Professor Richard Osborne1
Professor Marita McCabe1
Dr Sharon Haymes2
Professor Rachelle Buchbinder3
Dr John Furler4
Dr Jenni Livingstone1
Dr Sarity Dodson1
Dr Stuart Cavill5
1 Deakin University
2 Centre for eye research, Australia
3 Monash Department of Clinical Epidemiology and Cabrini Hospital
4 University of Melbourne
5 Southern Health
6 Arthritis Victoria incorporating Osteoporosis Victoria
Beyond Blue Victorian Centre of Excellence
Project completion year
Numerous self-management support (SMS) programs have been developed over recent years to build the capacity of individuals to maintain effective chronic disease self management. However, systematic reviews of Musculoskeletal (MSK) condition SMS programs have shown weak effects. Difficulties with retention and uptake appear related to inflexibility of content, inconvenience of attending face to face programs during work hours, and disinterest in group programs. Given the burden of MSK conditions, there is an urgent need to develop and test new approaches to SMS. Whilst web-based programs are not commonly offered by healthcare services, they now show promise as a platform for remote provision of tailored information and low intensity support.
In response to the shortcomings of existing SMS programs, and the lack of opportunities offered through a web-based platform, we developed and pilot tested SteppingUp using funds granted through the Beyond Blue Victorian Centre of Excellence in 2009. SteppingUp was designed as a low intensity intervention for consumers unable to access other SMS interventions, or for whom web-based delivery is preferable or more convenient.
Figure 1 below illustrates the main elements of the SteppingUp model, which includes a semi-structured assessment interview conducted over the phone or in person; a set of online learning modules that consumers work through independently over several weeks; and a final review consultation (again conducted by phone or in person by a clinician). Consumers receive weekly email contact from their clinician and can access online resources including a journal and activity schedule throughout the program.
Figure 1: Major elements of the SteppingUp program
Rationale and Aims of the Implementation Optimisation Trial
Results from the pilot showed potential for SteppingUp to enhance self management, mental health, and quality of life, but feasibility of implementation in mainstream healthcare was still unknown. Prior to rigorously testing SteppingUp in a large-scale RCT, two key research questions needed to be addressed: 1) can the SteppingUp clinical role effectively be undertaken by a variety of clinicians (e.g. nurses, dieticians, physiotherapists)?; and 2) is a web-based program like SteppingUp feasible in mainstream health services?
To address the research questions, three Victorian community health services participated in training and co-creation activities. Across the sites, fifteen clinicians offered SteppingUp to 93 consumers over a seven-month period. Evaluation activities focused on confidence and experience of clinicians; acceptability and feasibility of SteppingUp from the perspective of clinicians and site managers; and outcomes from the perspective of consumers.
Key Findings from the Implementation Optimisation Trial
Clinicians’ experience of implementing SteppingUp was mostly positive. Most enjoyed using SteppingUp and found the role of applying the program easy to manage. Some encountered difficulties with recruiting and engaging consumers, while others received consistently positive feedback and had few difficulties keeping consumers engaged. All but one clinician expressed strong interest in continuing to use SteppingUp with their consumers.
Site managers' experience of implementation, their impressions of clinicians’ experiences, and their understanding of consumer outcomes were all positive. They all expressed a strong interest in continuing to offer SteppingUp and being involved in future development activities. All three strongly advocated for the expansion of the program to other conditions.
Consumer feedback about the program and outcomes suggested that most consumers found the program very worthwhile and gained significantly from their participation. Improvements in self management were measured primarily using the Health Education Impact Questionnaire (heiQ) (pre and post intervention) and suggested that consumers improved in the areas of: a) positive and active engagement in life; b) emotional distress; c) skill and technique acquisition; d) health directed activities; e) constructive attitudes and approaches; f) social integration and support; and g) health service navigation. Results from Kessler Psychological Distress Scale (K10) (pre and post intervention) also showed a significant reduction in distress amongst participants.
Implications and Future Directions
Findings suggest the SteppingUp clinical role can be successfully undertaken by a variety of clinicians. Variability in consumer engagement observed across the clinician group did not appear related to clinical background. In the future, training needs to address the observed variability in approaches to goal setting; familiarity with the program and confidence to tailor the program; and approaches to the monitoring and support role.
Feedback from clinicians and site managers strongly suggests that a web-based program like SteppingUp is acceptable to stakeholders within community health, and is feasible to implement. All sites strongly endorsed SteppingUp and advocated for its adaptation to other chronic conditions. A large-scale RCT is now needed to confirm the value of SteppingUp.
Download the SteppingUp final report