Telehealth Walking Self-Management for Individuals With Amputation: A Qualitative Study of Therapist Perspectives on Adoption

Abstract

Objective

The aim of this study was to understand therapist-identified factors influencing clinical adoption of a telehealth walking self-management intervention for individuals with lower limb amputation.

Methods

Semi-structured focus groups were completed with actively practicing physical and occupational therapists treating populations that are medically complex. A qualitative explorative design was employed with conventional content analysis and iterative independent parallel coding using 2 analysts. Themes and subthemes were generated with a consensus building process identifying patterns and collapsing codes to represent participant perspectives.

Results

Thematic saturation was met after 5 focus groups (24 therapists). Therapists were on average 34 years old and predominantly female (n = 19; 79%) physical therapists (n = 17; 71%). Three primary facilitator and barrier themes were identified for intervention adoption: system, therapist, and person. System considerations included telehealth support and interprofessional care coordination. Therapist facilitators included self-management programming that overlapped with standard of care and personalization methods. However, limited behavioral theory training was a therapist level barrier. Finally, person factors such as patient activation could influence both positively and negatively. Person facilitators included social support and barriers included the complex health condition.

Conclusion

System, therapist, and person facilitators and barriers must be considered to maximize the adoption of similar telehealth walking self-management interventions and prior to larger scale implementation of the current intervention for individuals with lower limb amputation.

Impact

A telehealth walking self-management intervention has potential impact for individuals with lower limb amputation and must be considered in terms of optimizing system, therapist, and person level facilitators and barriers to implementation.

Introduction

After dysvascular lower limb amputation (LLA), most individuals define successful recovery as walking with a prosthesis.¹ However, even after acquiring a prosthesis, many individuals have difficulty sustaining walking capacity due to multimorbidity, high disability levels, and physical inactivity.^2,3 Decreased walking and chronic low physical activity exacerbate disability, comorbidities, and compound negative health outcomes.^4–6 Rehabilitation addresses gait training with the new prosthesis; nevertheless, many adults with LLA do not achieve the walking thresholds necessary for independence in the community,⁷ and they require support for increasing and sustaining walking activity.

Exercise interventions that integrate behavior-change principles to assist adults with LLA with motivation to incrementally progress walking goals are one option to increase and sustain walking exercise during the prosthetic training phase of rehabilitation.⁸ Therefore, we developed the Dysvascular Amputation Self-management of Health (DASH) intervention (NCT04083456). DASH is a phase 1 clinical trial comparing a telehealth walking self-management intervention to general health education (control); both the intervention and control group are combined with conventional outpatient physical therapy. The DASH intervention utilizes 6 behavior-change techniques (self-monitoring, barrier/facilitator identification, tailored feedback, problem solving promotion, action planning, and encouragement). Participants are guided using motivational interviewing principles, supported by social cognitive theory as a framework.

DASH is a novel intervention, and stakeholder engagement is essential to understand necessary early-stage adaptations prior to larger scale implementation.^9,10 Early engagement of clinicians can prompt the remediation of barriers and leveraging of facilitators, as well as prepare sites for future partnership or catalyze interest in partnership.¹¹ For example, early clinician stakeholder feedback can identify training gaps in the protocol.^12,13 Clinician buy-in is essential especially in telehealth programming because if therapists are not actively engaged in understanding and describing self-management protocols to patients, patients are less likely to participate in the program.¹⁴ Understanding factors influencing clinical adoption of a walking self-management intervention from therapists who could deliver future interventions may help address anticipated challenges and ease processes for training, referral, and delivery.¹⁵ Therefore, the purpose of this qualitative study was to identify barriers and facilitators to adoption of a telehealth-delivered walking self-management intervention (DASH).

