The Internet-Based Intervention Strategies for Empowering Activities in Everyday Life: Qualitative Study of Experiences of Clients With Stroke.

BACKGROUND: There is a need to enhance access to and support for self-management of activities in everyday life after a stroke. Internet-based solutions have the potential to contribute to this development. Consequently, an internet-based intervention called Strategies for Empowering Activities in Everyday Life (SEE) was developed. The intervention aims to assist clients in developing management strategies that promote a healthy distribution and balanced engagement in various activities performed in different places and with other people. To further support the development and feasibility of this intervention, more knowledge is needed about clients' experiences during the intervention process. OBJECTIVE: This study aims to explore and describe how clients with stroke experienced the SEE intervention process and whether participation in SEE influenced their experience of everyday life. METHODS: Overall, 9 clients with stroke who received SEE participated in the study-4 (44%) women and 5 (56%) men aged 37 to 73 years. Qualitative interviews about experiences with SEE were conducted twice during the intervention process with each participant. The data were analyzed using the constant comparative method of grounded theory. RESULTS: The participants' experiences with the intervention process of SEE formed the core category, conceptualized as The relevance of and readiness for entering a change process in activities of everyday life differ among clients, constituting of two main categories: (1) an eye-opener providing agency for a change process and (2) never beginning a change process in activities in everyday life. The results showed that the relevance of and readiness for SEE differed between the participants. The experiences of 78% (7/9) of the participants reflected that the intervention process provided them with an agency to drive their own change process for activities in everyday life to promote health. Overall, 22% (2/9) of the participants refrained from entering a change process during SEE as they did not recognize any need for changes in their activities. When SEE was relevant and adopted as expected, the participants described it as an eye-opener for how they can alter their health based on how they distribute and spend their time on various activities. CONCLUSIONS: SEE has the potential to support clients' development of self-management and to take an active role in influencing their engagement in activities in everyday life and health. This study identified necessary improvements in the educational program for professionals to enhance delivery and strengthen the therapeutic mechanisms of SEE for future research. To effectively implement internet-based interventions such as SEE, it is crucial to identify clients who express a need for self-management in activities and are ready to invest the effort required to adopt a change process. Furthermore, it is indicated that participants' self-analysis of their everyday activities empowers them to adopt new self-management strategies, which can also benefit other interventions.

Employer representatives' experiences of supporting employees with cognitive impairments in a digital work environment.

BACKGROUND: Digital work poses cognitive demands on all employees, but the impact is greater for employees with cognitive impairments. Digitalization also has significant implications for employer representatives as they are responsible for the work environment. However, knowledge is scarce concerning employer representatives' perspectives on identifying needs and support for employees with cognitive impairments working in a digital work environment. OBJECTIVE: To describe employer representatives' experiences of work environment management with focus on employees with cognitive impairments working in a digital environment. METHODS: Focus group methodology was used. Six employer representatives with work environment responsibilities participated. RESULTS: One overall theme "Mastering the interconnected processes in a transformative digital work environment" as well as three themes "Facilitating good digital work conditions", "Identifying needs and difficulties in work tasks among employees' with cognitive impairments" and "Pursuing knowledge and collaborations to support employees with cognitive impairments" with subthemes were identified. The themes describe employer representatives' challenges and efforts to identify fluctuating needs in employees with cognitive impairments and, also, to organize and reduce cognitive demands in the work environment to support them. CONCLUSIONS: Managing the challenges of an evolving digital work environment and matching individual work ability of employees with cognitive impairments in relation to cognitive demands is an ongoing process. The participants valued cooperation with employees with cognitive impairments but lacked support from expertise. The need to develop and implement a functioning support system for vocational rehabilitation to ensure a sustainable work in digital work environments is indicated.

Developing and testing the feasibility of a new internet-based intervention-A case study of people with stroke and occupational therapists.

