Evaluation on the Effects of a Brief Hope Intervention to the Symptoms in the Palliative Care Patients
Evaluation on the Effects of a Brief Hope Intervention to the Symptoms in the Palliative Care Patients
Aims. This paper describes the study protocol of a manualized brief positive intervention
 (BHI). In addition, it reports the on the modification of a hope intervention based on the
 theoretical proposition - hope theory, and its feasibility when applying to palliative cancer
 and non-cancer patients.

 Background. Hope was found to account for therapeutic changes in clients with depressive
 symptoms or chronic pain. Nevertheless, little is known about the integration of such active
 ingredients to brief and low intensity psycho-therapeutic interventions to patients receiving
 palliative care were not adequately tested.

 Design. The study included two stages: (1) manual development, and (2) a single blinded
 randomized controlled trial.

 Methods. Participants will be randomly assigned in equal number into either the brief hope
 intervention or the controlled arm on completion of the baseline assessment. Participants of
 the intervention group will be receiving the four-week intervention, while those allocated to
 the control arm will be receiving the routine care and social chats. The intervention is a
 manualized program that consists of four sessions at weekly intervals (two face to face
 sessions and two telephone follow up in between). The core content is modified from an eight
 sessions hope therapy. Expert panel feedback and trial on targeted populations were
 completed. Four participants received the program to determine its acceptability prior to
 feasibility testing. The process and practical considerations were evaluated to allow
 refinement of the program and to ensure the quality of intervention.

 Outcome measures comprise of changes in state hope score and the depression scores measured
 respectively by State Hope Scale and Centre for Epidemiological Study Depression Scale. The
 secondary outcomes are the common signs and symptoms in cancer patients measured by The
 Condensed Memorial Symptom Assessment Scale. Data collection will be done prior to the
 intervention (baseline), immediately and one month after the intervention. Additional use of
 qualitative interview to explore their experiences in the intervention, including
 satisfaction with the intervention and the treatment fidelity will be conducted.
Introduction According to the Medical Research Council guidance, there are four critical
 steps to systematically establish a standardize intervention content and mode of delivery
 through phased approach. Theory and evidence-based practice, feasibility or piloting to test
 the procedure, estimate recruitment/retention, determining sample size, evaluation and
 implementation are the four keys of the best practice described in the guideline. In this
 article, we reported three steps in developing an evidence-based intervention, namely brief
 hope intervention that addresses the management of cancer and palliative care patients: (1)
 preparation of the present program, (2) description of the protocol of the feasibility test,
 and (3) an experimental study using wait list control design.

 Background Hope intervention is grounded on positive psychology and is mapped onto
 cognitive-behavioral therapy. It aligns with the 2014-2018 Oncology Nursing Society research
 priorities, which indicated the need for evaluating the efficacy of integrating protective
 factors, such as hope, to the care delivery to the patient and family caregivers. In a
 similar vein, growing evidence has shown the increasing needs of quality palliative care for
 non-cancer patients, who suffer from complex illnesses and progressing to end-of-life. These
 patients having unpredictable disease trajectories, significant loss and grief, and
 anticipated death would lead to depression and hopelessness. As such, the intervention should
 be extended to non-cancer patients in their last phase of life. The goal of health-promoting
 palliative care is to create a supportive environment and strengthen actions that intervene
 along the journey of care giving, loss and death and dying. In a systematic review, hope was
 found to account for therapeutic changes in clients with depressive symptoms or chronic pain.
 Nevertheless, such active ingredients of the psychotherapy are not standard elements of
 multi-modal care management. This warrants the field testing of the present brief hope
 intervention in patients receiving palliative care.

 Hope Theory Hope theory is adopted as the framework in the present study, where hope was
 believed as the central agent to facilitate the change process. It focuses on three core
 features: (1) goal setting (goals), (2) problem solving (pathways) and (3) positive self-talk
 (agency). These elements underlie the key hope strategies used in the intervention. By
 increasing hope level, the likelihood of therapeutic change will be increased. Its current
 emphasis complemented the traditional cognitive behavioral therapy by shifting the primary
 focus on positive potentials as the starting point, thereby promoting meaning in life,
 fostering personal strengths, positive changes and improving well-being.

 Some believed that being overly optimistic is harmful. However, nurturing hope was found to
 be one of the significant elements in staying positive in the coping experiences of Chinese
 couples living with cancer. Evidence has shown that high-hope individuals were found to be
 more creative and effective problem solvers. More important, a number of studies have
 reported the positive effect of hope in newly diagnosed cancer patient, for example, health,
 quality of life, self-esteem, reduced major cancer symptoms, such as pain, fatigue, cough,
 and depression in lung cancer patients or promoting positive changes in breast cancer
 patients. However, many of these researches are cross-sectional surveys or qualitative
 studies; others are mindfulness-based or spiritual-based interventions where hope is only one
 of the active components in the program. Whether improving the hopeful state of cancer
 patients and palliative care patients would lead to better clinical outcomes remains under
 explored.