Methods

Design

We used a qualitative explorative design (focused on open exploration of therapists’ perspectives) and conventional content analysis to analyze therapists’ perspectives of the DASH intervention adoption.¹⁶ Conventional content analysis is employed to understand a phenomenon through rigorous coding, identifying patterns, and theme generation, centering around category development to organize the barriers and facilitators to program adoption that were identified.¹⁶ Consolidated criteria for reporting qualitative research guidelines were used to organize and report on the study.¹⁷ Approval for this study was obtained from the Colorado Multiple Institutional Review Board prior to participant recruitment.

Participants

Purposive sampling (maximum variation) was used to recruit therapists via email through research team contacts to ensure representation from different disciplines, practice settings, and time in practice. Therapists were included if they were actively practicing licensed physical or occupational therapists and were currently treating patient populations that are medically complex (ie, multiple comorbidities or chronic conditions). All participants completed an electronic consent form and were informed that focus groups were designed to learn more about the adoptability of a self-management walking intervention for individuals with LLA. Therapists who participated in a focus group were eligible for 45 minutes of continuing education units with the completion of a course evaluation.

Data Collection

Prior to the focus groups, participants completed a demographic form via the Research Electronic Data Capture secure online database (Tab. 1). Participants were assigned to focus group sessions based on their availability. Focus groups were conducted virtually via an online video platform. Each focus group included a 30-minute orientation to the DASH intervention (Tab. 2) and a 1-hour semi-structured discussion. Focus groups were conducted using a semi-structured guide aimed to discover potential barriers and facilitators to clinical adoption in varied practice settings for future implementation (Tab. 3).

Table 1.

Demographic and Questionnaire Data

Variable	Overall Sample (n = 24)
Age, y, median [range]	34 [27–52]
Sex, % female (n)	79 (19)
Race, % Caucasian (n)	100 (24)
Ethnicity, % Non-Hispanic (n)	100 (24)
Discipline, % (n)	71 (17) Physical therapy 29 (7) Occupational therapy
Years of practice, median [range]	8 [3–28]
Practice setting, % outpatient (n)	50 (12)

Table 2.

Orientation to the Dysvascular Amputation Self-Management of Health Intervention

Topic Covered	Content Details
Purpose of the intervention	Implement a 10-session behavior-change walking telehealth intervention alongside conventional outpatient physical therapy for individuals after dysvascular amputation Improve patient self-management as measured by habitual physical activity (walking)
Six key components of the intervention	Self-monitoring Tailored feedback Barrier and facilitator identification Problem-solving promotion Action planning Encouragement
Basics of motivational interviewing	Person-centered Principles (resistance, discrepancy, empathy, self-efficacy) Micro-skills
Logistics of the intervention	Content: 1 in-person session, 9 telehealth sessions with a trained behavior-change interventionist Duration: 30 minutes per session
	Timing: delivered across 6 months: 1×/week for sessions 1–5, 2×/month for sessions 6–8, 1×/month for sessions 9–10

Table 3.

Sample Focus Group Questions^a

Example Prompt	Example Question
Tell us about aspects of the DASH intervention you currently use that work well.	Can you give an example of a patient experience where the behavior-change approach worked well? What are some informal ways you use behavior-change with patients? What would be the benefits of using telehealth? Which behavior-change technique do you use frequently (eg, self-monitoring, tailored feedback, barrier/facilitator identification, problem solving promotion, action planning, encouragement)?
Tell us about the challenges that might influence implementation of the DASH intervention.	How do you work with a patient who has no interest in changing their behavior (eg, exercise, walking, activity)? Which of these behavior-change components would be difficult to implement (eg, self-management, self-monitoring, tailored feedback, barrier/facilitator identification, problem solving promotion, action planning, encouragement)? What would be the challenges of using telehealth?
Is there anything we have not talked about that you think would be important when implementing a self-management program like this?	Tell me more about that. What would that look like in practice?

^a DASH = Dysvascular Amputation Self-management of Health.

