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Clarann Weinert
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Women to Women Phase III
History

Women to Women (WTW) was a multi-phase intervention that provided social support and enhanced self-management skills for geographically isolated women with chronic conditions via the use of telecommunication technology. The ultimate goal of the intervention was to enhance the women’s ability to adapt more successfully to living with chronic illness. In earlier phases of WTW, it was quickly seen that rural women would readily embrace and actively participate in virtual support groups and the on-line health education activities. During this period, much was learned about research design and intervention/delivery approaches, and our conceptual thinking matured and expanded as well.

Because the Phase II research design and intervention were labor intensive, costly, and complex, our observations and a review of the literature gave support to the idea that a more streamlined intervention of shorter duration, increased intensity, and revised focus of health teaching could be just as effective in enhancing psychosocial adaptation. Therefore in Phase III, the complexity of the design was simplified by reducing the number of groups from three to two, utilizing one online discussion forum in lieu of two, minimizing expert input and participation during the intervention, and decreasing the duration of the intervention and number of data collection points. The focus of the health teaching units was shifted from specific health content to problem solving processes.

With the increased use of computers by rural women, we found that most could be effectively taught the use of the intervention platform (WebCT) via the telephone and a printed tutorial, minimizing the need for home visits. With this telephone capability, it was possible to expand our recruitment range beyond Montana to surrounding states with similar vulnerable rural populations.

In addition to the changes made in design and delivery, we refined and enriched our conceptual thinking about psychosocial adaptation, drawing on the work of Roy and Pollock, other nurse scientists, and the current research team. From this introspection, The Women to Women Conceptual Model for Psychosocial Adaptation to Chronic Illness has evolved and now addresses not only the complex process of psychosocial adaptation, but also focuses on the outcomes of chronic illness self-management and quality of life, prerequisites to sustained behavior change. It is expected that with the strengthening and refinement of the new conceptual model in Phase III of WTW, the state of the science regarding adaptation to chronic illness will be advanced, and guidance for expanding intervention research related to chronic illness management will be provided. Thus, the anticipated unique contributions of Phase III are the: simplification of the research design and intervention; changes in delivery and recruitment scope; and refinement of a model of psychosocial adaptation to chronic illness. See figure below.

WTW3 Conceptual Model
Phase III Description
Aims. Given this history, the overall goal of WTW, Phase III, was to test the impact of a more parsimonious, computer-based intervention on psychosocial adaptation, chronic illness self-management, and quality of life (QOL) for rural women with chronic illness. Within this context, the specific aims were to:
  • (1). Test the effectiveness of a more parsimonious computer-based intervention on psychosocial adaptation.
    H.1. Compared with controls, women in the intervention group will score significantly higher on measures of psychosocial adaptation including social support, self-esteem, and acceptance.
    H.2. Compared with controls, women in the intervention group will score significantly lower on measures of psychosocial adaptation including depression, loneliness, and stress.

  • (2). Test the effectiveness of a more parsimonious computer-based intervention on chronic illness self-management.
    H.3. Compared with controls, women in the intervention group will score significantly higher on measures of chronic illness self-management including self-efficacy, empowerment, resource utilization, and forming partnerships.

  • (3). Test the effectiveness of a more parsimonious computer-based intervention on QOL.
    H.4. Compared with controls, women in the intervention group will score significantly higher on measures of QOL.

  • (4). Explore associations among focal, contextual, and residual stimuli (illness characteristics, demographics, degree of rurality, hardiness, optimism, spirituality), psychosocial adaptation, chronic illness self-management, and quality of life.

  • (5). Analyze the discussion forum computer exchanges among women to explicate the complex process of managing chronic illness within the rural context.

Conceptual model. The Women to Women Conceptual Model for Psychosocial Adaptation to Chronic Illness formed the organizing framework for the Phase III investigation. Measures of environmental stimuli focused on chronic illness, rurality/demographics, hardiness, optimism, and spirituality. Psychosocial responses were assessed by measures of social support, self-esteem, acceptance, depression, loneliness, and stress. Illness self-management was evaluated by measuring the women's self-efficacy and empowerment in achieving the skills of self-management, ability to utilize resources, and form partnerships with their health care providers. Quality of life and happiness were also assessed.

