Step two: Matrices of change objectives
Based on the needs assessment, the overall behavioural outcome was defined as "Self-management behaviour at work".
The aim of the CDSMP for employees with a chronic somatic disease is to obtain self-management behaviour at work. Self-management behaviour at work has been operationalized as follows:
1), To be able to ask help from colleagues and supervisor when needed (ask for facilities at work, ask for change in job demands).
2), To be able to cope with symptoms as pain, fatigue, breathing problems and emotional ups and downs at work and carry out a healthy lifestyle.
3), To be able to re-organize work according to disease (to plan work according to disease, to take pauses when needed and to say no when needed).
Furthermore the main determinants of behaviour change according to the theory of planned behaviour [
33]; (1) the attitude, (2) social influence and (3) perceived behavioural control to behaviour (Figure
2) have been operationalized as follows:
1. Attitude: A person's attitude consists of the perceived cognitive and emotional advantages and disadvantages of the behaviour, including beliefs that a specific type of behaviour can be completed. How positive is the person about the capability to ask support from colleagues and supervisor at work, to cope with symptoms as pain, fatigue, breathing problems and emotional ups and downs, to carry out a healthy lifestyle and to reorganize work according to the disease.
2. Social influence: (perception of) social support at work and acquiring social support at work. Social influences consist of the perception of others carrying out this type of behaviour (social modelling), the norms that people have with respect to these behaviours (social norms) and the support that they perceive from others in carrying out a particular type of behaviour.
3. Self-efficacy: how confident is the person on his ability to ask for support when needed at work, to cope with symptoms at work, to carry out a healthy lifestyle and to reorganize work according to the disease. Self-efficacy refers to a person's perception of his capability to carry out the type of behaviour.
The intervention is aimed to influence all three determinants of behaviour but specially the self-efficacy at work. According to the theory of planned behaviour, behaviour is best predicted by the intention of the person to perform that behaviour [
24]. Recent findings support that action planning is a better predictor of behaviour than the intention [
43]. Interventions are proven to be more effective if they focus on improving participants' action planning activity, their self-efficacy and self regulatory capabilities rather than focusing on intention-enhancing risk perceptions [
44,
45].
Step three: Theory-based methods and practical strategies
There is systematic evidence available on effective methods to stimulate self-management behaviour at work. A systematic review on the effectiveness of empowerment interventions at the workplace [
16] showed that most existing interventions have the objective:
• to increase knowledge (about the disorder and its consequences, legal rights and work accommodations)
• to gain a clear understanding of work-related problems or work barriers
• to increase feelings of control (general control or perceived self-efficacy in the process to request work accommodations)
• to develop skills (coping skills and social competences)
• to increase activities aimed at work accommodations
The objectives of existing empowerment interventions at the workplace focus primarily on acquiring skills and behaviour change. The CDSMP programme for employees focuses on skills and behaviour change by improving participants' action planning activity, self-efficacy and self regulatory capabilities as well as influencing their intention and risk perceptions. In table
2 the different techniques used in the course to influence the determinants of behaviour are shown.
The techniques for behavioural change used in the self-management programme to influence the determinants are: consciousness raising (belief selection, decisional balance), risk perception, positive reframing, self-re-evaluation, enhancing self-efficacy and social support, skill mastery, reinterpretation of symptoms, goal setting, social comparison, modelling, and persuasion of positive outcomes [
24,
46,
47].
The attitude of the participants is influenced by awareness exercises to raise their consciousness on situations at the workplace which are difficult to deal with a chronic disease. Participants are encouraged to formulate possible solutions. Self-management behaviour is also influenced by the attitude and actions of the other participants.
The social support at work is influenced by encouraging employees to talk about the course and action plans with colleagues and supervisor.
The
self-efficacy is influenced by social comparison [
48,
49] through success stories of other participants. Through goal setting (action plans) the participants can focus on working on their self-efficacy, based on the level of the participant. Goal setting leads to better performance because people with explicit goals exert themselves to a greater extent and persevere in their tasks [
50,
51]. A goal should be behaviourally SMART formulated (specific, measurable, attainable, realistic and timely) and should be stated in terms of behaviour (ask for help at work) instead of health outcomes, e.g. oriented on more social support from colleagues [
47,
52]. Participants formulate weekly a goal with regard to self-management behaviour, for example, to exercise, to practice time management at work or to take pauses at work, which they intend to accomplish during the following week. After formulating the plan, the participant has to state how confident he is that he will execute the action plan. If the level of confidence is below 7 (on a 1-10 scale), the participant is coached in re-formulating his action plan by the course leaders until a higher level of confidence is achieved [
47]. During the next session, the participants report whether or not they have accomplished their action plan, and to give an account if any possible problems that might have arisen are solved. This feedback is an integral part of skills mastery.
Step four: programme
In step four, we created a modified plan for the programme taking into account the budget and resources for the programme materials. The course consists of six sessions of each two and a half hour, this conform the programme plan of the original CDSMP. An overview of the adapted CDSMP for employees is shown in table
3. For this target group, two extra sessions have been developed based on the model of work load and work capacity [
53] by using the methods of the original CDSMP (e.g. consciousness raising, risk perception, positive reframing, skill mastery, goal setting). Furthermore the original CDSMP topics were enriched with new topics on the work situation of employees with a chronic disease.
Table 3
Content of the self-management programme for employees with a chronic somatic disease.
