A multi-modal intervention for Activating Patients at Risk for Osteoporosis (APROPOS): Rationale, design, and uptake of online study intervention material

Maria I Danila, Ryan C Outman, Elizabeth J Rahn, Amy S Mudano, Tammi F Thomas, David T Redden, Jeroan J Allison, Fred A Anderson, Julia P Anderson, Peter M Cram, Jeffrey R Curtis, Liana Fraenkel, Susan L Greenspan, Andrea Z LaCroix, Sumit R Majumdar, Michael J Miller, Jeri W Nieves, Monika M Safford, Stuart L Silverman, Ethel S Siris, Daniel H Solomon, Amy H Warriner, Nelson B Watts, Robert A Yood, Kenneth G Saag, Maria I Danila, Ryan C Outman, Elizabeth J Rahn, Amy S Mudano, Tammi F Thomas, David T Redden, Jeroan J Allison, Fred A Anderson, Julia P Anderson, Peter M Cram, Jeffrey R Curtis, Liana Fraenkel, Susan L Greenspan, Andrea Z LaCroix, Sumit R Majumdar, Michael J Miller, Jeri W Nieves, Monika M Safford, Stuart L Silverman, Ethel S Siris, Daniel H Solomon, Amy H Warriner, Nelson B Watts, Robert A Yood, Kenneth G Saag

Abstract

Objective: To develop an innovative and effective educational intervention to inform patients about the need for osteoporosis treatment and to determine factors associated with its online uptake.

Methods: Postmenopausal women with a prior fracture and not currently using osteoporosis therapy were eligible to be included in the Activating Patients at Risk for OsteoPOroSis (APROPOS). Four nominal groups with a total of 18 racially/ethnically diverse women identified osteoporosis treatment barriers. We used the Information, Motivation, Behavior Skills conceptual model to develop a direct-to-patient intervention to mitigate potentially modifiable barriers to osteoporosis therapy. The intervention included videos tailored by participants' race/ethnicity and their survey responses: ranked barriers to osteoporosis treatment, deduced barriers to treatment, readiness to behavior change, and osteoporosis treatment history. Videos consisted of "storytelling" narratives, based on osteoporosis patient experiences and portrayed by actresses of patient-identified race/ethnicity. We also delivered personalized brief phone calls followed by an interactive voice-response phone messages aimed to promote uptake of the videos.

Results: To address the factors associated with online intervention uptake, we focused on participants assigned to the intervention arm (n = 1342). These participants were 92.9% Caucasian, with a mean (SD) age 74.9 (8.0) years and the majority (77.7%) had some college education. Preference for natural treatments was the barrier ranked #1 by most (n = 130; 27%), while concern about osteonecrosis of the jaw was the most frequently reported barrier (at any level; n = 322; 67%). Overall, 28.1% (n = 377) of participants in the intervention group accessed the videos online. After adjusting for relevant covariates, the participants who provided an email address had 6.07 (95% CI 4.53-8.14) higher adjusted odds of accessing their online videos compared to those who did not.

Conclusion: We developed and implemented a novel tailored multi-modal intervention to improve initiation of osteoporosis therapy. An email address provided on the survey was the most important factor independently associated with accessing the intervention online. The design and uptake of this intervention may have implications for future studies in osteoporosis or other chronic diseases.

Keywords: Osteoporosis; Patient directed intervention; Treatment barriers; Video-based intervention.

Figures

Fig. 1
Fig. 1
Intervention design for women in the Activating Patients at Risk for OsteoPOroSis (APROPOS) Study. (a) Nominal groups were used to generate a list of barriers (Appendix A) that experts reduced to those potentially modifiable by an intervention. Potentially modifiable barriers were ranked by participants on surveys and these responses were used to tailor the first layer of the intervention, followed by the second layer of tailoring (self-identified race/ethnicity) (b). Participants received video segments with three components: an introduction, videos tailored based on participant ranked specific barriers or general osteoporosis treatment barriers, and a video on “How to talk to your doctor” communication techniques *Women who self-identified other than Caucasian, African American, and/or Hispanic comprised less than 2% of our intervention population and received intervention videos with Caucasian female educators and patient actresses.
Fig. 2
Fig. 2
Intervention deployment workflow for women in the Activating Patients at Risk for OsteoPOroSis (APROPOS) Study. IVR, interactive voice-response.
Fig. 3
Fig. 3
Tailoring of video segments for women in the intervention arm of the Activating Patients at Risk for OsteoPOroSis (APROPOS) Study. Individuals were assigned video segments based on four mutually exclusive, hierarchical levels: Group I: Ranked barriers to osteoporosis treatment, Group II: Other barriers identified on the survey including a physician recommended break from medications and/or ≥5 years treatment, or concerns about long term adverse effects as identified on the Patients’ Views about Osteoporosis (osteo) and therapy scale, Group III: Readiness to behavior change based on the Weinstein Precaution Adoption Process Model (PAPM), or Group IV: Previous treatment history. ONJ, osteonecrosis of the jaw.
Fig. 4
Fig. 4
Proportion of participants interacting with the video program online by contact information. Phone only, email only, phone & email indicate phone number, email, or both provided on baseline survey, respectively. No email/phone indicates no email or phone number was provided on the baseline survey. Warm handoff call informed participant of reason for intervention materials, as well as attempted to identify and address barriers to watching videos. Reminder package contained copy of introductory letter detailing instructions on how to access video program online and another DVD with individualized video intervention. * Timing of these materials varied up to ∼1week. +Varied based on when/if warm handoff call completed. IVR, interactive voice-response .

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