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Goal-setting within rehabilitation is a common practice ultimately geared toward helping patients make functional progress.
The purposes of this study were to (1) qualitatively analyze data from a wellness program for patients with spina bifida (SB) and spinal cord injury (SCI) in order to generate software requirements for a goal-setting module to support their complex goal-setting routines, (2) design a prototype of a goal-setting module within an existing mobile health (mHealth) system, and (3) identify what educational content might be necessary to integrate into the system.
A total of 750 goals were analyzed from patients with SB and SCI enrolled in a wellness program. These goals were qualitatively analyzed in order to operationalize a set of software requirements for an mHealth goal-setting module and identify important educational content.
Those of male sex (
Innovative mHealth tools can be developed to support commonly set goals by individuals with disabilities.
Goal-setting within rehabilitation is a common practice ultimately geared toward helping patients make functional progress. Goal-setting has been explored within many different conditions relevant to rehabilitation. For example, it has been used in pediatric rehabilitation [
Motivation of patients can be critical in promoting and maintaining behavioral change. According to self-determination theory (SDT), a theory of motivation that has been applied to multiple domains, including the health domain, several key psychological needs individually and cumulatively promote behavioral change [
Over 20 years after Schut and Stam’s landmark article, controversy still exists over the most efficacious tools for increasing motivation and maintaining behavior change. The Functional Independence Measure is a well-known tool widely used in inpatient rehabilitation facilities and is used to track progress with functional activities [
We used our own approach to goal-setting within a wellness intervention consisting of a nurse case manager and an evidence-based protocol for the treatment and prevention of secondary conditions in individuals with spina bifida (SB) and spinal cord injury (SCI) [
The use of electronic tools has been suggested as a way to effectively engage patients in goal-setting [
Our ultimate goals in this study were to:
Qualitatively analyze the goals set by patients with SB and SCI in a wellness program to generate a list of software requirements for a goal-setting module within iMHere. Specifically, to accomplish this task we wished to answer several research questions:
What functionalities would be needed in a goal-setting module in order to support the various types of goals that people with SB or SCI desire to achieve?
What are the most common themes that describe the goals that people with SB and SCI set for themselves?
Is achievement of goals related to patient factors or characteristics of the goals?
Design a basic goal-setting module within iMHere, based on the PSFS.
Identify the educational needs of our target population to determine what content is important for the educational module within iMHere.
This study was approved by the University of Pittsburgh Institutional Review Board. All research participants signed informed consent in order to participate. This study was a subcomponent of a larger, parent study reported previously in more detail [
After the study was complete, all goals set by participants were first reviewed by one investigator and coded according to
A Cronbach alpha level of
A total of 69 individuals with SB and SCI were consented; 4 were excluded for failing to meet inclusion criteria or withdrawing before baseline data could be collected. The remaining 65 participants enrolled in the intervention. Of those 65 participants, 50 completed a wellness plan. Goal data from these 50 participants who completed a wellness plan were included in this study. A total of 24 participants (48%) were female; 26 participants (52%) were male. Furthermore, 37 (74%) had SB; 13 (26%) had SCI. Average age was 38.7 (SD 14.1) years. Additional demographic data obtained from the parent study can be found in the prior publication [
Fifteen goals (5 short term, 5 long term, and 5 maintenance goals) from each of the 50 individuals were analyzed, for a total sample of 750 wellness goals.
Of the 750 wellness goals, 15 themes were identified.
Based on the types of goals that participants selected, investigators identified three methods that were used to help participants and the nurse track progress toward achieving those goals.
Checklist: 24% of goals involved a simple checklist indicating whether or not the event or aim was achieved. This type of goal would need to be manually “checked off” the list.
A single task that occurs at one point in time (eg, scheduling an appointment with a neurologist).
A task that begins but then is an ongoing event after the task is accomplished. The goal focuses on the initiation of the task, not monitoring continued compliance with the task (eg, beginning to wear wrist splints for carpal tunnel syndrome).