INTRODUCTION: Internet-based interventions are called for within rehabilitation to meet the limited access to support for self-management after stroke. Therefore, a new intervention program, "Strategies for Empowering activities in Everyday life" (SEE) was developed. The aim of this study was to explore and describe how clients with stroke and their occupational therapists experienced the SEE intervention process and whether SEE has the potential to promote an active everyday life. METHODS: A qualitative descriptive case study was designed. Four people with stroke (two of each sex, mean age 66,5 years) and their two occupational therapists (one of each sex) were included. A mix of data collection methods as interviews, assessments, registration forms and fieldnotes was used to uncover the participants' experiences and potential changes. Data were analysed with pattern matching. FINDINGS: The analysed data formed three categories: "Not being able to take on the internet-based intervention", "Being facilitated in the change process of everyday life through the internet-based intervention", and "Providing a new internet-based intervention is a transition from ordinary practice". These categories included two to four subcategories that reflected aspects of SEE feasibility and acceptability with a focus on content and delivery. CONCLUSION: The first test of the intervention indicates that the content and delivery of SEE can be feasible and acceptable both for clients and occupational therapists. The findings suggest that SEE has the potential to support clients' self-reflections and their adoption of strategies that influence engagement in daily activities and satisfaction with life in various ways. Further research with large-scale studies is needed.

Making choices in digital play spaces: Children's experiences.

BACKGROUND: Digital spaces are rapidly emerging as a space for children to engage in autotelic play. AIM: To explore and describe children's experiences of choice-making in their play in digital spaces from the perspective of children themselves. METHODS: Focus groups were conducted with a total of eight children aged six years of age within their school, in a large city in Ireland. A Mosaic Approach with drawing, cutting, and colouring in was used to elicit the children's voices to ensure their active engagement throughout the data collection. Data was analyzed using focus group analysis. RESULTS: Data analysis revealed three main themes; children enjoy the ability to make choices in their play, that they are often constrained in their ability to make choices, and that they negotiate ways in which they can select options for play in digital spaces. CONCLUSIONS: Findings indicate that children are agentic individuals who are capable of making decisions in their play in digital spaces. This knowledge provides implications for Occupational Therapists to enhance play as an occupation in digital spaces.

Experiences with continuous quality improvement work based on the Occupational Therapy Intervention Process Model.

BACKGROUND: Sustainability is an important issue in implementation processes in health care, and more knowledge is needed to facilitate improvement work in occupational therapy practice. AIM: The aim of this study was to explore how occupational therapists experienced continuous quality improvement work based on the Occupational Therapy Intervention Process Model after 17 years. METHOD: Two focus group interviews were conducted with a total of 12 occupational therapists. The data were analysed using qualitative content analysis. RESULTS: The analysis resulted in three themes with related subthemes describing the occupational therapists' experiences of their model-based long-term improvement work. The themes were labelled as follows: 'sharing a safe and well-known professional reasoning', 'reaching normality and empowerment' and 'questioning and reshaping the too safe and too well-known normality'. The model functioned as a sustainable framework both for ordinary clinical practice and for continuous improvement work. CONCLUSION: By using the model, the occupational therapists had established a safe and well-known professional reasoning in which continual quality improvement work had become sustainable.

Children's experiences of play in digital spaces: A scoping review.

The United Nations Convention on the Rights of the Child has substantiated play for play's sake, thus focusing on the doing or being of play rather than any potentially desired outcomes. Examining this type of play from the perspective of the child acknowledges children as meaning-makers. A scoping review was conducted to expose and map the extent of the evidence available in the emerging and diverse field of children's experiences of play in digital spaces. Specifically, the literature was examined with regards to relevance to children's everyday lives, the personal and ecological relevance, and the methods used. A systematic search of the literature over the past fifteen years found thirty-one articles appropriate for inclusion. The analysis of the literature revealed that the articles formed four categories of how play in digital spaces was approached: 'Videogames, behaviours, and societal norms', 'Videogames for its own sake', 'Videogames for learning', and 'Active Videogames for health promotion'. This scoping review has identified a lack of articles focusing on children's experiences of play in a digital space, and these perspectives are essential for parents, professionals, game designers, and policymakers alike to contribute to an enhanced understanding of the role of play in digital spaces.

Team-based rehabilitation after traumatic brain injury: a qualitative synthesis of evidence of experiences of the rehabilitation process.