PhD trained researchers with extensive qualitative training and clinical backgrounds (L.A.S [occupational therapist] and M.L.M [nurse practitioner]) facilitated each focus group, with 1 researcher leading and 1 present to ask clarifying questions and take field notes. Facilitators entered the study with the belief that rehabilitation to increase walking exercise is beneficial to adults with LLA, and that the self-management intervention may facilitate positive changes in walking behavior. Facilitator biases were bracketed, and leading questions were avoided to reduce the potential for biased responses; however, participants were informed that the overall goal of the DASH intervention was to increase step count. Focus group facilitators encouraged both convergent and divergent views, while also prompting participants who were not speaking with gentle redirection from overarchingly dominant voices.¹⁸ All focus groups were audio-recorded, transcribed verbatim by a professional transcriptionist, and conducted until thematic saturation was reached (ie, both no codebook changes and no new significant meaning was added to the understanding of barriers and facilitators).¹⁹

Data Analysis

Demographic data were analyzed for normality and reported descriptively (mean [± standard deviation], median [range], or proportion). Therapist perspectives from focus groups were explored using a conventional approach to qualitative content analysis.^16,20 Codes were developed based on immersive inductive analysis of focus group transcripts to identify exhaustive examples of therapist perspectives on barriers and facilitators to a telehealth walking self-management intervention (see the Figure). Two qualitative researchers (L.A.S and M.L.M) utilized a manual coding approach to identify emergent codes through an iterative consensus building process until a final codebook with corresponding definitions was established. Code patterns were identified within barriers and facilitators, and codes and sub-codes were considered collectively, collapsed to reduce redundancy, and organized into a coding matrix. The coding matrix was further refined and reduced to create final themes and sub-themes. After thematic saturation was reached and quotes were chosen to represent themes, the quote was edited to remove filler and repetitive words.

Figure.

Analytic process.

Qualitative Rigor

Four categories were used to ensure rigor throughout the process: credibility, transferability, dependability, and confirmability.²⁰ Credibility was enhanced through verification of transcripts for accuracy with comparison to facilitator notes, and triangulation through a process of cross-checking interpretations across themes and focus groups by 2 independent qualitative researchers. Researchers confirmed the majority of themes were represented across multiple focus groups (maximal variation of themes).²¹ Transferability was optimized through purposive sampling and ongoing focus groups until thematic data saturation was met.^19,20 Dependability was achieved by conducting the current study with 2 expert qualitative researchers coding data, and 4 investigators interpreting the raw data examples and final themes.²² Confirmability was ensured using an audit trail throughout the semi-structured guide development, data collection, and analytic processes.²⁰

Role of the Funding Source

The funders played no role in the design, conduct, or reporting of the study.

Results

Thematic saturation was met after 5 semi-structured focus groups with a total of 24 participants(range of 2 to 6 therapists per group). However, 2 contacted therapists did not participate because 1 had time constraints and 1 was not currently practicing. The average time for the audio-recorded focus group portion was 52.85 (±4.44) minutes. Overall, the majority of participants were female (79%) physical therapists (71%) (Tab. 1). Two therapists had some prior exposure to the DASH intervention and had previously carried out the conventional outpatient physical therapist portion, but had not yet implemented the telehealth walking self-management portion.

Three theme categories were identified: system, therapist, and person each with corresponding sub-themes. Table 4 presents themes, sub-themes, definitions, examples of codes included within each sub-theme, and corresponding salient quotes. Quotes were represented based on focus group (individual voices could not be separated due to the nature of the focus group).

Table 4.