A goal that is focused on an outcome with no specific date attached (eg, achieve employment, or stop smoking).
A goal focused on the initiation of a behavior (eg, begin to seek employment).
Achieving a situation in which the person is “free of a certain condition” (eg, achieve intact skin, free of pressure ulcers). This type of goal was discouraged because it may be difficult to achieve even if a participant is compliant with treatment, but nonetheless, participants chose some of these goals.
A situation that arises only under certain circumstances (eg, if skin breakdown occurs, participant will notify a clinician).
“As needed” goal (eg, participant will take a medication for pain when it is needed).
Data-tracking: 48% of goals involved recording data sequentially over repeated time intervals. This type of goal would be achieved if the value of the data fell within a certain range, achieved a threshold value, or reached a threshold by a specific date.
Achieving or maintaining certain health parameters (eg, goal to achieve a target weight or maintain blood pressure within specific parameters).
Achieving or maintaining a certain goal for health activities (eg, intake a specific amount of fruits, vegetables, fluid, protein, or sodium).
Achieving a degree of compliance with self-management activities that occur at a certain frequency (eg, skin checks, exercise regimen, medications, appointments, or bladder or bowel program).
Achieving a specific goal by a certain date (eg, reach target weight by the participant’s birthday).
Fact-finding: 28% of goals involved recalling specific facts or finding information about topics that can impact health, promote health outcomes, and prevent secondary complications.
Recalling specific knowledge (eg, being able to identify the signs and symptoms of skin breakdown or urinary tract infections, foods that are more appropriate in diabetes, or foods low in sodium).
Seeking a reference that will serve as a blueprint for future action (eg, finding an exercise program that can be performed while in a wheelchair, or finding information about housing).
Goal themes.
Goal theme | Description of theme | Total |
Proportion of total goals (%) |
Diet | Improve or maintain caloric intake, make good food choices, or reach a weight loss goal through diet | 108 | 14.4 |
Bladder/Bowel | Maintain or improve continence, recognize important signs or symptoms, adhere to a prescribed regimen for bowel or bladder care or appointments | 102 | 13.6 |
Exercise | Improve or maintain physical activity amount, quality or frequency, or to reach a weight loss goal through exercise, adhere to prescribed physical therapy regimen, identify adaptive exercises | 100 | 13.3 |
Skin | Be more compliant with prescribed skin care regimens or proper use of wheelchair equipment with the goal of preserving skin integrity or healing an open wound | 95 | 12.6 |
Appointments | Track and maintain or improve adherence to medical appointments | 64 | 8.5 |
Other/Medical | Adhere to care prescribed by primary care physician, gynecologist or other specialist, manage lymphedema | 55 | 7.3 |
Medications | Track and maintain or improve adherence to medication schedule, learn about medications | 52 | 6.9 |
Equipment | Maintain, acquire, or properly use assistive technology and orthoses for mobility or self-management | 48 | 6.4 |
Other/Non-Medical | Participate in home and community activities | 39 | 5.2 |
Work/School | Acquire or maintain employment, participate in vocational rehabilitation or school activities | 23 | 3.1 |
Cardiovascular risk factors | Blood pressure and diabetes control, smoking reduction/cessation | 16 | 2.1 |
Mood/Sleep | Identify methods or coping mechanisms to improve mood or restful sleep, follow recommendations of psychologist or psychiatrist, practice better sleep hygiene | 14 | 1.9 |
Weight loss | Achieve a desired target weight without specifying the plan to do so | 14 | 1.9 |
Pain | Prevent, reduce or maintain pain thresholds or be compliant with prescribed pain regimens | 12 | 1.6 |
Driving/ Transportation | Acquire or properly use assistive technology for driving or transportation, acquiring a license or skills needed to drive | 8 | 1.1 |
Detailed display regarding how goal theme was related to gender, goal type and goal classification.
