4779308
Multimedia psychoeducational interventions to support patient self-care in degenerative conditions: A realist review
Abstract Objective: Multimedia interventions are increasingly used to deliver information in order to promote self-care among patients with degenerative conditions. We carried out a realist review of the literature to investigate how the characteristics of multimedia psychoeducational interventions combine with the contexts in which they are introduced to help or hinder their effectiveness in supporting self-care for patients with degenerative conditions. Method: Electronic databases (Medline, Science Direct, PSYCHinfo, EBSCO, and Embase) were searched in order to identify papers containing information on multimedia psychoeducational interventions. Using a realist review approach, we reviewed all relevant studies to identify theories that explained how the interventions work. Results: Ten papers were included in the review. All interventions sought to promote self-care behaviors among participants. We examined the development and content of the multimedia interventions and the impact of patient motivation and of the organizational context of implementation. We judged seven studies to be methodologically weak. All completed studies showed small effects in favor of the intervention. Significance of Results: Multimedia interventions may provide high-quality information in an accessible format, with the potential to promote self-care among patients with degenerative conditions, if the patient perceives the information as important and develops confidence about self-care. The evidence base is weak, so that research is needed to investigate effective modes of delivery at different resource levels. We recommend that developers consider how an intervention will reduce uncertainty and increase confidence in self-care, as well as the impact of the context in which it will be employed.
27353315
Patient and public involvement in chronic illness: beyond the expert patient
Coping with a long term illness requires much more than medical management. Trisha Greenhalgh looks at different models of patient involvement and argues that we need a wider approach
45568237
Comparative analysis of print and multimedia health materials: a review of the literature.
OBJECTIVE
Evaluate the evidence regarding the relative effectiveness of multimedia and print as modes of dissemination for patient education materials; examine whether development of these materials addressed health literacy.


METHODS
A structured literature review utilizing Medline, PsycInfo, and the Cumulative Index to the Nursing and Allied Health Literature (CINAHL), supplemented by reference mining.


RESULTS
Of 738 studies screened, 30 effectively compared multimedia and print materials. Studies offered 56 opportunities for assessing the effect of medium on various outcomes (e.g., knowledge). In 30 instances (54%), no difference was noted between multimedia and print in terms of patient outcomes. Multimedia led to better outcomes vs. print in 21 (38%) comparisons vs. 5 (9%) instances for print. Regarding material development, 12 studies (40%) assessed readability and 5 (17%) involved patients in tool development.


CONCLUSIONS
Multimedia appears to be a promising medium for patient education; however, the majority of studies found that print and multimedia performed equally well in practice. Few studies involved patients in material development, and less than half assessed the readability of materials.


PRACTICE IMPLICATIONS
Future research should focus on comparing message-equivalent tools and assessing their effect on behavioral outcomes. Material development should include explicit attention to readability and patient input.
23451804
Tailored interactive multimedia computer programs to reduce health disparities: opportunities and challenges.
OBJECTIVE
To review the theory and research evidence suggesting that tailored interactive multimedia computer programs (IMCPs) aimed at optimizing patient health behaviors could lessen socio-demographic health disparities.


METHODS
Selective critical review of research regarding IMCPs tailored to psychological mediators of behavior and their effects on health behavior and outcomes among socio-demographically disadvantaged patients.


RESULTS
Tailored IMCPs can address patient factors (e.g. language barriers, low self-efficacy) and buffer provider (e.g. cognitive bias) and health system (e.g. office visit time constraints) factors that contribute to poor provider-patient communication and, thereby, suboptimal health behaviors. Research indicates disadvantaged individuals' interactions with providers are disproportionately affected by such factors, and that their behaviors respond favorably to tailored information, thus suggesting tailored IMCPs could mitigate disparities. However, no randomized controlled trials (RCTs) have examined this question. The optimal design and deployment of tailored IMCPs for disadvantaged patients also requires further study.


CONCLUSION
Preliminary research suggests tailored IMCPs have the potential to reduce health disparities. RCTs designed expressly to examine this issue are warranted.