Final Themes, Definitions, Collapsed Codes, and Salient Quotes

Theme Sub-Theme	Definition (− = Barrier, + = Facilitator)	Example Codes Collapsed Into Sub-Theme
System
Telehealth considerations	(−): Barriers related to technology, associated platforms, access (connectivity or device access), or difficulty delivering care virtually (+): Elements of technology or associated platforms that would support intervention implementation	Environmental separation, telehealth problems, socioeconomic status challenges, limitations with lack of hands-on feedback, telehealth positive
Care coordination	(−): Coordination of necessary disciplines, intervention timing, etc. that would negatively impact intervention implementation (+): System structure that supports connected care and/or communication among disciplines	Care coordination problems, time constraints, reimbursement concerns, multidisciplinary care, continuity of care
Therapist
Lack of related training	(−): Therapist lack of behavior-change theory and technique education, motivational interviewing, or training related to intervention components	Lack of biobehavioral education, lack of biobehavioral training, inaccurate expectations
Components within standard practice	(+): Elements therapists currently integrate in evaluations or plans of care that are pieces of the intervention and facilitate intervention adoption	Action planning, goal setting, self-monitoring, problem solving, tailored feedback, motivational interviewing
Personalization approach is consistent with building therapeutic alliance	(+): Positive elements of the therapist–patient relationship as explained by the therapist that could facilitate intervention adoption	Therapeutic alliance, overlapping expectations
Person
Patient activation	(−): A lack of knowledge, ability, and self-efficacy to manage health care planning that would hinder intervention adoption (eg, low motivation, low activity levels, low readiness for change) (+): A high degree of knowledge, ability, and self-efficacy to manage health care planning that would help intervention adoption	Low/high readiness to change, low activity, passive, low follow through, inaccurate self-monitoring, lack of proactivity, established self-monitoring, goal setting, proactivity
Complex health condition	(−): Heath features which negatively impact intervention participation (eg, comorbidities, cognition, sensation, etc.)	Cognition, demographic features, health features
Positive social support	(+): Social elements that support patient participation	Positive social support

System Level

At the system level, participants discussed 2 primary themes that could act as either barriers or facilitators to the telehealth walking self-management intervention adoption: telehealth considerations and care coordination. In terms of telehealth barriers, DASH sessions are delivered virtually, and some therapists were concerned about patients being able to access technology:

“Two things that come to mind is outside of the metro national area, it’s actually pretty rural, so I feel like the biggest barrier with any telehealth, obviously, is connectivity.”—FG4

“I would say for our patient population [a program barrier is] access to technology, or access to a plug to charge their phone. For especially our homeless populations, that’s a real challenge—they might have a phone, but they can’t plug it in or if they can’t pay for it.”—FG3

Yet other therapists mentioned that telehealth, if supported at the institution level, offered a platform that could potentially facilitate therapy access:

“being able to have that opportunity to be able to access [the patient] where they’re at or if they aren’t, for whatever reason, able to come into the clinic, that’s excellent.”—FG2

Additionally, therapists noted the benefits patients may experience with minimized travel and preparation time before a virtual session:

“…from an energy conservation perspective, people don’t want to waste their energy going to doctor’s appointments or PT appointments sometimes if it’s a long drive or it takes a lot to get a shower and get dressed, and get in the car. And, if they can just check in on a [telehealth] appointment basis and then kind of get back to their life.”—FG3

Others considered the time saving aspect of telehealth, but were concerned about lack of hands-on feedback. The DASH intervention is delivered verbally with motivational interviewing cues to advance walking activity, such as “what would be the benefits of increasing your step count on a weekend day?” Many therapists are accustomed to providing physical assistance, physical cueing, or reassurance in the same physical space, and participants noted this gap or concern when using a telehealth platform:

“I’m very tactile and I like just being able to touch a patient, if they’re opening up or you’re having that motivational interview, touching an arm and just kind of engaging in that way. I would think [lack of touch] might be a disadvantage.”—FG4

Others agreed that “rapport is a little harder to develop when you’re not in person” and conducting a therapy session through a screen is “significantly different than being in the same room with them” (FG3).

Another system level consideration was care coordination, which depending on the level of cohesiveness could support or hinder the DASH intervention. Therapists noted that reimbursement for an additional intervention, or care outside of their typical scope of practice could be difficult. Similarly, therapists expressed concerns about integrating a protocolized 30-minute session into their standard practice, because many therapists thought timing would be problematic across settings:

“time in the acute care setting [is a barrier]…they're in and out in, like three days, so just thinking about how we would maybe even just broach the subject of this [program] would just be an education piece, and then kind of handing it off to the next setting that they go to.”—FG4

They also contemplated caseload expectations, and thought the DASH intervention would be difficult to integrate from a productivity standpoint. One therapist mentioned that seeing 2 to 4 patients an hour limits intervention time because, “these conversations [for DASH] that, ideally would take place in 30 minutes would, if you can even attempt it, have to take place in, like, five minutes” (FG2). Considering productivity expectations and other standard practice elements, most therapists felt it would be best if the DASH intervention was delivered by a separate designated therapist.