Participants. Women were recruited through newspapers advertisements, word of mouth, and contacts with health professionals, and voluntary agencies. They contacted the research office via a tool free telephone number, were screened in a telephone interview, and entered into the potential participant pool.  Criteria for participation included:  (a) 35 to 65 years of age; (b) diagnosis of a chronic illness; (c) visual acuity sufficient to read a computer screen; (d) upper extremity motor skills adequate to do at least one-finger keyboard strokes; (e) functional hearing and speaking ability for participation in telephone screening interviews; (f) availability of a telephone in the home; (g) ability to read and write English; (h) willingness to commit to participate for 24 weeks, and (i) residence in rural areas in Montana, North Dakota, South Dakota, Nebraska, Wyoming, Idaho, eastern Washington, or eastern Oregon. See the following table for the women’s demographics:

Phase III Participants:  Demographics

 

Participants

Percent

Age

 

 

30-39

18

5.83

40-49

47

15.21

50-59

132

42.72

60-69

104

33.66

70-79

8

2.59

Total

309

100.00

 

 

 

Ethnicity

 

 

White

281

91.23

Afro-American

0

0.00

Mexican American

9

2.92

Asian American

6

1.95

Native American

11

3.57

Other

1

0.32

Total

308

100.00

 

 

 

Marital Status

 

 

Married

237

76.95

Divorced

41

13.31

Separated

2

0.65

Widowed

9

2.92

Never Married

12

3.90

Common Law

0

0.00

Living Together

7

2.27

Total

308

100.00

 

 

 

Education

 

 

12 or Less

68

22.08

13-15

129

41.88

16-18

89

28.90

19+

22

7.14

Total

308

100.00

 

 

 

Income

 

 

Less than $15,000

43

14.24

$15,000 to $24,999

44

14.57

$25,000 to $34,999

55

18.21

$35,000 to $44,999

48

15.89

$45,000 to $54,999 

38

12.58

$55,000 to $64,999

23

7.62

$65,000 to $74,999

19

6.29

$75,000 to $84,999

11

3.64

$85,000+

21

6.95

Total

302

100.00

 

 

 

Employment

 

 

(outside home)

 

 

No

160

52.81

Yes

143

47.19

Total

303

100.00

 

 

 

State Living in

 

 

Montana

121

39.16

N. Dakota

24

7.77

S. Dakota

41

13.27

Wyoming

24

7.77

Washington

26

8.41

Oregon

29

9.39

Nebraska

8

2.59

Idaho

34

11.00

Iowa

2

0.65

Total

309

100.00

 

 

 

Illness Category

 

 

Cardiovascular

6

1.94

Pulmonary disorders

8

2.59

Renal disorders

7

2.27

Gastrointestinal disorders

10

3.24

Hepatic disorders

6

1.94

Endocrine disorders

50

16.18

Rheumatoid disorders

119

38.51

Neurologic disorders

65

21.04

Allergies

3

0.97

Trauma

6

1.94

Cancer

15

4.85

Auto-immune

6

1.94

Other

8

2.59

Total

309

100.00

Design. A two-group study design (intervention/ and control) was used with measures taken at baseline, the end of week 11 (at the conclusion of the intervention), and the end of week 24. Both the intervention and the control groups completed the repeated measure mail questionnaires at each time point. The intervention was 11 weeks during which time the intervention group had 24/7 access to an asynchronous on-line discussion forum and to weekly health teaching units. A total of eight cohorts participated in the study (N=308).

Data analysis. Data from the mail questionnaires were entered into SPSS, files set-up and cleaned, and the data analysis is actively in process. The exchanges among the women in the discussion forum were downloaded, de-identified, entered into N-VIVO, and coded. These data are also actively being analyzed.

Summary

The implementation and evaluation of the first two phases of WTW have contributed to the understanding of the role this intervention is playing in enhancing the women's self-management skills in an effort to help them successfully adapt to chronic illness. In Phase I, the technical and protocol aspects of conducting a computer-based nursing support and health education intervention were refined, and the positive impact of the intervention on the women's psychosocial well-being was demonstrated, using social support theory as a major focus. In Phase II, adaptation to chronic illness was adopted as the overarching conceptual framework for the study, and the scope of the project was expanded to include a multidisciplinary focus, a wider population, and guided learning on the internet. In Phase III, the research trajectory moved toward reducing the complexity of the research design and intervention and further developing and refining a model of psychosocial adaptation to chronic illness.

Last updated: December 16, 2009


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