PRACTICE IMPLICATIONS
Many socio-demographic health disparities exist, and there is a dearth of proven disparity-reducing interventions. Thus, if tailored IMCPs were shown to lessen disparities, the public health implications would be considerable.
42437440
Multimedia educational aids for improving consumer knowledge about illness management and treatment decisions: a review of randomized controlled trials.
Psychiatric practice is becoming increasingly more complex in terms of the available treatment options, use of new technologies for assessments, and a need for psychiatric patients and their caregivers to be familiar with general medical procedures. This trend will only intensify in the years to come. Routine methods of providing information relevant to clinical decision making about healthcare evaluations or management are often suboptimal. Relatively little research has been done on enhancing the capacity of psychiatric patients and the caregivers to make truly informed decisions about management. In this paper, we review studies that compared the effects of multimedia (video- or computer-based) educational aids with those of routine procedures to inform healthcare consumers about medical evaluations or management. Although most of these investigations were conducted in non-psychiatric patients, the results should be relevant for psychiatric practice of tomorrow. We searched MEDLINE, PsycINFO, and CINAHL bibliographic databases. Randomized controlled trials that used objective measures of knowledge or understanding of the information provided were selected. Studies were rated as positive if the multimedia educational aid resulted in a greater improvement in knowledge or understanding than the control condition. The quality of each study was also rated using a newly developed Scale for Assessing Scientific Quality of Investigations (SASQI). A total of 37 randomized controlled trials were identified. Nearly two-thirds of the studies (23/37) in diverse patient populations and for varied medical assessments and treatments reported that multimedia educational aids produced better understanding of information compared to routine methods. SASQI scores for the positive and negative studies were comparable, suggesting that lower quality was not related to positive findings. In conclusion, multimedia educational aids hold promise for improving the provision of complex medical information to patients and caregivers. It is likely that as psychiatric patients and their treating clinicians face increasingly complex choices regarding mental health treatment, multimedia decisional aids could become an effective supplement to the clinician patient interaction in near future.
19887340
Health behavior models in the age of mobile interventions: are our theories up to the task?
Mobile technologies are being used to deliver health behavior interventions. The study aims to determine how health behavior theories are applied to mobile interventions. This is a review of the theoretical basis and interactivity of mobile health behavior interventions. Many of the mobile health behavior interventions reviewed were predominately one way (i.e., mostly data input or informational output), but some have leveraged mobile technologies to provide just-in-time, interactive, and adaptive interventions. Most smoking and weight loss studies reported a theoretical basis for the mobile intervention, but most of the adherence and disease management studies did not. Mobile health behavior intervention development could benefit from greater application of health behavior theories. Current theories, however, appear inadequate to inform mobile intervention development as these interventions become more interactive and adaptive. Dynamic feedback system theories of health behavior can be developed utilizing longitudinal data from mobile devices and control systems engineering models.
9133437
Realist review - a new method of systematic review designed for complex policy interventions
Evidence-based policy is a dominant theme in contemporary public services but the practical realities and challenges involved in using evidence in policy-making are formidable. Part of the problem is one of complexity. In health services and other public services, we are dealing with complex social interventions which act on complex social systems-things like league tables, performance measures, regulation and inspection, or funding reforms. These are not ‘magic bullets‘ which will always hit their target, but programmes whose effects are crucially dependent on context and implementation. Traditional methods of review focus on measuring and reporting on programme effectiveness, often find that the evidence is mixed or conflicting, and provide little or no clue as to why the intervention worked or did not work when applied in different contexts or circumstances, deployed by different stakeholders, or used for different