In some settings, participants saw care coordination as smooth and a potential facilitator to program adoption. In certain systems, like the Veterans Health Administration, referral pathways were a built-in facilitator with “a pretty easy ability to communicate and refer or guide somebody into a mental health resource” (FG4). Similarly, some departments had outlined relationships with:

“social workers who have pretty much told us, if a patient expresses to you that they, are dealing with depression and anxiety or anything else that social work could be of assistance with that we can just reach out to them, that they will contact the patient. So, that’s kind of nice, 'cause it in a way took it off of our plate.”—FG4

These suggestions for cohesive care were not included in the original DASH intervention, but suggested to be considered prior to larger scale implementation.

Therapist Level

At the therapist level, participants discussed more facilitators (components within standard of practice, and personalization supports therapeutic alliance) than barriers (lack of related training). Therapists spoke about many of the self-management techniques which they already use in everyday practice or consider as standard of care. Because most therapists were familiar with these concepts, they felt a walking self-management intervention would be more easily adopted. For example, every therapist spoke about some level of goal setting with each patient and the importance of reevaluating goals:

“I think as physical therapists, we’re fairly good at action planning because goal setting is mandatory to our documentation, but also how we work as physical therapists is very goal oriented. And so, that becomes a big part of just treatment in general.”—FG2

Another therapist discussed how, similar to the DASH intervention, returning to goals is important to “make sure that they’re on track. Because they can change over time and they should change over time” (FG2). This therapist appreciated that ongoing action planning revision was built into the intervention.

In addition to self-management techniques, the DASH intervention is individualized and provides tailored one-on-one discussion. Therapists thought the personalized approach would help with clinical implementation by naturally building a therapeutic alliance which they all noted is essential in everyday practice. Additionally, some therapists mentioned ways that the individualized approach could be further bolstered. For example, therapeutic alliance can be further fostered based on session structure and initial patient interactions:

“I usually start my sessions with is there anything specific we need to work on or did you run into anything….So, usually, several sessions in then they’re a bit more comfortable bringing problems up.”—FG1

Barriers were the least discussed clinician-related subthemes among participants; however, multiple participants highlighted how lack of related training could impact clinical adoption. Some physical or occupational therapy degree programs cover behavioral education, motivational interviewing, or behavior-change components, while other degree programs are just beginning to integrate some of these key elements.

“Courses that would feature something like behavioral change kind of stuff… I think can probably speak for a lot of my classmates that I was going through the program with was that there was very little that was covered…I can’t say that my confidence was super high with it.”—FG2

Participants described a need for having some background on theoretical underpinnings, but also noted the interventionists would need training specific to the given intervention to increase potential efficacy for changing patient behaviors and facilitating long-term walking self-management.

“I think [the intervention] depends on the questions that are being asked and the format of the asking, the way that you guys have kind of broken that down. But I think because you’re working on changing a behavior, you have to have that person asking the questions has to be trained to ask them in a way that will provide the results you’re looking for.”—FG2

Person Level

Therapists in each focus group noted 3 sub-themes of person characteristics that could impact clinical adoption: patient activation (barrier or facilitator), the complex health condition (barrier), and positive social support (facilitator). For this study, we defined patient activation as exhibiting the knowledge, ability, and self-efficacy to manage health care planning.²³ Low patient activation included poor self-initiation in care planning and implementation. Multiple therapists highlighted how patients that are medically complex can often experience minimal motivation to change:

“I think a lot of these folks tend to be fairly passive too. So, not making a decision is kind of a decision in itself. I think maybe that’s something that’s kind of gotten them into this, situation too, so, really having to change that mindset and start making some good decisions could be difficult for these folks.”—FG1

The concept of low patient activation was related to patients that are medically complex, specifically individuals with dysvascular amputations (DASH participant population):

“Vascular amputees tend to have difficulty with follow through. So, I do spend a lot of time trying to help them follow through with healthy choices.”—FG1

Related to exercise desire or activation, therapists thought some patients likely knew there was a decision surrounding exercise participation but “a lot of people are not interested in changing their behavior to include more exercise” (FG3). Some patients may have settled into low patient activation or participation in health care, and although it could be a barrier initially, the DASH intervention could help ameliorate this barrier and improve motivation to engage. Particularly some patients that are medically complex “don’t necessarily have realistic ideas about what their activity is” (FG1) and therapists thought “being able to see how much they’re actually moving or how little and then following it is good. Because I think many of them are in denial about how deconditioned they are and all of the barriers that have kind of cropped up around activity” (FG1).

Conversely, therapists’ thought high patient activation would stimulate program adoption because patients would be more likely to engage. Some patients come to therapy with high self-initiation and preassigned meaning to their goals:

“Most of my patients tell me, not that they just want to walk two miles, but they want to be able to walk to the park with their grandkids or something like that. So, they’re assigning their meaning to that distance. That’s not me doing it. And to them, that’s what’s significant.”—FG3

Therapists discussed the potential of helping patients improve the degree of activation through the intervention, but if a patient entered the intervention with high motivation or readiness to change, that could maximize participation and create a foundation for improvement throughout the intervention. Evaluating readiness to change before intervention initiation could help determine which patients would be the best candidates for walking self-management.

Although some patients enter rehabilitation interventions ready to change, others were noted by the therapists to have characteristics related to poorer participation. Therapists considered complex health conditions to be a barrier for participation for patients. For example, a participant’s cognitive status could lead to poor, or disengaged, participation in the DASH intervention:

“Motivation, that’s definitely something we struggle with, especially with cognitive impartments and health literacy being some of our biggest issues…that’s a huge barrier with these patients.”—FG3

Dealing with health care for multiple comorbidities, and potentially mental health conditions, could make patients skeptical of self-management intervention:

“[Some patients say], ‘I was told to come to this appointment, so I’m here,’ and identifying if there’s, something to work towards, especially when there are mental health, depression, anxiety, other things limiting them from leaving the house and engaging in things….is a huge barrier also impacting kind of their activity participation, then that’s something I don’t always feel like—yes, I can encourage people to exercise.”—FG4

In contrast, positive social support was noted to facilitate potential intervention participation, as a motivating factor:

“I’ve worked with a couple of patients who were trying to find individuals in their life that have a strong meaning to them where they can make a change in their life, so that they can be around to be in their life for an extended period of time, whether it was grandchildren or children as they grow into adulthood. So those are really some of the most motivating aspects that I’ve used.”—FG5

Discussion

Therapists identified barriers and facilitators that would strengthen and challenge the clinical adoption of a telehealth-delivered walking self-management intervention in 3 levels: system, therapist, and person. At the system level, the use of telehealth was seen as both a potential barrier and facilitator. The DASH intervention specifically was developed prior to the COVID-19 pandemic, and telehealth in the rehabilitation domain was still developing. Throughout the pandemic, and in general over time, technology and telehealth services have advanced. Currently, telehealth use and access have greatly expanded across disciplines, which could benefit telehealth intervention adoption.²⁴ Similarly, new billing options could ameliorate therapist concerns about reimbursement for the intervention. Throughout the COVID-19 pandemic, many therapists were able to bill for telehealth services, which will likely continue and change rehabilitation delivery.²⁵ Yet despite the uptick in use and ability to bill, many therapists were still concerned about lack of hands-on care. Other allied health clinicians (primarily physical therapists) echoed the same sentiment and 42% reported telehealth care was not as effective as in-person, and 21% did not feel adequately trained for telehealth delivery, which came up later in our therapist level barriers.²⁶