Goal theme | Sex | Goal temporality | Goal type | ||||||||
Total number | Female |
Male |
Short-term |
Long-term |
Maintenance | Data tracking | Fact finding | Checklist | |||
Diet | 108 | 51 | 57 | 46 | 48 | 14 | 49 | 57 | 2 | ||
Bladder/Bowel | 102 | 50 | 52 | 45 | 19 | 38 | 29 | 43 | 30 | ||
Exercise | 100 | 50 | 50 | 23 | 42 | 35 | 70 | 26 | 4 | ||
Skin | 95 | 38 | 57 | 59 | 12 | 24 | 24 | 38 | 33 | ||
Appointments | 64 | 34 | 30 | 8 | 5 | 51 | 59 | 0 | 5 | ||
Medications | 52 | 28 | 24 | 6 | 2 | 44 | 47 | 3 | 2 | ||
Equipment | 48 | 20 | 28 | 15 | 28 | 5 | 25 | 6 | 17 | ||
Other | 181 | 89 | 92 | 48 | 94 | 39 | 54 | 40 | 87 | ||
Total | 750 (100%) | 360 (48%) | 390 (52%) | 250 (33%) | 250 (33%) | 250 (33%) | 357 (48%) | 213 (28%) | 180 (24%) |
Themes of the fact-finding goals which identify educational needs.
Theme | Details |
Skin integrity | Signs and symptoms of skin breakdown and wound infection; areas at risk for skin breakdown; how to prevent skin breakdown; importance of position changes; equipment affecting skin breakdown |
Bowel/bladder | Signs and symptoms of urinary tract infections; basics of a bowel program; benefits of a bowel program |
Shunts | Signs and symptoms of shunt malfunction |
Medication | Identify the indication for each medication |
Diet | Basics of good nutrition; nutrition foods; information on “my healthy plate” or food pyramid; proper portion sizes or portion control; foods to help meet the daily energy requirement; recommendations on fluid intake; whole and wholesome foods versus junk foods or empty calories; nutritious foods high in protein to promote wound healing |
Exercise | Benefits of exercise; how to start an exercise program; exercises that can be performed in a wheelchair; exercises that can be performed at home |
Sleep | Sleep hygiene; techniques to promote restful sleep |
Pain | Alternatives to pain medications; techniques to promote pain control; common over-the-counter medications for pain |
Weight control | Benefits of weight control; risks of being overweight |
Mood | Relaxation techniques; techniques to improve mood; coping techniques |
Smoking | Effects of smoking on health and on circulation; effects of smoking on skin breakdown or wound healing |
Of the 750 total wellness goals, 669 (89%) were achieved; 81 (11%) were not achieved. Furthermore, 20 out of 50 participants (40%) achieved all of their goals, and 42 participants (84%) achieved at least 13 out of 15 goals (87%). Eight individuals accounted for 67% of the goals that were not achieved. There was a significant difference in achievement of goals based on sex (
Shorter temporality of the goal coincided with a higher likelihood that the goal would be achieved. Almost all goals surrounding fact-finding were achieved. There was no significant difference in achievement based on goal theme (
Achievement of goals according to various factors.
Factor | Achieved | Total number | Percent achieved (%) | Not achieved | |||||
669 | 750 | 89 | 81 | ||||||
Female (24 people) | 311 | 360 | 86 | 49 | |||||
Male (26 people) | 358 | 390 | 92 | 32 | |||||
SB (37 people) | 479 | 555 | 86 | 76 | |||||
SCI (13 people) | 190 | 195 | 97 | 5 | |||||
Short-term | 246 | 250 | 98 | 4 | |||||
Long-term | 222 | 250 | 89 | 28 | |||||
Maintenance | 201 | 250 | 80 | 49 | |||||
Diet | 102 | 108 | 94 | 6 | |||||
Bladder/Bowel | 93 | 102 | 91 | 9 | |||||
Exercise | 89 | 100 | 89 | 11 | |||||
Skin | 87 | 95 | 92 | 8 | |||||
Appointments | 58 | 64 | 91 | 6 | |||||
Medications | 45 | 52 | 87 | 7 | |||||
Equipment | 43 | 48 | 90 | 5 | |||||
Other | 152 | 181 | 84 | 29 | |||||
Data tracking | 312 | 357 | 87 | 45 | |||||
Fact finding | 210 | 213 | 99 | 3 | |||||
Checklist | 147 | 180 | 82 | 33 |
Participants chose gift cards as incentives for achieving goals. The most popular preference was for healthy dining or groceries at 41.2% of participants, followed by 27.7% opting for entertainment, 12.4% for general retail, and 11.3% for clothing or personal care. Only 4.5% of participants chose gift cards catering to home improvement, and 2.8% chose gift cards for gasoline.
