Evaluation of a Peer Coach-Led Intervention to Improve Pain Symptoms (ECLIPSE)
Phase: NA
Conditions: Chronic Pain
Sponsor: VA Office of Research and Development

 
 
 
 
 
 
 
 
 
 
Evaluation of a Peer Coach-Led Intervention to Improve 
Pain Symptoms (ECLIPSE) 
 
NCT02380690 
 
July 1, 2015 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

RESEARCH DESIGN AND METHODS 
Conceptual Model 
Our prior work, described above, informed the conceptual model guiding this study.  Our 
work has consistently demonstrated that pain self-
management requires not only the use of specific 
strategies, such as exercises and activity 
modification, but also help and support from another 
person, who serves a larger function beyond 
teaching strategies.  In prior studies, a nurse care 
manager delivered a self-management curriculum 
and fulfilled different functions for patients, as the 
Figure depicts: 1) teaching self-management 
strategies; 2) finding “what works”; 3) goal setting 
and accountability to goals; and 4) providing 
motivation and support.24,25  Importantly, the top half 
of this model outlines practical aspects of self-
management:  the strategies themselves and 
troubleshooting to find what works for each 
individual.  The bottom half focuses on support, by 
helping Veterans to stay on target, motivated, and 
supported. This model closely parallels Dennis et 
al.’s31 analysis of the elements of peer support, 
described in section B3. 
Based on our work with Veterans with chronic 
pain, coupled with studies demonstrating 
effectiveness of peer support in other chronic conditions, the next step in our research is to 
explore the effectiveness of placing a peer coach in a role similar to that of the nurse care 
manager.  Although a peer coach does not have a nurse’s clinical training, the coach has 
successfully adopted self-management strategies, and shares many of the same experiences 
as other Veterans with pain.  This unique position potentially places a Veteran peer coach in a 
stronger position to deliver motivation, support, and accountability—characteristics that 
Veterans in our prior studies tout as critical to effective self-management. Examining peer 
coaching for Veterans with chronic pain is a logical next step based on our prior research, and 
research in other conditions suggests a peer coaching model may be an effective intervention 
for Veterans with chronic pain, with high potential for implementation across VA.    
 
Overview of Study Design 
 
 
We will conduct a 2-arm randomized controlled trial with Veterans who have chronic 
musculoskeletal pain.  The trial will compare a 6-month peer coaching self-management 
intervention with a control group consisting of a 2-hour class on pain and pain self-management.  
We will compare changes in pain between the two groups (Aim 1) and examine secondary 
outcomes: self-efficacy, pain coping, patient activation, social support, health-related quality of 
life, and health service utilization (Aim 2). The 2-arm design will allow for direct comparison 
between Veterans receiving information on self-management (control), versus receiving self-
management information combined with the motivation and support delivered by a peer coach 
and described in our conceptual model.   
 

In addition to testing the effectiveness of the intervention, we will assess facilitators and 
barriers to implementation through qualitative interviews with study participants (peer coaches 
and Veterans from the intervention arm) and PACT staff, where a peer support program would 
most likely be implemented. The study duration will be 4 years, to allow for peer coach and 
Veteran recruitment, peer coach training, completion of the 6-month intervention, assessment of 
outcomes at 6 and 9 months, and the pre-implementation interviews.   
 
Study Sites 
 
Roudebush VAMC (RVAMC) is an urban, university-affiliated tertiary care center which 
provides health care for more than 50,000 veterans and houses five primary care clinics.  An 
RVAMC expansion clinic, Indy West Clinic, opened in 2010 and will also serve as a study site.  
RVAMC is the parent facility of three Community-Based Outpatient Clinics (CBOCS), in Terre 
Haute, Martinsville, and Bloomington, IN. These 9 clinics, which staff 75 primary care providers, 
will serve as study sites. 
 
Recruitment and Training of Peer Coaches 
 
Recruitment:  We have three primary sources for recruiting peer coaches:  1)  Veterans 
who served as peer coaches in IMPPRESS (7 out of 9 expressed interest in serving as a coach 
again); 2) Veterans who completed the intervention arm of one of our previous chronic pain 
studies involving pain self-management instruction (ESCAPE, PI:  Bair; CAMEO, PI: Bair; 
SCOPE, PI: Kroenke).  In these studies completers were asked for permission to be contacted 
for future studies.  We successfully recruited 10 peer coaches for IMPPRESS in one month 
using this approach. From these two completed and one ongoing study we have a pool of 
approximately 250 potential peer coaches.  3) Veterans with chronic pain (see ICD-9 codes in 
Section D2c) who are recommended by their PCPs.  Although we did not need this strategy in 
IMPPRESS because of successful recruitment of participants from prior studies, one of our co-
investigators, Dr. Heisler, has successfully used this method for peer studies of Veterans with 
diabetes.  
 