purposes. This paper offers a model of research synthesis which is designed to work with complex social interventions or programmes, and which is based on the emerging ‘realist’ approach to evaluation. It provides an explanatory analysis aimed at discerning what works for whom, in what circumstances, in what respects and how. The first step is to make explicit the programme theory (or theories) - the underlying assumptions about how an intervention is meant to work and what impacts it is expected to have. We then look for empirical evidence to populate this theoretical framework, supporting, contradicting or modifying the programme theories as it goes. The results of the review combine theoretical understanding and empirical evidence, and focus on explaining the relationship between the context in which the intervention is applied, the mechanisms by which it works and the outcomes which are produced. The aim is to enable decision-makers to reach a deeper understanding of the intervention and how it can be made to work most effectively. Realist review does not provide simple answers to complex questions. It will not tell policy-makers or managers whether something works or not, but will provide the policy and practice community with the kind of rich, detailed and highly practical understanding of complex social interventions which is likely to be of much more use to them when planning and implementing programmes at a national, regional or local level.
54837780
A realist diagnostic workshop
The realist approach can now be said to be part of the repertoire of evaluation methods. There has been a corresponding shift in methodological focus. Polemical thrust and counter-thrust about the realist contribution as compared to that of other evaluative approaches such as randomized trials and meta-analysis has given way to closer examination of its practice ‘on the ground’. This article seeks to make a contribution to the literature on how to conduct realist inquiry through a constructive critique of recently published ‘realist evaluations’.
10106910
Internet-based medical education: a realist review of what works, for whom and in what circumstances
BackgroundEducational courses for doctors and medical students are increasingly offered via the Internet. Despite much research, course developers remain unsure about what (if anything) to offer online and how. Prospective learners lack evidence-based guidance on how to choose between the options on offer. We aimed to produce theory driven criteria to guide the development and evaluation of Internet-based medical courses.MethodsRealist review - a qualitative systematic review method whose goal is to identify and explain the interaction between context, mechanism and outcome. We searched 15 electronic databases and references of included articles, seeking to identify theoretical models of how the Internet might support learning from empirical studies which (a) used the Internet to support learning, (b) involved doctors or medical students; and (c) reported a formal evaluation. All study designs and outcomes were considered. Using immersion and interpretation, we tested theories by considering how well they explained the different outcomes achieved in different educational contexts.Results249 papers met our inclusion criteria. We identified two main theories of the course-in-context that explained variation in learners' satisfaction and outcomes: Davis's Technology Acceptance Model and Laurillard's model of interactive dialogue. Learners were more likely to accept a course if it offered a perceived advantage over available non-Internet alternatives, was easy to use technically, and compatible with their values and norms. 'Interactivity' led to effective learning only if learners were able to enter into a dialogue - with a tutor, fellow students or virtual tutorials - and gain formative feedback.ConclusionsDifferent modes of course delivery suit different learners in different contexts. When designing or choosing an Internet-based course, attention must be given to the fit between its technical attributes and learners' needs and priorities; and to ways of providing meaningful interaction. We offer a preliminary set of questions to aid course developers and learners consider these issues.
25991121
RAMESES publication standards: realist syntheses.
BACKGROUND
There is growing interest in realist synthesis as an alternative systematic review method. This approach offers the potential to expand the knowledge base in policy-relevant areas - for example, by explaining the success, failure or mixed fortunes of complex interventions. No previous publication standards exist for reporting realist syntheses. This standard was developed as part of the RAMESES (Realist And MEta-narrative Evidence Syntheses: Evolving Standards) project. The project's aim is to produce preliminary publication standards for realist systematic reviews.