OBJECTIVE: To synthesize and explore experiences of the rehabilitation process for adults with traumatic brain injury receiving team-based rehabilitation. DATA SOURCES: A qualitative evidence synthesis was conducted according to the "Enhancing transparency in reporting the synthesis of qualitative research" (ENTREQ) Guidelines, of qualitative studies published in 5 databases in 2000-21. STUDY SELECTION AND DATA EXTRACTION: Screening, selection of relevant studies, assessment of methodological limitations, systematic qualitative content analysis and assessment of confidence with Grading of Recommendations Assessment, Development, and Evaluation- Confidence in the Evidence from Reviews of Qualitative research (GRADE-CERQual) were carried out by independent researchers. DATA SYNTHESIS: The 10 included studies revealed how people with traumatic brain injury perceived that they struggled on their own for a long time to adapt their daily life. They experienced that access to team-based rehabilitation was scarce and that the interventions offered were neither individually tailored nor coordinated. A respectful attitude from professionals and individually adapted information facilitated their rehabilitation process. CONCLUSION: This qualitative evidence synthesis indicates areas for improvement and a need to develop person-centred team-based rehabilitation for adults with traumatic brain injury, in terms of accessibility, coordination, continuity, content and participation. Given the limited opportunities for team-based rehabilitation after hospital discharge, further research is needed to understand how rehabilitation can support the adaptation of everyday life.

Self-initiated management approaches in everyday occupations used by people with acquired cognitive impairment.

BACKGROUND: Striving to cope with day-to-day challenges is a basic human behaviour. Self-initiated management approaches provide a resource that has yet to be discovered and systematically used in occupational therapy practice. This resource might be especially important for people with dementia who are less likely to adopt management approaches initiated by others. AIMS/OBJECTIVES: Based on the findings of former studies on management and problem-solving actions among people with cognitive impairment, this article aims to identify and categorize the study participants' self-initiated management approaches and how these may be manifested in strategies in everyday occupations. MATERIAL AND METHODS: The study utilized a form of meta-synthesis; an aggregated analysis, where findings from 11 studies published 2004-2020 were compared and categorized, incorporating the views of participants with dementia/mild cognitive impairment, or acquired brain injury. RESULTS: Thirty strategies were identified and grouped into seven categories of management approaches, used in a variety of everyday occupations and situations. A majority of the strategies were found in both populations, suggesting that management approaches are more similar than different across populations with cognitive impairment. CONCLUSIONS AND SIGNIFICANCE: Attending to the rich variation of self-initiated management approaches/strategies among persons with cognitive impairment offers possibilities for developing occupational therapy interventions.

Optimising the development of sustainable internet-based occupational therapy interventions: Important key actions and perspectives to consider.

BACKGROUND: By examining the health needs of the general population and utilising the potential of digitalisation as a driving force, new internet-based services need to be developed in occupational therapy. However, existing guidelines for the development of complex interventions provide scant information on how to develop internet-based interventions. AIM: The aim of this paper is to share experiences and illustrate important key actions and new perspectives to consider during the innovation process of developing and designing an internet-based occupational therapy intervention. METHOD AND MATERIALS: International guidelines for intervention development was reviewed to add important perspectives in the innovation process. RESULTS: The illustration focuses on five key actions in the development phase to highlight new perspectives and questions important to consider when designing new internet-based occupational therapy interventions. CONCLUSION: The new perspectives can complement existing guidelines to enhance the development of more effective and sustainable internet-based interventions. SIGNIFICANCE: The illustration provided has potential to improve the sustainability in innovation processes of new internet-based occupational therapy interventions.

Work and everyday life in a digitalized time: Experiences of people with subjective cognitive difficulties related to neurological disorders.

INTRODUCTION: Digitalization has changed working life and increased cognitive demands on employees in general. Nevertheless, the consequences for employees with cognitive impairments and subjective cognitive difficulties are to a large extent unexplored. The aim of this study was to explore and describe how employees with subjective cognitive difficulties who are performing digital work tasks experience their vocational situation and how this situation influences their everyday life. METHODS: A qualitative, descriptive, multiple-case study was designed. Self-reports, assessments and qualitative interviews were used to collect data from the seven participants with neurological disorders. The data were analysed using pattern matching. FINDINGS: The analysed data formed four categories conceptualized as "Working to my full potential", "Working, but it is largely up to me", "Working at the expense of everyday life" and "Working without known difficulties", and these categories included one to four subcategories. CONCLUSION: Managing subjective cognitive difficulties in vocational situations and everyday life was challenging in a digitalized working life for participants with neurological disorders. To provide equal access to preventive measures and rehabilitation and a sustainable working life, it is important to investigate the influence of subjective cognitive difficulties systematically on work, everyday life and management strategies in people with neurological disorders in digitalized work.

