94/225, 41.8%). CONCLUSIONS: The uptake of telemonitoring in Dutch chronic care remained stable during 2014-2019 but increased among medical specialists. According to both patients and professionals, telemonitoring improves the quality of life and quality of care. Skills for suitably including eligible patients and for allocating the tasks of data monitoring and follow-up care within the team would help to further increase the use of telemonitoring.

Harmonization of the ICHOM Quality Measures to Enable Health Outcomes Measurement in Multimorbid Patients.

Objectives: To update the sets of patient-centric outcomes measures ("standard-sets") developed by the not-for-profit organization ICHOM to become more readily applicable in patients with multimorbidity and to facilitate their implementation in health information systems. To that end we set out to (i) harmonize measures previously defined separately for different conditions, (ii) create clinical information models from the measures, and (iii) restructure the annotation to make the sets machine-readable. Materials and Methods: First, we harmonized the semantic meaning of individual measures across all the 28 standard-sets published to date, in a harmonized measure repository. Second, measures corresponding to four conditions (Breast cancer, Cataracts, Inflammatory bowel disease and Heart failure) were expressed as logical models and mapped to reference terminologies in a pilot study. Results: The harmonization of semantic meaning resulted in a consolidation of measures used across the standard-sets by 15%, from 3,178 to 2,712. These were all converted into a machine-readable format. 61% of the measures in the 4 pilot sets were bound to existing concepts in either SNOMED CT or LOINC. Discussion: The harmonization of ICHOM measures across conditions is expected to increase the applicability of ICHOM standard-sets to multi-morbid patients, as well as facilitate their implementation in health information systems. Conclusion: Harmonizing the ICHOM measures and making them machine-readable is expected to expedite the global adoption of systematic and interoperable outcomes measurement. In turn, we hope that the improved transparency on health outcomes that follows will let health systems across the globe learn from each other to the ultimate benefit of patients.

Toward an Objective Assessment of Implementation Processes for Innovations in Health Care: Psychometric Evaluation of the Normalization Measure Development (NoMAD) Questionnaire Among Mental Health Care Professionals.

BACKGROUND: Successfully implementing eMental health (eMH) interventions in routine mental health care constitutes a major challenge. Reliable instruments to assess implementation progress are essential. The Normalization MeAsure Development (NoMAD) study developed a brief self-report questionnaire that could be helpful in measuring implementation progress. Based on the Normalization Process Theory, this instrument focuses on 4 generative mechanisms involved in implementation processes: coherence, cognitive participation, collective action, and reflexive monitoring. OBJECTIVE: The aim of this study was to translate the NoMAD questionnaire to Dutch and to confirm the factor structure in Dutch mental health care settings. METHODS: Dutch mental health care professionals involved in eMH implementation were invited to complete the translated NoMAD questionnaire. Confirmatory factor analysis (CFA) was conducted to verify interpretability of scale scores for 3 models: (1) the theoretical 4-factor structure, (2) a unidimensional model, and (3) a hierarchical model. Potential improvements were explored, and correlated scale scores with 3 control questions were used to assess convergent validity. RESULTS: A total of 262 professionals from mental health care settings in the Netherlands completed the questionnaire (female: 81.7%; mean age: 45 [SD=11]). The internal consistency of the 20-item questionnaire was acceptable (.62≤alpha≤.85). The theorized 4-factor model fitted the data slightly better in the CFA than the hierarchical model (Comparative Fit Index=0.90, Tucker Lewis Index=0.88, Root Mean Square Error of Approximation=0.10, Standardized Root Mean Square Residual=0.12, χ22=22.5, P≤.05). However, the difference is small and possibly not outweighing the practical relevance of a total score and subscale scores combined in one hierarchical model. One item was identified as weak (λCA.2=0.10). A moderate-to-strong convergent validity with 3 control questions was found for the Collective Participation scale (.47≤r≤.54, P≤.05). CONCLUSIONS: NoMAD's theoretical factor structure was confirmed in Dutch mental health settings to acceptable standards but with room for improvement. The hierarchical model might prove useful in increasing the practical utility of the NoMAD questionnaire by combining a total score with information on the 4 generative mechanisms. Future research should assess the predictive value and responsiveness over time and elucidate the conceptual interpretability of NoMAD in eMH implementation practices.

Quantifying the strength of the associations of prototype perceptions with behaviour, behavioural willingness and intentions: a meta-analysis.