 Brief Hope Intervention The present study aimed to examine the effectiveness of a brief hope
 intervention in improving the hope level and the physical and mental health of cancer and
 non-cancer Hong Kong Chinese patients who are receiving palliative care. This low intensity
 psychological intervention can be delivered by caregiver such as nurses to address the needs
 of these patients and to build their mental and/or physical abilities. Additionally, the
 skills could be streamlined in daily nursing practice and an ongoing self-help strategy.
 Would brief hope intervention be as effective as the standard session in clinical population?

 Optimal Length of Hope Intervention Preliminary evidence was found. Literature showed that
 the role and value of hope at the early counseling sessions enhanced a literal shift to
 experience a sense of worthiness. Focused hope intervention (90 minutes) has led to higher
 level of hope and increase in perceived life meaning. The statistical robustness is supported
 by the comparable effect sizes achieved by both the eight 2-hours sessions and the 90-minute
 single session in previous studies on hope therapy. The effect sizes on the agency and
 pathway hope scale scores were 0.65 and 0.38 respectively in the long intervention, and were
 0.43 and 0.38 in the brief interventions. One large scale brief positive psychology
 intervention with hope-based intervention (single session plus one booster session) recruited
 1,734 participants from the community, showed positive significant changes in well-being and
 family happiness (ES 0.11-0.14) (Zhou et al., 2015). Encouraging results were also
 demonstrated is other studies, which has tested a brief meaning in life intervention for
 advanced cancer Chinese patients (2-sessions: 30-60 and 15-30 minutes respectively). It
 showed improvement in quality of life and existential distress. Wong, Wong, & Chang (2015)
 also found a four-sessions program (one visit plus three telephone follow up) effective in
 reducing hospital readmission in community dwelling patients with chronic illnesses.
 Nevertheless, there is insufficient evidence on the optimal length of hope intervention for
 cancer and palliative patients that would produce the desired effect. Thus the present study
 results could underpin effective palliative care provision across a range of services from
 hospitalization to discharge facilitation.

 Aims The primary research question is whether brief hope intervention would improve the
 hopeful state and reduce physical symptoms and/or depression level of patients receiving
 palliative care. Fidelity was assured at the design level and in intervention delivery to
 establish a standardized procedure, skill adequacy and translating the intervention from
 research into clinical practice.

 Intervention Description of the intervention The present Brief Hope Intervention is a
 four-weeks individual intervention, helping participants to develop positive thoughts through
 skills in goal setting, problem solving and positive self-talk. The program consists of four
 sessions in total: two face-to-face sessions (1-hour) and two telephone follow up sessions
 (30 minutes) in between. This serves to create the momentum and continuity of intervention.
 The first session is the core intervention and the final face-to-face session is a summary
 talk. Two telephone follow up will review their progress and encourage the practice of hope
 exercises. Hope enhancement strategies included sharing and recalling past successes,
 hope-based goal mapping exercises, examining possible pathways to reach the targeted goals,
 hope visualization exercise and positive self-talk. A booklet will be prepared for the
 participants for reviewing their planned goals and recording achieved targets. Successful
 experiences and solutions to perceived barriers are entered. Such take-home exercise helps to
 extend the participants' practice of hope-based skills into their daily living.

 Design and Randomization This study is a randomized controlled trial. On completion of the
 baseline assessment and the screening procedure, eligible participants will be randomly
 assigned in equal number into either a brief hope intervention or the control group using
 sets of computer-generated random numbers. The research assistant conducting the assessments
 will be blinded to the treatment type. However, participants are inevitably aware of the
 conditions they have been randomized to. To reduce expectancy effects of the advantages of
 the program, the control arm is casted as a social intervention. Figure 1 presented the data
 collection using the Consolidated Standards of Reporting Trials, which will be done before
 the commencement of the intervention (Time1), immediately post-intervention (Time2) and one
 month after the completion of program (Time 3).

 Participants Chinese cancer and non-cancer patients in Hong Kong, who have completed the
 curative treatment regimen (surgery and/or chemotherapy and/or radiotherapy) or not eligible
 for the aforementioned treatment, but receiving palliative care will be invited to join the
 study.
Inclusion Criteria:

 1. Age ≥ 18 years

 2. Clinically diagnosed to have cancer or patients receiving palliative care

 3. Willing to participate in face-to-face activities and telephone follow up

 4. Alert and oriented, able to sustain for approximately one hour of attention and
 interaction

 5. Communicable in Cantonese, able to read and write Chinese

 6. Could be reached by phone

 Exclusion Criteria:

 Patients having one or above of the below conditions will be excluded from the study.

 1. Patients who have planned operation or further chemotherapy and/or radiotherapy within
 three months

 2. Patients who are unable to communicate in Cantonese

 3. Patient who has hearing deficit

 4. Patient who are disoriented, delirious or cognitively impaired

 5. Patients who have been or is receiving counseling or psychotherapy

 6. Patients who are clinically depressed diagnosed by medical doctors