DESIGN
A mixed method study synthesising data between 2011-2012 from a literature review, online Delphi panel and feedback from training, workshops and email list.


METHODS
We: (a) collated and summarized existing literature on the principles of good practice in realist syntheses; (b) considered the extent to which these principles had been followed by published syntheses, thereby identifying how rigour may be lost and how existing methods could be improved; (c) used a three-round online Delphi method with an interdisciplinary panel of national and international experts in evidence synthesis, realist research, policy and/or publishing to produce and iteratively refine a draft set of methodological steps and publication standards; (d) provided real-time support to ongoing realist syntheses and the open-access RAMESES online discussion list to capture problems and questions as they arose; and (e) synthesized expert input, evidence syntheses and real-time problem analysis into a definitive set of standards.


RESULTS
We identified 35 published realist syntheses, provided real-time support to 9 ongoing syntheses and captured questions raised in the RAMESES discussion list. Through analysis and discussion within the project team, we summarized the published literature and common questions and challenges into briefing materials for the Delphi panel, comprising 37 members. Within 3 rounds this panel had reached consensus on 19 key publication standards, with an overall response rate of 91%.


CONCLUSIONS
This project used multiple sources to develop and draw together evidence and expertise in realist synthesis. For each item we have included an explanation for why it is important and guidance on how it might be reported. Realist synthesis is a relatively new method for evidence synthesis and as experience and methodological developments occur, we anticipate that these standards will evolve to reflect further methodological developments. We hope that these standards will act as a resource that will contribute to improving the reporting of realist syntheses.
5952178
Randomized study of the effect of video education on heart failure healthcare utilization, symptoms, and self-care behaviors.
OBJECTIVE
Adherence to self-care behaviors improves heart failure (HF) morbidity and life quality. We examined short-term impact of video education (VE) in addition to standard education (SE) on HF healthcare utilization and self-care behavior adherence.