Prototypes (i.e., social images representing perceptions of typical persons engaging in or refraining from certain behaviour) have been shown to explain health-related behaviours. The present meta-analysis quantified the strength of the associations of prototype perceptions with health motivation and behaviour. Specifically, the analysis addressed (i) the relationship of prototype favourability (i.e., degree of likability) and similarity (i.e., perceived resemblance to the self) with behaviour, willingness and intentions; (ii) the effect of the interaction between favourability and similarity; and (iii) the extent to which health-risk and health-protective prototypes differed in their association with these outcomes. A total of 80 independent studies were identified based on 69 articles. The results indicated that prototype favourability and similarity were related to behaviour, intentions and willingness with small-to-medium effect sizes (r+ = 0.12-0.43). Direct measures of prototype perceptions generally produced larger effects than indirect measures. The interaction between favourability and similarity produced small-to-large effect sizes (r+ = .22-.54). The results suggest that both health-risk and health-protective prototypes might be useful targets for interventions (r+ = .22-.54). In order to increase health-protective behaviours, intentions and behaviour could be targeted by increasing similarity to health-protective prototypes. Health-risk behaviour might be decreased by targeting willingness by modifying health-risk prototype favourability and similarity.

Drinker prototype alteration and cue reminders as strategies in a tailored web-based intervention reducing adults' alcohol consumption: randomized controlled trial.

BACKGROUND: Excessive alcohol use is a prevalent and worldwide problem. Excessive drinking causes a significant burden of disease and is associated with both morbidity and excess mortality. Prototype alteration and provision of a cue reminder could be useful strategies to enhance the effectiveness of online tailored interventions for excessive drinking. OBJECTIVE: Through a Web-based randomized controlled trial, 2 strategies (ie, prototype alteration and cue reminders) within an existing online personalized feedback intervention (Drinktest) aimed to reduce adults' excessive drinking. It was expected that both strategies would add to Drinktest and would result in reductions in alcohol consumption by intrinsic motivation and the seizure of opportunities to act. METHODS: Participants were recruited online and through printed materials. Excessive drinking adults (N=2634) were randomly assigned to 4 conditions: original Drinktest, Drinktest plus prototype alteration, Drinktest plus cue reminder, and Drinktest plus prototype alteration and cue reminder. Evaluation took place at 1-month posttest and 6-month follow-up. Differences in drinking behavior, intentions, and behavioral willingness (ie, primary outcomes) were assessed by means of longitudinal multilevel analyses using a last observation carried forward method. Measures were based on self-reports. RESULTS: All conditions showed reductions in drinking behavior and willingness to drink, and increased intentions to reduce drinking. Prototype alteration (B=-0.15, P<.05) and cue reminder usage (B=-0.15, P<.05) were both more effective in reducing alcohol consumption than when these strategies were not provided. Combining the strategies did not produce a synergistic effect. No differences across conditions were found regarding intentions or willingness. CONCLUSIONS: Although individuals' awareness of their cue was reasonable, their reported alcohol consumption was nevertheless reduced. Individuals appeared to distance their self-image from heavier drinking prototypes. Thus, prototype alteration and cue reminder usage may be feasible and simple intervention strategies to promote reductions in alcohol consumption among adults, with an effect up to 6 months. TRIAL REGISTRATION: Nederlands Trial Register (NTR): 4169; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=4169 (Archived by WebCite at http://www.webcitation.org/6VD2jnxmB).

Explaining young adults' drinking behaviour within an augmented Theory of Planned Behaviour: temporal stability of drinker prototypes.

OBJECTIVES: Prototypes (i.e., social images) predict health-related behaviours and intentions within the context of the Theory of Planned Behaviour (TPB). This study tested the moderating role of temporal stability of drinker prototype perceptions on prototype-intentions and prototype-behaviour relationships, within an augmented TPB. The study examined abstainer, moderate drinker, heavy drinker, tipsy, and drunk prototypes. DESIGN AND METHODS: An online prospective study with 1-month follow-up was conducted among 410 young adults (18-25 years old, Mage = 21.0, SD = 2.14, 21.7% male). Assessed were prototype perceptions (favourability and similarity, T1, T2), stability of prototype perceptions, TPB variables (T1), intentions (T2), and drinking behaviour (T2). Intention analyses were corrected for baseline behaviour; drinking behaviour analyses were corrected for intentions and baseline behaviour. RESULTS: Hierarchical regressions showed that prototype stability moderated the relationships of drunk and abstainer prototype similarity with intentions. Similarity to the abstainer prototype explained intentions to drink sensibly more strongly among individuals with stable perceptions than among those with unstable perceptions. Conversely, intentions were explained stronger among individuals with stable perceptions of dissimilarity to the drunk prototype than among those with unstable perceptions. No moderation effects were found for stability of favourability or for relationships with behaviour. CONCLUSIONS: Stable prototype similarity perceptions were more predictive of intentions than unstable perceptions. These perceptions were most relevant in enhancing the explanation of young adults' intended drinking behaviour. Specifically, young adults' health intentions seem to be guided by the dissociation from the drunk prototype and association with the abstainer prototype. Statement of contribution What is already known on this subject? Prototypes have augmented the Theory of Planned Behaviour in explaining risk behaviour. Temporal stability has been shown to successfully extend the TPB in explaining intentions. Temporal stability of TPB variables can moderate the relationships with behaviour and intentions. What does this study add? Stability of prototype perceptions moderates the prototype-intentions relationship. Stability of abstainer and drunk prototype similarity enhances the explanation of (intentional) drinking. Stable prototype perceptions are more explanatory than unstable perceptions.

