Can Self Determination Theory explain presence or absence of change in patients with multimorbidity, living in areas of high socio-economic deprivation, involved in a primary care-based complex intervention?

Problem

Multimorbidity, now recognised as the “norm” for most patients with chronic disease, is more prevalent, and starts at an earlier age, in areas of high socio-economic deprivation. Evidence regarding how best to manage patients with multimorbidity is sparse, including coherent theoretical frameworks to base future interventions.

The CARE-plus study was a whole system, primary-care based, complex intervention aiming to improve the quality of life of multimorbid patients living in areas of very high socio-economic deprivation. A phase 2 exploratory randomised controlled trial showed it was cost-effective. Throughout this trial 14 in-depth interviews were carried out with patients to explore their experience of the intervention.

Self-determination theory (SDT) is a meta-theory of motivation that focuses on how social and cultural factors facilitate, or undermine, volition and initiative, as well as individual well-being. It states that conditions that support the individual’s experience of autonomy, competence and relatedness result in the most volitional and high quality engagement, whilst thwarting of these psychological needs will be detrimental to well-being.

The aim of this study was

• To explore patient experience of CARE-plus

• To determine whether change, or lack of change, could be explained by self-determination theory

Approach

Fourteen in-depth interviews took place throughout the intervention to explore patients’ experience of CARE-plus. Interviews were recorded, and transcribed verbatim. A sample of interviews were read by all authors and broad codes developed. MM then coded all interviews, with refinement of codes carried out during regular group discussion.

Presence or absence for change was evaluated using the ORIDL scoring system. To aid further analysis some of the codes were then merged resulting in three patient groups: moderate/significant change affecting ADLs, minor change not affecting ADLs and no change. The outcomes were agreed independently by two team members with disagreement agreed by team consensus.

Thematic analysis using self-determination theory as a framework is being carried out.

Findings

Three key themes were identified regarding experience of CAREplus:

Value of time:

• To be listened to

• To understand their conditions

• To deal with more than one thing

• To be honest

Relaxed consultations:

• Patients felt relaxed, and perceived their doctors to be

More than medicine:

• Recognising and dealing with the social issues directly impacting health

Analysis is being carried out to see whether the psychological needs of competence, autonomy and relatedness can help explain presence or absence of change in this patient group.

Consequences

Understanding patient experience of CAREplus allows further refining of the initiative, as well as clarifying what is valued by this patient group.

Analysis of the scripts using an SDT framework will clarify whether this theory helps explain presence or absence of change for patients with multimorbidity in areas of high socio-economic deprivation.