METHODS
One hundred and twelve hospitalized patients were randomly assigned to SE (n=53) or SE plus VE (n=59). Differences between groups were analyzed in patients who underwent 3-month follow-up (39 SE and 37 VE patients). Mean age was 60+/-14 years; mean HF length was 57 months.


RESULTS
Three-month healthcare utilization was similar between groups but VE patients needed less extra diuretic dosing (P<0.02), received more HF literature (P<0.03), and had less healthcare team telephone communication (P<0.04). VE patients had greater sign/symptom reduction (P<0.04); especially related to edema (P<0.01) and fatigue (P<0.01) and initiated more actions for edema (P<0.05) and dyspnea (with exercise or rest, both P<0.01). Overall, VE patients had a higher mean self-care behavior score (P<0.01), reflecting greater self-care adherence.


CONCLUSION
Video education prompts self-care behavior adherence to control worsening signs/symptoms of volume overload. During 3-month follow-up, utilization of most healthcare resources was unchanged.


PRACTICE IMPLICATIONS
VE is a useful adjunct to in-person education.
8911430
Pilot testing of a self-care education intervention for patients with heart failure
Background: A key component of the structured approach to the management of chronic heart failure (CHF) is effective patient education. Patient education is a precursor to performing appropriate health-related behaviours that can decrease rehospitalizations. Aim: To pilot test an educational intervention and to determine the efficacy of a self-care manual combined with a DVD for patients with CHF. Outcomes of interest included heart failure-related knowledge and self-care behaviours. Methods: This pilot study enrolled a sample of 38 patients with CHF. A pre-test/post-test design was conducted to assess changes in knowledge and self-care abilities. Knowledge was assessed with the Dutch Heart Failure Knowledge Scale and self-care behaviours were assessed using the Self-Care of Heart Failure Index. Results: Of the 38 participants 71% were male, 50% were aged between 65 and 74 years, and 31.6% had not completed Year 10 education. There was a statistically significantly difference in the pre- and post-test scores for knowledge (p < 0.0001). Self-care showed positive improvement between pre- and post-test scores; maintenance (p = 0.027), management (p < 0.0001) and confidence (p = 0.051). Conclusion: This pilot study has indicated that a patient-centred self-care manual combined with a DVD is beneficial and is associated with an improvement in patients’ knowledge and self-care abilities. Practice implications: Healthcare professionals should utilize multimedia educational resources specifically designed to meet the learning needs of patients with CHF.
10457840
Improving self-care for heart failure for seniors: the impact of video and written education and decision aids.
Heart failure poses a substantial burden on health care expenditures and quality of life; therefore, strategies to improve health behaviors for heart failure are essential. Highly effective medical decision aids can enable health improvements for people with heart failure. In this randomized controlled study, individuals with heart failure in a private Medicare plan were randomized into either an intervention or control group. Participants in the intervention group received basic program information and a simple fact sheet about heart failure, plus a medical decision aid, Living with Heart Failure DVD and booklet; patients randomized to the control group received the basic written materials only. The study was powered to detect a 5% difference in the primary outcome measure (daily weight monitoring). Participants were surveyed 4 weeks after outreach materials were mailed. There were 480 survey respondents: 246 in the intervention group; 234 in the control group. Intervention group respondents were significantly more likely to weigh themselves daily (P=0.05) than control group respondents (44% versus 38%). The intervention group was more likely than the control group to monitor fluid intake (47% versus 44%) and follow a low-sodium diet (83% versus 77%). Other health behavior differences were not statistically significant. The DVD decision aid increased levels of daily weight monitoring and other important health behaviors. Broad application of inexpensive behavior change interventions, such as a DVD/booklet program, should help to facilitate important, routine self-care behaviors for individuals with heart failure.
24357111
Brief DVD-based educational intervention for patients with cancer pain: feasibility study
Patient attitudes and knowledge regarding cancer pain and strong opioid analgesia can sometimes be a barrier to good pain control. Educational interventions that address these barriers are effective in oncology outpatients but have not been evaluated in patients with more advanced disease. We assessed the feasibility of a randomized, controlled clinical trial evaluating a brief DVD-based educational intervention for cancer pain in palliative care patients. Participants were shown DVD at baseline (V1) and at 1 week (V2). Outcomes were assessed using Brief Pain Inventory (BPI) and Patient Pain Questionnaire (PPQ) before intervention, and at V2 and V3 (4 weeks later). Fifteen patients and 10 carers were recruited. Between V1 and V2, total BPI and PPQ scores improved significantly by 9.6% (p = 0.02) and 17% (p = 0.04) respectively with no further improvements at V3. Our findings suggest that this intervention is feasible and potentially effective between 7—30 days follow up. A multicentre clinical trial is now needed to evaluate this intervention further.
1106816
ProsCan for Couples: Randomised controlled trial of a couples-based sexuality intervention for men with localised prostate cancer who receive radical prostatectomy
BackgroundProstate cancer is the most common male cancer in the Western world. The most substantial long term morbidity from this cancer is sexual dysfunction with consequent adverse changes in couple and intimate relationships. Research to date has not identified an effective way to improve sexual and psychosocial adjustment for both men with prostate cancer and their partners. As well, the efficacy and cost effectiveness of peer counselling as opposed to professional models of service delivery has not yet been empirically tested. This paper presents the design of a three arm randomised controlled trial (peer vs. nurse counselling vs. usual care) that will evaluate the efficacy of two couples-based sexuality interventions (ProsCan for Couples: Peer support vs. nurse counselling) on men's and women's sexual and psychosocial adjustment after surgical treatment for localised prostate cancer; in addition to cost-effectiveness.Methods/designSeventy couples per condition (210 couples in total) will be recruited after diagnosis and before treatment through urology private practices and hospital outpatient clinics and randomised to (1) usual care; (2) eight sessions of peer-delivered telephone support with DVD education; and (3) eight sessions of oncology nurse-delivered telephone counselling with DVD education. Two intervention sessions will be delivered before surgery and six over the six months post-surgery. The intervention will utilise a cognitive behavioural approach along with couple relationship education focussed on relationship enhancement and helping the couple to conjointly manage the stresses of cancer diagnosis and treatment. Participants will be assessed at baseline (before surgery) and 3, 6 and 12 months post-surgery. Outcome measures include: sexual adjustment; unmet sexuality supportive care needs; attitudes to sexual help seeking; psychological adjustment; benefit finding and quality of life.DiscussionThe study will provide recommendations about the efficacy of peer support vs. nurse counselling to facilitate better sexual and couple adjustment after prostate cancer as well as recommendations on whether the interventions represent efficient health service delivery.Trial RegistrationACTRN12608000358347
12054752
Effectiveness of multimedia interactive patient education on knowledge, uncertainty and decision-making in patients with end-stage renal disease.
AIM
This study tested the efficacy of a multimedia interactive DVD as an education tool for patients with end-stage renal disease in terms of enhancing patient knowledge and decision-making skills and decreasing uncertainty.