Within the system level, interdisciplinary care coordination throughout the rehabilitation process was also seen as a barrier or facilitator, depending on cohesiveness. The needs of individuals with LLA are ever evolving during the rehabilitation process and while training with a prosthesis. Clinical practice guidelines for individuals with LLA recommend the use of a transdisciplinary amputation care team throughout rehabilitation to maximize functional outcomes.²⁷ Creating clear referral pathways from surgery to rehabilitation and from rehabilitation to mental health or social work services could support intervention adoption by easing any burden on the therapist and preventing practice outside of their scope or training.

At the therapist level, the only identified barrier to the clinical adoption of the walking self-management intervention was a lack of related therapist training. For theory-driven exercise interventions across populations, therapists cite training as essential toward implementation.^28,29 In this study, therapists discussed variable experiences with behavior-change techniques, indicating a lack of standardization across clinical degree programs. Physical and occupational therapy accreditation standards require training in behavioral sciences, but the depth of the training is not explicitly outlined.^30,31 Due to varied breadth and depth of professional training in behavioral sciences, training prior to DASH intervention implementational should include behavioral theory education, program-specific training, and assigned mentors at each site.^32,33

Interestingly, many therapists discussed self-management techniques for patients that were already standard in their practice and therefore would be efficiently integrated into new interventions. Therapists in this study may have been more familiar with using self-management techniques than other therapists because they agreed to participate in a study involving self-management principles. Yet, most of the therapists talked about these techniques being driven by the therapist—for example, it was the therapist’s responsibility to guide self-monitoring, goal setting, or problem-solving. However, in most self-management interventions, techniques are designed to advance from interventionist-driven to patient-driven as the program progresses to promote sustainability of behavior beyond the intervention. Potentially, more comprehensive training on behavioral theories and mentoring on how to best facilitate walking self-management intervention could help therapists transition to patient-driven discussion of self-management techniques.³⁴ Patient-driven sessions may facilitate self-efficacy growth and sustainability of physical activity at the person level.

Otherwise, therapists expressed that some intervention components and the personalized approach of the intervention were within standard practice and would help facilitate adoption. Personalized discussion may facilitate a positive therapeutic alliance between therapist and patient because of tailoring to individual interests and motivators. Stronger therapeutic alliance scores are associated with better program retention and greater perceived patient functional gains.^35,36 Improving retention and functional outcomes will likely promote system, therapist, and person commitment and lead to better adoption of walking self-management interventions.

At the person level, consideration of the degree of patient activation is essential to intervention feasibility and efficacy. Therapists discussed how the degree of patient activation would positively or negatively influence intervention engagement and correspondingly implementation. One component of patient activation—self-efficacy or confidence initiating and planning care—is a target of the DASH intervention.²³ Therapist participants mentioned that entering an intervention with a certain level of self-efficacy is consistent with self-efficacy theory that self-efficacy is modified through past successes and failures and likely already shaped upon intervention entry; yet further, social cognitive theory supports the assertion that self-efficacy can be developed.^37,38 Self-management techniques that improve self-efficacy (eg, action planning) also are related to improvements in the behavior itself (eg, walking exercise or step count).³⁹ Both explicitly targeting self-efficacy and considering patient activation levels upon entry into the intervention could optimize outcomes and increase justification of larger scale implementation and overall clinical adoption of self-management walking interventions.