Strategies for Empowering activities in Everyday life (SEE 1.0): study protocol for a feasibility study of an Internet-based occupational therapy intervention for people with stroke.

BACKGROUND: Rehabilitation after stroke seldom focuses on needs related to an active everyday life and the process of change that people must undergo to adapt to an altered capacity and life situation. In particular, occupational therapy in the late phase needs to support clients in adopting sustainable self-initiated management strategies to regain daily activities and an active everyday life. To improve access to rehabilitation, the use of digital solutions has been suggested. This study aims to evaluate the feasibility of the Internet-based occupational therapy intervention "Strategies for Empowering activities in Everyday life" (SEE, version 1.0). We will investigate the feasibility of the intervention process in terms of acceptability and adherence as well as the most suitable outcome measures to evaluate SEE and improve the knowledge about the potential changes and outcomes of SEE for clients with stroke. METHODS: This feasibility study is based on a pretest posttest design without a control group. Quantitative and qualitative data will be collected from clients and staff concurrently embedded in a mixed-method design during the entire study. DISCUSSION: The project is a first test of a novel Internet-based occupational therapy intervention, and the research will contribute to the continued development and evaluation of the SEE programme. SEE can provide people with strategies in daily activities that can support them to live an active everyday life despite changed capacity and to improve access to rehabilitation interventions. TRIAL REGISTRATION: NCT04588116 . Name of the registry: Strategies Empowering Activities in Everyday Life (SEE 1.0). A Web-based Occupational Therapy Intervention. URL of trial registry record. Date of registry: Trial first posted: October 19, 2020; first submitted: October 2, 2020.

Perceived occupational balance in people with stroke.

BACKGROUND: The balance of activities in daily life can become disrupted after a stroke; however, previous research has mainly focused on the performance of daily activities. Therefore, it is important to understand the impact that stroke has on various aspects of balance in activities for working-age people. PURPOSE: To describe how persons with stroke perceived their occupational balance and to explore whether occupational balance was associated with the severity of disability, fatigue and sociodemographic characteristics. METHODS: This cross-sectional study included 63 working-age persons with stroke. The Occupational Balance Questionnaire, Glasgow Outcome Scale and Fatigue Severity Scale were used and analyzed statistically. RESULTS: The majority of participants disagreed or strongly disagreed that they perceived occupational balance in most of the investigated aspects. Moreover, few significant associations were found between total summed occupational balance and injury and sociodemographic characteristics. CONCLUSION: These results demonstrate the importance of considering occupational balance in the rehabilitation of persons with stroke to support their engagement in a variety of meaningful activities that contribute to health.IMPLICATIONS FOR REHABILITATIONRehabilitation need to support persons with stroke to monitor their entire patterns of activities and perceived balance to support wider engagement in meaningful activities and promote health.Balance between all kinds of activities in daily life besides work, needs to be considered in the later phase of rehabilitation in persons with stroke.A majority of the participants with stroke in this study disagreed that they had a satisfying level of occupational balance.Perceived balance between all activities in daily life can together with performance of activities add to the understanding of consequences after stroke.

[Traumatic brain injury rehabilitation - assessment of quantitative and qualitative research]. / Brister i rehabilitering för vuxna med traumatisk hjärnskada.

The Swedish Agency for Health Technology Assessment and Assessment of Social Services has evaluated quantitative and qualitative research regarding rehabilitation for persons with traumatic brain injury (TBI) through systematic reviews. The results indicate that specialized brain injury rehabilitation for persons with post-concussion symptoms after mild TBI results in improved health, when compared to usual care (results with low certainty according to GRADE). As few high-quality studies were identified, it was not possible to assess the effects of vocational rehabilitation, rehabilitation with case management/coordinator, residential living or specialized brain rehabilitation for persons with moderate to severe TBI. A synthesis of qualitative studies showed that persons with TBI experience insufficient coordination of health services and access to rehabilitation (results with low to moderate confidence according to CERQual).

Occupational challenges in a digital society: A discussion inspiring occupational therapy to cross thresholds and embrace possibilities.