BACKGROUND
End-stage renal case numbers in Taiwan are growing by approximately 6000 new patients per year. Helping patients choose an optimal treatment method to maximise quality of life is an important healthcare issue for this patient population.


DESIGN
This study adopted a quasi-experimental design and focused on subjects being treated at one medical centre in southern Taiwan. The study divided subjects into experimental and control groups.


METHODS
The experimental group received three multimedia interactive DVD nursing-guided interventions. The control group received only normal hospital health education. The study gathered data using several scales addressing knowledge, uncertainty perception and decision regret. Scales were implemented immediately before and after the multimedia interactive DVD nursing guidance intervention and at four and eight weeks postintervention. This study used an independent t-test, chi-square test and repeated measures analysis of variance.


RESULTS
This study found significant improvements in the experimental group in terms of knowledge, pre-dialysis uncertainty and decision regret. Experimental group subjects scored particularly less in terms of decision regret than those in the control group.


RELEVANCE TO CLINICAL PRACTICE
This study demonstrated the efficacy of the developed multimedia interactive DVD in significantly improving end-stage renal patient knowledge and reducing patient uncertainties and postdecision regret. Study findings can be used as a reference guide for clinical nursing education efforts in hospital and other healthcare settings.
207693707
Face-to-Face Interaction Compared With Video Watching on Use of Physical Activity in Peripheral Arterial Disease: A Pilot Trial
Few studies have defined the association of physician-patient communication with physical activity levels in patients with peripheral arterial disease. We hypothesized that a face-to-face intervention versus video watching would improve physical activity levels in patients with peripheral arterial disease. The authors conducted a randomized trial involving 2 interventions. The face-to-face intervention included a brief dialogue with patients to understand their perceptions of peripheral arterial disease and importance of walking. The comparison group watched a video that included an overview of peripheral arterial disease. The primary outcome was changed from baseline to follow-up in levels of physical activity. Fifty-one patients with peripheral arterial disease were randomized. There were no statistically significant differences between the 2 groups in reported activity level or walking ability at 12 weeks. For within group changes, the patients in the video-watching group improved their walking speed (8.5%; SD = 4.1; P = .05). Patients with peripheral arterial disease may benefit from the use of an educational video to increase the use of unsupervised physical activity. Further research is needed to identify interventions that can increase the use of unsupervised physical activity in this population.
349606
Randomized trial of a DVD intervention to improve readiness to self-manage joint pain
Summary Evidence about how the motivational impact of written information on pain self‐management can be improved, which could help to prepare people for more intensive self‐management interventions. Abstract A DVD (digital video disk) intervention to increase readiness to self‐manage joint pain secondary to hemophilia was informed by a 2‐phase, motivational‐volitional model of readiness to self‐manage pain, and featured the personal experiences of individuals with hemophilia. The DVD was evaluated in a randomized controlled trial in which 108 men with hemophilia completed measures of readiness to self‐manage pain (Pain Stages of Change Questionnaire) before and 6 months after receiving the DVD plus information booklet (n = 57) or just the booklet (n = 51). The effect of the DVD was assessed by comparing changes in Pain Stages of Change Questionnaire scores (precontemplation, contemplation, and action/maintenance) between groups. The impact on pain coping, pain acceptance, and health‐related quality of life was tested in secondary analyses. Repeated‐measures analysis of variance, including all those with complete baseline and follow‐up data regardless of use of the intervention, showed a significant, medium‐sized, group × time effect on precontemplation, with reductions among the DVD group but not the booklet group. Significant use × time effects showed that benefits in terms of contemplation and action/maintenance were restricted to those who used the interventions at least once. The results show that low‐intensity interventions in DVD format can improve the motivational impact of written information, and could be used to help prepare people with chronic pain for more intensive self‐management interventions. The findings are consistent with a 2‐phase, motivational‐volitional model of pain self‐management, and provide the first insights to our knowledge of readiness to self‐manage pain in hemophilia.
24105341
Use of on-demand video to provide patient education on spinal cord injury
Abstract Background/objective Persons with chronic spinal cord injury (SCI) have a high lifetime need for ongoing patient education to reduce the risk of serious and costly medical conditions. We have addressed this need through monthly in-person public education programs called SCI Forums. More recently, we began videotaping these programs for streaming on our website to reach a geographically diverse audience of patients, caregivers, and providers. Design/methods We compared information from the in-person forums to that of the same forums shown streaming on our website during a 1-year period. Results Both the in-person and Internet versions of the forums received high overall ratings from individuals who completed evaluation forms. Eighty-eight percent of online evaluators and 96% of in-person evaluators reported that they gained new information from the forum; 52 and 64% said they changed their attitude, and 61 and 68% said they would probably change their behavior or take some kind of action based on information they learned. Ninety-one percent of online evaluators reported that video is better than text for presenting this kind of information. Conclusion Online video is an accessible, effective, and well-accepted way to present ongoing SCI education and can reach a wider geographical audience than in-person presentations.
11566623
Toward the development of a motivational model of pain self-management.
Adaptive management of chronic pain depends to a large degree on how patients choose to cope with pain and its impact. Consequently, patient motivation is an important factor in determining how well patients learn to manage pain. However, the role of patient motivation in altering coping behavior and maintaining those changes is seldom discussed, and theoretically based research on motivation for pain treatment is lacking. This article reviews theories that have a direct application to understanding motivational issues in pain coping and presents a preliminary motivational model of pain self-management. The implications of this model for enhancing engagement in and adherence to chronic pain treatment programs are then discussed. The article ends with a call for research to better understand motivation as it applies to chronic pain self-management. In particular, there is a need to determine whether (and which) motivation enhancement interventions increase active participation in self-management treatment programs for chronic pain.