Week 1
|
Introduction
Importance of physical exercise
| - Overview of the course |
| | - Objectives of the course |
| | - Objectives of the participants |
| | - Inventory of problems encountered at work by the chronic disease |
| | - Introduction to cope with symptoms by using guided imagery |
| | - The importance of physical exercise for people with a chronic disease |
| | - Introduction to making action plans |
Week 2
|
Coping with pain, fatigue and stress at work
| - Symptoms that interfere with the ability to work |
| | - Situations causing stress, pain or fatigue (at work) |
| | - Solutions to deal with stress, pain or fatigue (at work) |
| | - Breathing exercises |
| | - Introduction to cognitive symptom management |
Week 3
|
Importance of healthy nutrition/Problems encountered at work
| - Introduction to healthy nutrition |
| | - The importance of healthy nutrition for people with a chronic disease |
| | - Introduction to working with a chronic disease |
| | - Introduction to the model of work load and work capacity |
| | - Solutions at the workplace |
Week 4
|
Communication techniques at the workplace
| - Communication techniques |
| | - How to communicate with supervisor and colleagues about the problems encountered at work |
| | - How to communicate with supervisor and colleagues about possible solutions at work |
| | - How to communicate with family and friends about the problems and possible solutions to combine work and home |
Week 5
|
Working together with occupational health professionals
| - Working together with occupational health professionals and HRM advisors at work |
Week 6
|
Plans for the future
| - What has been accomplished the past six weeks? |
| | - What have we learned in the course? |
| | - Formulating long-term plans |
The programme plan has been produced conform the boundary limits of the original CDSMP. The original programme is intended for (lay)-trainers who have completed the Master trainers programme at Stanford University. The original CDSMP design is a high feasible low-cost programme which can practically be implemented in every setting. The only boundary limits for the programme are: two trainers (one must be a master trainer at Stanford University and the other trainer must have received a leaders training by the master trainer), inset time approximately 5 hours per session (training plus preparation time) and an accessible accommodation (room) for minimal 15 participants and facilities like access to beverages, toilet access and an elevator.
Step five: Adoption and implementation plan
The results of step five were a well defined set of inclusion criteria for the participants, a plan for the recruitment of participants for the training in the context of the evaluation study, a plan to train the facilitators and a Dutch manual for the participants and the facilitators [
54].
The inclusion criteria to select participants for the course were: employees with a diagnosed chronic physical disease, with a paid job at the moment of the course, who encounter problems at work because of their disease and who were motivated to follow the course. The exclusion criteria were: Employees with predominant psychiatric conditions, more than three months totally absent from work and fully work-disabled.
Participants for the course were recruited through the departments of Human Resource Management from companies, general practitioners and occupational health services in the region of Arnhem and Nijmegen in the Netherlands. An information letter and leaflet of the course were sent to 82 companies, 88 general practitioners and 10 occupational health services in both municipalities. Also several advertisements have been placed in regional newspapers. Participants were requested to contact the researcher (SD) by telephone or email for more information or to apply for the programme. Before being admitted to the programme participants were screened on the inclusion criteria by telephone. After registration the participants received a written confirmation, the informed consent form, the questionnaire and information about the procedures. All participants who have been admitted to the programme by telephone were randomized to either the control group or the intervention group. The control group consisted of care as usual and the intervention group consisted of care as usual plus the self-management programme. Both groups were followed for eight months.
Participants in the control group who were followed for eight months and had returned all the questionnaires in the control group and still wanted to apply for the self-management programme were allowed to follow the programme. The data of these participants has been included in the analysis of the control group and excluded from the analysis of the intervention group in the evaluation study.
We modified the course handbook for the participants and translated the manual in Dutch under the title "Werken met een chronische aandoening" (Working with a chronic disease) [
54]. We also produced a manual for the facilitors including step by step instructions on how to implement the intervention. The course must be facilitated by two moderators. One of them is to be trained at the University of Stanford to be a master trainer of the CDSMP.
Step six: Evaluation Plan
The result of step six was an evaluation plan for the evaluation study. The study design and operationalization of the evaluation study have been approved by the Medical Ethics Committee of the Radboud University Nijmegen and are registered in the Dutch Trial Register as (NTR 1737).
The effect-evaluation consists of a randomized controlled trial (n = 104) with eight months follow-up and a qualitative evaluation among the participants of two training groups (n = 15). In this study, we wanted to include at least 35 patients in the RCT in each group in order to be able to detect a statistically significant difference on the outcome SF-12 and coping with symptoms (Stanford questionnaire coping with symptoms). This sample size was based on a intervention study, in which 35 patients in each group were needed in order to achieve an effect-size of 0.8 on the SF-12 with a power of 80% and an alpha at <5% (two tailed) [
55,
56]. Assuming a drop-out rate of 20% during the trial a total of 104 participants have to be included in the randomization process.
Our primary analysis was by intention to treat and participants were at random selected for the control group or the intervention group. After selection they were informed about the intervention and control conditions. The control group received care as usual and the intervention group consisted of care as usual plus the self-management programme. A questionnaire has been developed including primary and secondary outcome measures. The primary outcome measures of the effect evaluation are self-efficacy at work, the intention to communicate with supervisor and occupational physician, work pleasure (VBBA) [
57] and work productivity (WAI) [
58], coping with symptoms like pain and fatigue (Stanford questionnaire coping with symptoms) and Quality of life and general health (SF-12) [
59]. For the purpose of measuring self-efficacy at work, a self-efficacy at work instrument has been developed. The content of this questionnaire has been developed with the information obtained through the focus groups with professionals and patients.
The qualitative evaluation study consists of semi-structured interviews with fifteen participants. The participants were interviewed two times, at the beginning and after the course. Secondly, all brainstorm topics generated during the course related to the problems encountered at work and the solutions will be analyzed using content analysis.
The results of the RCT and the qualitative evaluation will be presented, when available, in separate articles.