Based on the cumulative results, a list of software requirements was developed:
Patient can select a goal functionality (checklist, data tracking, or fact-finding) when creating a goal
Patient can generate a checklist of multiple goals
Patient can choose from a default list of common goals or create his or her own goals
Patient can record whether a goal was achieved or is in progress
Patient can self-report progress toward achieving each goal
App can auto-populate goals with data to show progress in goal-achievement
Patient can record goals that are related to obtaining and understanding educational material
Caregiver, peer or clinician can view goals of a patient and provide encouragement
Caregiver, peer or clinician can suggest goals to patient
Patient can choose designees who are able to access and modify goals
Goals should be linked to deadlines or calendars
App should provide tips on goal-setting
A goal-setting module was created for iMHere, based on the PSFS (see
Prototype of goal-setting module for iMHere.
To our knowledge, this is the first study to examine patient goals in an effort to develop more robust mHealth tools that support goal achievement in self-management. We successfully developed a goal-setting module based on the PSFS. We also identified three functionalities that may possibly help users track and achieve goals when using mHealth systems.
About one-quarter of the goals required the functionality of a checklist. The checklist is a simple tool that has been shown to produce improved outcomes in a number of health-related and other disciplines [
Approximately half of the goals required ongoing tracking of progress toward meeting that goal. On the PSFS, patients are asked to rate on a scale how well they subjectively feel they are accomplishing their goal. However, within mHealth systems, it is now possible to collect, analyze, and display summary data back to the user as a way to “automate” the tracking of progress toward a goal. Data collected and displayed in this manner can be self-reported data or objectively gathered data. For example, in the current version of iMHere, users are able to report on a regular basis whether they have been taking each of their medications. In future versions of iMHere, data on self-reported compliance with medications will be displayed back to the users as a bar graph to indicate how often the users indicated they took medications over a period of a week or a month. Objectively gathered data can also be collected from peripheral devices. For example, activity monitors connected to future versions of iMHere will be used to show users how well they are meeting a physical activity goal.
The remaining goals involved recalling specific facts or finding information about health topics. Tracking achievement of a fact-finding mission can be accomplished with a checklist. Because almost all fact-finding goals were achieved, it is possible that participants chose fact-finding goals that were “easy” to achieve; therefore, more complex checklists or other functionalities may be needed if a patient would choose a more complex fact-finding goal that has multiple steps within it. Recall of specific information from materials accessed could be evaluated through a quiz. In the current version of iMHere, an educational module presents medical information relevant to a user’s health and also provides quizzes about that information. A future version of iMHere will link the educational quizzes to the goal-setting feature. A goal of our study was to identify the educational needs of our target population to determine what content is important for the educational module within iMHere. Based on the fact-finding goals set by participants, we will be building educational content to support themes identified in
The data collected on themes of goals set by participants were useful in several ways. First, the data validated the importance of modules that have already been developed for iMHere (medication management, bowel management, bladder management, skin integrity, and mood). Second, the data generated development ideas for modules for other important health domains such as diet, exercise, weight management, appointment scheduling, tracking needs for items such as wheelchairs or adaptive driving, vocational and school activities, pain, and sleep. In this study, the theme with the largest representation of goals was diet. Therefore, it is not surprising that the gift cards participants selected for meeting those goals included options for healthy eating or purchasing groceries. Thus, a third concept that emerged was that specific incentives could be linked to types of goals achieved. Finally, data helped inform what types of goals could be included as “default” goals from which patients can select.