Relatedly, many therapists discussed how patient populations that are medically complex are often passive in their own health management. Passivity is related to low self-efficacy because individuals are accepting health consequences rather than playing an active role in care, but separate medical conditions also play a role in the ability to actively engage. For example, cognitive impairment may also be present in patient populations that are medically complex, and individuals with cognitive impairment have difficultly managing their health and chronic conditions.⁴⁰ Oftentimes, people may have difficulty understanding the myriad of health care information provided to them, resulting in a lack of follow-through with interventions.⁴⁰ Similar disengagement of people in their health decisions can result from comorbid depression or anxiety.^41,42

Social support was the final person level facilitator identified by therapists in this study to foster clinical adoption. Therapists primarily talked about social support as a catalyzing factor to motivate self-management. In fact, social support can assist in chronic disease management.⁴³ But beyond disease management, social support was also found to be a facilitator to physical activity itself, perhaps because of the accountability and routine formation of being active with another person.⁴⁴ Explicitly adding questions to a walking self-management intervention to generate participant social engagement and draw attention to social facilitators could ultimately improve adoption from the person level.

The results of this qualitative analysis of stakeholder input will guide the study team in developing a program focused on promoting and sustaining healthy walking behaviors for individuals with LLA for future implementation and efficacy testing and for clinical use. Specifically, the present study findings highlight the need to integrate and coordinate an exercise behavior-change intervention with the interdisciplinary annual LLA visit in the Veterans Affairs Regional Amputation Center clinical team, comprising physiatrist, physical therapy, and prosthetics to maximize clinical adoption of a telehealth behavior-change program. Additionally, we have added peer support groups to promote sustainability of walking exercise for individuals with LLA.

Limitations

This study provides insights to how a telehealth walking self-management intervention can be refined to maximize adoption; however, limitations exist in generalization of the data. Therapist participants were provided only a 30-minute orientation to the intervention. In-depth therapist training and experience administering the specific intervention would potentially have provided the therapist participants with better insight into the potential for clinical adoption. Additionally, therapists were purposively sampled based on discipline, practice years, and setting; however, we did not see large variation in race/ethnicity or geographic distribution, which could be moderating factors to the clinical adoption insights gained.⁴⁵ Although focus groups allow for convergent and divergent thoughts in real-time, and a larger volume of data at once, individual interviews may have allowed for richer feedback on barriers and facilitators from each participant.

Conclusion

Therapists were generally receptive to a telehealth walking self-management intervention and identified opportunities at the system, therapist, and person levels to support adoption for patients that are medically complex. Telehealth interventions are becoming more commonly used, yet we must consider access, equipment, and therapist comfort. Therapist training should be leveraged to maximize patient walking exercise self-management, including mentorship with trained facilitators. Finally, person barriers need to be considered, while person facilitators (eg, social support) should be explicitly integrated.

Author Contributions

Laura Swink (Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Resources, Writing—original draft, Writing—review & editing), Meredith L. Mealer (Conceptualization, Data curation, Formal analysis, Funding acquisition, Methodology, Writing—review & editing), Matthew J. Miller (Conceptualization, Funding acquisition, Methodology, Project administration, Writing—review & editing), Chelsey B. Anderson (Conceptualization, Formal analysis, Methodology, Validation, Writing—review & editing), Paul F. Cook (Conceptualization, Funding acquisition, Methodology, Writing—review & editing), Jennifer E. Stevens-Lapsley (Conceptualization, Funding acquisition, Project administration, Resources, Supervision, Writing—review & editing), and Cory L. Christiansen (Conceptualization, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Supervision, Validation, Writing—review & editing)

Ethics Approval

This study was approved by the Colorado Multiple Institutional Review Board.

Funding

This study is funded by a grant from the National Institute of Nursing Research (US NIH Grant/Contract: R01NR018450). Additionally, use of REDCap was supported in part by the CCTSI Grant NIH/NCATS UL1-TR001082.

Disclosure and Presentations

The authors completed the ICMJE Form for Disclosure of Potential Conflicts of Interest and reported no conflicts of interest.

Some authors are employed through the Veterans Administration. The contents of this study are the authors’ sole responsibility and do not necessarily represent the views of the National Institutes of Health of the views of the US Department of Veterans Affairs or the US Government.

The abstract of this study was presented at poster session at the American Occupational Therapy Inspire Annual Conference & Expo 2022; April 2, 2022; San Antonio, Texas.