The digital transformation of society and the increased need for digital competence implies extensive changes in peoples' everyday lives and occupations. Heretofore, the discussion in the field of occupational therapy about the consequences of digitalisation has been vague. The aim of this discussion paper is to outline some reflections and to offer some arguments on how to meet the changes following digitalisation and its impact on occupational therapy. The discussion focuses on three issues: the new conditions for participation in a digital society and the role of occupational therapy and occupational therapists in the evolving digital society as well as what occupational therapists need to be pro-active and to embrace the ongoing changes in a digital society. In conclusion, occupational therapy needs to advance its position and become pro-active to cross the threshold and to embrace the possibilities that digitalisation holds for peoples' everyday lives to support occupational justice and health.

Everyday activities outside the home are a struggle: Narratives from two persons with acquired brain injury.

Background: Participation restriction is a common consequence after acquired brain injury (ABI).Aim: To explore and identify problematic situations in everyday activities outside the home for persons with acquired brain injury.Material and Method: Two persons of working age with ABI were included. Data were generated through repeated semi-structured interviews and participant observations. Narrative analysis was used to capture ongoing processes related to problematic situations during engagement in everyday activities outside the home.Results: The narratives reflect how places, everyday activities and social relations were closely connected and influenced engagement in everyday activities outside the home. The participants visited fewer places and performed more of their everyday activities alone in their homes after the injury compared to before. They were struggling to create meaning in their lives and trying to reformulate their identity. Problematic situations often occurred outside the home as a result of unexpected events. The narratives indicate a struggle to find new routines to handle challenging situations.Conclusions: The results provide an understanding of how problematic situations occurred and were managed in different ways. By observing everyday situations professionals can gain access to how persons with ABI act in and reflect upon problematic situations which can eventually improve the design of individually tailored interventions.

Gender and diagnostic impact on everyday technology use: a differential item functioning (DIF) analysis of the Everyday Technology Use Questionnaire (ETUQ).

Background: As the use of everyday technology is increasingly important for participation in daily activities, more in-depth knowledge of everyday technology use in relation to diagnosis and gender is needed. The purpose of this study was to investigate the stability of the perceived challenge of a variety of everyday technologies across different samples of varying diagnoses including both males and females. Methods: This cross-sectional study used 643 data records from clinical and research samples, including persons with dementia or related disorders, acquired brain injury, intellectual disability, various mental or medical disorders, and adults without known diagnoses. The Everyday Technology Use Questionnaire, comprising 93 everyday technology artifacts and services (items) measuring the level of everyday technology challenge and relevance of and perceived ability to use these was used for data gathering. A two-faceted Rasch model in combination with differential item functioning (DIF) analyses were used for comparing item hierarchies across samples. Results: Only three items (3.2%) demonstrated a clinically relevant DIF by gender, and nine items (9.7%) by diagnosis. Discussion: The findings support a stable hierarchy of everyday technology challenge in home and community that can facilitate planning of an accessible and inclusive society from a technological departure point. Implications for Rehabilitation The ability to manage everyday technology is increasingly important for participation in everyday activities at home and in the community for people with and without disabilities. This study demonstrates that differences in perceived challenges in using various everyday technologies across gender and diagnosis are minimal. The findings provide evidence of no or minor systematic bias in testing when using the Everyday Technology Use Questionnaire in clinical practice and research. Empirical knowledge about the perceived challenge of specific everyday technologies of people with variations in gender or diagnosis is still sparse, hence this study can inspire practice and future research.

Return to work in people with acquired brain injury: association with observed ability to use everyday technology.

PURPOSE: The aim of this study was to explore how the observed ability to use everyday technology (ET), intrapersonal capacities and environmental characteristics related to ET use contributes to the likelihood of return to work in people with ABI. The aim was also to explore whether these variables added to the likelihood of return to work to earlier defined significant variables in the group: age, perceived ADL ability and perceived ability in ET use. METHOD: A cross-sectional study. The Management of Everyday Technology Assessment (META), the short version of the Everyday Technology Use Questionnaire (S-ETUQ) and a revised version of the ADL taxonomy were used to evaluate 74 people with ABI. Individual ability measures from all assessments were generated by Rasch analyses and used for additional statistical analysis. RESULTS: The univariate analyses showed that the observed ability to use ET, as well as intrapersonal capacities and environmental characteristics related to ET use were all significantly associated with returning to work. In the multivariate analyses, none of these associations remained. CONCLUSION: The explanatory precision of return to work in people with ABI increased minimally by adding the observed ability to use ET and the variables related to ET use when age, perceived ability in ET use and ADL had been taken in account.