Associations between abstainer, moderate and heavy drinker prototypes and drinking behaviour in young adults.

OBJECTIVE: Previous research has focused mostly on abstainer and/or general drinker prototypes. The present studies examined an abstainer, moderate drinker and heavy drinker prototype in relation to drinking behaviour. DESIGN: Two studies among young adults aged 18-25 (paper-and-pencil, cross-sectional, N = 140; online, prospective, N = 451) assessed prototype favourability and participants' perceived similarity to the prototypes. Participants were also categorised into abstainers, moderate, and heavy drinkers. RESULTS: Similarity and favourability had similar sequences in both studies: the moderate drinker and abstainer prototypes were evaluated most favourable and felt similar to; the heavy drinker prototype was rated the least favourable and felt similar to. Importantly, heavy drinking participants felt most similar to the moderate drinker prototype and rated the heavy drinker least desirable. The results suggest a need for research to include other prototypes, such as the moderate drinker, besides the abstainer and heavy drinker. CONCLUSION: The studies provide insights into the contribution of alternative prototypes (i.e. moderate drinker) into the relationship between prototype perceptions and drinking behaviour. The results suggest tailoring prototype-based interventions according to drinking behaviour. Importantly, realistic perceived similarity to the more favourable moderate drinker prototype may therefore need to be encouraged only after appropriate reductions in heavy drinkers' alcohol consumption.

Clustering of drinker prototype characteristics: what characterizes the typical drinker?

Prototypes (social images) have been shown to influence behaviour, which is likely to depend on the type of image. Prototype evaluation is based on (un)desirable characteristics related to that image. By an elicitation procedure we examined which adjectives are attributed to specific drinker prototypes. In total 149 young Dutch adults (18-25 years of age) provided adjectives for five drinker prototypes: abstainer, moderate drinker, heavy drinker, tipsy, and drunk person. Twenty-three unique adjectives were found. Multilevel latent class cluster analysis revealed six adjective clusters, each with unique and minor overlapping adjectives: 'negative, excessive drinker,' 'moderate, responsible drinker,' 'funny tipsy drinker,' 'determined abstainer cluster,' 'uncontrolled excessive drinker,' and 'elated tipsy cluster.' In addition, four respondent classes were identified. Respondent classes showed differences in their focus on specific adjective clusters. Classes could be labelled 'focus-on-control class,' 'focus-on-hedonism class,' 'contrasting-extremes-prototypes class,' and 'focus-on-elation class.' Respondent classes differed in gender, educational level and drinking behaviour. The results underscore the importance to differentiate between various prototypes and in prototype adjectives among young adults: subgroup differences in prototype salience and relevance are possibly due to differences in adjective labelling. The results provide insights into explaining differences in drinking behaviour and could potentially be used to target and tailor interventions aimed at lowering alcohol consumption among young adults via prototype alteration.

Implementation intentions for buying, carrying, discussing and using condoms: the role of the quality of plans.

Forming implementation intentions (i.e. action plans that specify when, where and how a person will act) could be effective in promoting condom use on a large scale. However, the technique implies that people are able to form high quality implementation plans that are likely to induce behaviour change. Young single females, aged 16-30 years old, were asked to form either an implementation intention for the target behaviour using condoms (n = 159) or preparatory implementation intentions for buying, carrying, discussing and using condoms (n = 146). Condom preparations were assessed at follow-up 2 months later. The implementation intentions that participants formed were rated on quality. In general, it appeared hard for young women to form high quality general implementation intentions for the target behaviour condom use. Implementation intentions for the preparatory behaviours were of better quality than general implementation intentions. Females who formed strong implementation intentions in the preparatory behaviours condition were more committed to these plans and perceived them as more useful. Plan commitment and perceived usefulness predicted condom preparations at follow-up. We conclude that it is important to ask individuals to form implementation intentions for the preparatory behaviours rather than for the target behaviour alone.