A constipation intervention program for PD patients based on a combination of the Health Action Process Approach and nudge strategies is scientifically sound
Through a literature review and two rounds of expert correspondence, the theoretical basis and basic framework of a constipation intervention program for PD patients combining the Health Action Process Approach and nudge strategies were identified in this study, and the significance and feasibility of the intervention program were determined. The correspondence work demonstrated that the experts had rich clinical practice experience as well as authority and representativeness by 15 experts from clinical and university settings, all with rich working experience, 13 (86.67%) with associate senior titles and above, 12 (80.00%) with master's degrees and above, and 12 (80.00%) with ≥ 15 years of working experience in neurology-related fields. The expert correspondence results revealed that the experts’ authority coefficient Cr in both rounds was greater than 0.7, indicating that the experts had a high level authority and were scientific. In the two rounds, the recovery rate of expert questionnaires was 93.8% and 100%, respectively, and the rate of expert opinions raised was 80.00% and 20.00%. This demonstrates that the experts are highly motivated. The Kendall's W for the importance rating of the two rounds of expert correspondence was 0.313 and 0.421, respectively, with coefficients of variation of 0.25 for each item, indicating that the experts' opinions tend to be consistent and the correspondence results are more scientific.
Practicality of a constipation intervention program for PD patients based on a combination of the Health Action Process Approach and nudge strategies
One study emphasized the importance of focusing on the management of non-motor symptoms in patients with PD, including non-pharmacological treatment, personalization, and long-term general practice management[24]. In this study, we used a combination of the Health Action Process Approach and nudge strategies to design an intervention program for improving constipation in PD patients, taking into account the disease characteristics of PD as well as the patients' own characteristics, including interventions in the pre-intentional, intentional, and action phases, with the intervention program built using the MINDSPACE strategy framework in nudge[20].
(1) Pre-intention stage of the intervention program. This phase of the intervention program primarily uses initiation and information support from the strategy framework to prompt patients to form an intention to improve constipation. Constipation symptoms in PD are complex, persistent, and difficult to treat when compared to functional constipation[25]. This program provides health education to PD patients and their families through prominent and directed information, such as cases, videos, and pictures, with the goal of assisting patients and families in correcting incorrect disease perceptions, generating correct disease perceptions, increasing alertness to disease perceptions, and encouraging patients to form intentions to improve constipation. Prior to being diagnosed with PD, some patients with constipation symptoms tend to disregard the importance of proper diagnosis and treatment, delaying the disease and causing a burden on individuals, families, and society[26]. As a result, it is critical to improve patient cognition at this stage, which is important for disease diagnosis and treatment.
(2) Intention stage of the intervention program. In this phase, intervention programs primarily use salience in the nudge strategy to strengthen patients' intentions to improve constipation. Non-pharmacological treatment of constipation in PD patients begins with lifestyle changes, including dietary changes and changes in daily activities[13]. Individualized action plans and coping plans involving diet, exercise, and lifestyle interventions are developed in this program, with the individual preferences and needs of patients with PD in relation to their condition and constipation taken into account. It also strengthens or reinforces patients' intentions to improve constipation by sharing role models or norms among patients and encouraging patients to make public commitments. In this program, patients and family members are introduced to PD diet, exercise, and defecation through the application of targeted, salient information; recommended, authoritative PD treatment modalities and types of anti-Parkinsonian drugs, their usage and precautions, and timely psychological care, so that they have targeted, detailed knowledge required for PD treatment and care, do not become too ill to seek treatment, and relieve anxiety and depression. At this stage, the emphasis is on improving the acceptance of relevant information by patients with PD and their families, stimulating the motivation for behavior change in order to reduce care dependence, and nudging the realization of improving constipation and healthy behavior in patients with PD.
(3) Action stage of the intervention program. This stage of the intervention program focuses on motivating people with PD to develop, maintain, or restore health behaviors that improve constipation, primarily through the use of self-image and motivation in nudge strategies. Constipation symptoms are complex, difficult to treat, and difficult to improve during hospitalization due to the long course of PD. As a result, post-discharge care is crucial for patients with PD constipation. This phase encourages patients to develop and maintain healthy behaviors to alleviate constipation by gradually guiding them to perceive the benefits of self-behavior changes and communicating with them on a regular basis to build or restore their sense of self-efficacy. Patients with PD constipation have a high incidence of depression[27], and this program encourages and provides emotional support to patients on multiple occasions by utilizing the Affective Support (Affect) strategy in MINDSPACE to help them improve their cognitive understanding of the disease and help them build confidence in overcoming the disease; encourage patients to participate in social activities and play the social roles they want to become to achieve their goals. Simultaneously, health education and guidance were provided to the patients' families, encouraging them to strengthen the patients' company, create a peaceful family atmosphere, inform the importance of respecting the patients' habits and personality, and providing timely and adequate emotional support to the patients. This phase of the intervention program was more focused on the patients' psychological needs and spiritual care, assisting patients with PD to improve their constipation health behaviors and thus their quality of life.
The intervention program for constipation in PD based on a combination of the Health Action Process Approach and nudge strategies emphasizes assessment, guidance, and support for patients, and is practical in that it promotes the transformation of patients from passive to active behavior and improves their self-efficacy through small, minor strategies based on the formation of patients' health behavior intentions. Therefore, through literature review and expert correspondence, this group developed this program by combining the characteristics of non-motor symptoms (gastrointestinal dysfunction) of PD and the needs of patients, in order to provide some reference basis for improving constipation symptoms and practical clinical care for patients with PD.