Achievement of goals was related to several factors. Individuals with SB and females achieved fewer goals than those with SCI and those of male sex. It may be that those with SB or females set goals that were lofty and therefore more difficult to achieve, they were less motivated to achieve their goals, or they had greater medical complexity, making goal achievement somewhat more difficult. More work is needed on larger samples to understand the factors that contributed to goal achievement. It was not surprising that short-term goals were achieved more often than long-term goals, since the participants tended to set more easily achievable activities as the short-term goals. Despite having some degree of impairments in executive function [
Based on the variety of goals set and lessons learned from the clinical trial, we also identified other features that are important in creating goal-setting features in mHealth. First, a clear need exists for patients, clinicians, and even caregivers to be involved in the goal-setting process. Caregiver goals may be quite different from the goals of the persons they assist [
The results of this study inform the software requirements for the graphical user interface of the iMHere goal-setting module. Several design changes will be made in order to meet these requirements. First, when entering a new goal, the patient will be able to: (1) select a goal functionality (checklist, data tracking, or fact-finding), which will determine how the app will track user progress toward achieving the goal, (2) choose one or more individuals (eg, user, clinician, caregiver) who will be responsible for independently determining whether the goal was achieved, and (3) choose supporters (eg, caregivers or peers) who are able to provide encouragement. Second, the goals will be marked as “in progress” by default until they are marked as “achieved” by a patient or his or her designee. Third, patients or designees will be able to enter a goal by typing as free text or choosing from a list of common “default” goals categorized by themes in
A few limitations of this study deserve discussion. Our sample was limited to SB and SCI. External validity of this study is therefore limited to these populations. However, some findings may be relevant or translatable only to those particularly interested in engaging in health promotion activities. Our sample was also small; however, due to the large number of goals set by each participant, a large amount of goal-setting data was collected. One limitation of the parent study is that it lacked a control group. Because it was a clinical program, it was not possible or ethical to randomize participants into a group that did not receive these services. We therefore designed the parent study as a cohort trial and used intention to treat analysis, given the increasing popularity of integrated delivery systems and clinical utility of pragmatic research designs.
In future work, more complex functionalities could be added to the software, such as stakes (eg, consequences for not achieving the goal such as peers being notified), suggestions for brainstorming barriers (eg, option to contact clinician for help, extend deadline, or delete goal), and ability to opt into participating in socially persuasive group challenges, or pre-built goal modules that are designed around best practices (eg, workflow that guide the user how to conduct an evidence-based pressure ulcer prevention program). We plan to study the goal-setting module with patient, caregiver, and clinician users in future usability and feasibility trials.
In conclusion, lessons learned from analyzing wellness goals of participants with SB and SCI have been distilled into recommendations intended to help spearhead future development of iMHere. Goal-setting features in mHealth apps such as iMHere may be able to aid individuals in creating, pursuing, and achieving their wellness goals.
Interactive Mobile Health and Rehabilitation
mobile health
patient specific functional scale
spina bifda
spinal cord injury
self-determination theory
The contents of this publication were developed under a grant from the University of Pittsburgh Medical Center (UPMC) Health Plan, the UPMC Rehabilitation Institute Pilot Grant, the National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR grant numbers 90DPGE0002-01-01, 90DP0064-01-00, and 90DP5004-01-00) and the Craig H. Neilsen Foundation. NIDILRR is a Center within the Administration for Community Living (ACL), Department of Health and Human Services (HHS). The contents of this publication do not necessarily represent the policy of NIDILRR, ACL, HHS, and you should not assume endorsement by the Federal Government.
Drs Dicianno and Parmanto are inventors of the iMHere mHealth system.