Participation and occupation in occupational therapy models of practice: A discussion of possibilities and challenges.

BACKGROUND: Occupation has been the focus in occupational therapy practice to greater or lesser degrees from a historical viewpoint. This evokes a need to discuss whether concepts that are added to our field will enhance or blur our focus on occupation. AIM: To explore how the concept of participation in the International Classification of Functioning, Disability and Health (ICF) is related to the concept of occupation by reviewing and comparing its use in three models of practice within occupational therapy. The aim was also to generate discussion on possibilities and challenges concerning the relationship of participation and occupation. METHOD: The models reviewed were The Model of Human Occupation (MOHO), the Canadian Model of Occupational Performance and Engagement (CMOP-E) and the Occupational Therapy Intervention Process Model (OTIPM). RESULTS: The concept of participation was related to occupation in different ways in these models. Based on the review some challenges and considerations for occupational therapy were generated. CONCLUSION: Relating the concept of participation from the ICF to the concept of occupation in models of practice can be challenging. At the same time, relating the concepts can be a resource to develop occupational therapy and the understanding of occupational issues in society.

The rehabilitation plan can support clients' active engagement and facilitate the process of change - experiences from people with late effects of polio participating in a rehabilitation programme.

PURPOSE: To explore how the rehabilitation plan influences the rehabilitation process and its outcome in people with late effects of polio participating in an individualised goal-oriented interdisciplinary rehabilitation programme. METHODS: Four women and two men with late effects of polio were interviewed before rehabilitation, at discharge, and at follow-up. Data were analysed according to the constant comparative method of grounded theory. FINDINGS: The participants' experiences formed one core category: "The same starting point but different rehabilitation processes". Before rehabilitation, all participants experienced a similar starting point: Naïve understanding of rehabilitation. During rehabilitation, two separate processes followed. Four participants experienced their rehabilitation as being a mutually shared process that led to a process of change. They were actively engaged, using the rehabilitation plan, and working towards goals targeting a broad perspective of daily activities. The remaining two participants experienced their rehabilitation as a staff-directed process, with limited use of the rehabilitation plan, focusing on goals mainly related to body functions and self-care, not leading to any substantial changes. CONCLUSION: When clients experience that they develop a mutually shared rehabilitation process, based on a rehabilitation plan, they became more engaged in their rehabilitation and gained a better understanding of their participation during the process. Knowledge of the differences in how clients use the rehabilitation plan during the rehabilitation process can support their active engagement during rehabilitation. This, in turn, can promote a more holistic view among clients and professionals during the rehabilitation for people with late effects of polio. Implications for Rehabilitation Clients who experience a rehabilitation that is mutually shared with professionals, have a better understanding of their engagement during the rehabilitation process. When clients and professionals use the rehabilitation plan as a mutual tool, clients become more actively engaged in their rehabilitation process. A structured rehabilitation plan can serve as a map, and support clients' process of change during the rehabilitation process, also after the rehabilitation period is completed.

Stability of person ability measures in people with acquired brain injury in the use of everyday technology: the test-retest reliability of the Management of Everyday Technology Assessment (META).

AIM: To evaluate the test-retest reliability of the Management of Everyday Technology Assessment (META) in a sample of people with acquired brain injury (ABI). METHOD: The META was administered twice within a two-week period to 25 people with ABI. A Rasch measurement model was used to convert the META ordinal raw scores into equal-interval linear measures of each participant's ability to manage everyday technology (ET). Test-retest reliability of the stability of the person ability measures in the META was examined by a standardized difference Z-test and an intra-class correlations analysis (ICC 1). RESULTS: The results showed that the paired person ability measures generated from the META were stable over the test-retest period for 22 of the 25 subjects. The ICC 1 correlation was 0.63, which indicates good overall reliability. CONCLUSION: The META demonstrated acceptable test-retest reliability in a sample of people with ABI. The results illustrate the importance of using sufficiently challenging ETs (relative to a person's abilities) to generate stable META measurements over time. Implications for Rehabilitation The findings add evidence regarding the test-retest reliability of the person ability measures generated from the observation assessment META in a sample of people with ABI. The META might support professionals in the evaluation of interventions that are designed to improve clients' performance of activities including the ability to manage ET.