Manual:  Each peer coach will be given a manual to refer to and serve as a guide during 
the intervention.  The Peer Coach Manual consists of two parts:  1) Self-Management 
Knowledge (this portion is identical to the Veteran manual), and 2) How to be a Peer Coach.  
See Table 1.  This manual was developed and refined in IMPPRESS, drawing on the study 
manual from Dr. Bair’s ESCAPE trial (Part 1), and on the Peer Specialist Manual used by VHA’s 
Office of Mental Health Services (Part 2, shared by Dan O’Brien-Mazza, Director of VA Peer 
Support Services, see letter of support). In addition, during IMPPRESS, our study psychologist, 
Dr. Kukla, developed a section on motivational strategies, grounded in the motivational 
interviewing literature.  The peer coach manual is in Appendix 1.   
Training:  Three to 4 coach training sessions will be scheduled as coaches are recruited.  
Once 10 coaches are recruited, a training session will be scheduled, and coaches will be 
assigned Veterans. This process will continue until all peer coaches are recruited, trained, and 
matched with Veterans. 
Peer coach training will consist of one 3-hour session taught by Carol Kempf, RN. Ms. 
Kempf has trained peer coaches for IMPPRESS and has delivered self-management instruction 
to Veterans with chronic pain in several prior studies conducted by Drs. Bair and Kroenke. Each 
training session will be audio recorded to ensure quality and consistency. Training will 
emphasize the elements of self-management and support highlighted in the conceptual model 
(Section D1): 1) self-management strategies/exercises, 2) making adjustments in strategies to 
find what works, 3) setting and providing accountability to goals, 4) motivating/supporting. 
Training will be didactic and participative.  Particular focus will be on teaching and role-playing 
to help peer coaches work with their assigned Veterans to accomplish the four intervention 

elements listed above. The direct-observation fidelity checklist will be used as a training tool 
during role-playing. 
Peer Coach 
Supervision:  Ms. Kempf will be 
available on an ongoing basis 
for consultation with questions 
or problems. In addition, she 
will conduct 1) individual 
“check-in” calls with peer 
coaches, and 2) regular group 
supervision (“booster”) 
sessions with peer coaches via 
conference call.  “Check-in” 
calls will be with individual peer 
coaches primarily at the 
beginning of the intervention 
period to ensure that coaches 
are successfully making initial contact with their assigned Veterans, to help facilitate this contact 
when needed, and provide any other individual help or guidance needed. Ms. Kempf will also 
make individual calls throughout the intervention as needed. All calls will be logged (date/time, 
peer coach, brief summary, length of call, any other relevant information). 
 Group supervision (“booster”) telephone sessions will be conducted by Ms. Kempf every 
2 weeks for the first 2 months of the intervention period, after which time they will occur monthly.  
(Frequency of meetings can be adjusted if needed.) This was the schedule followed in 
IMPPRESS.  These “booster” supervision sessions are relatively informal, involving discussion 
among peer coaches on how their calls/meetings with Veterans are going and providing follow-
up tips on communication strategies and reinforcement.  Many peer coaches in IMPPRESS 
found these booster sessions to be more helpful than the initial training, since they were able to 
discuss practical situations and problems as they arose.  Booster sessions serve several key 
functions:  1)  “Getting things going” at the beginning of the intervention when peer coaches and 
Veterans are making initial contact; 2)  Reminding peer coaches to contact their Veterans 
regularly; 3) Troubleshooting issues or questions; 4) Providing additional training on the use of 
motivational strategies to address any difficulties with Veterans’ goal attainment; 5) Providing 
motivation, encouragement, and reinforcement of their roles as peer coaches; and 6) Serving as 
a tool to check and maintain intervention fidelity.46-48  An added benefit of these regular calls in 
IMPPRESS was the peer coaches developed a sense of camaraderie and community among 
themselves as they shared stories of their experiences in the study.  This culminated with a 
pizza party for the coaches at the end of the intervention period.  Because these sessions 
involve multiple study participants, coaches are instructed not to use participant names when 
talking about their assigned partners, to protect participants’ private health information.  Ms. 
Kempf will keep detailed field notes documenting the content and duration of these calls, as we 
did in IMPPRESS. 
 
Recruitment of Veterans 
Our Center’s Data Management Group will run a query in CPRS (Computerized Patient 
Record System) to identify potentially eligible patients, who will be recruited from 9 clinics:  
Roudebush VAMC’s 5 primary care clinics, the Indy West Clinic, and the 3 Community-Based 
Outpatient Clinics (CBOCs) at Bloomington, Martinsville, and Terre Haute. Veterans with 
musculoskeletal pain (ICD-9 codes 715, 719, 721, 722, 723, 724, 726, 729.0, 729.1, 729.3, 
729.5, 738.4, 738.5) will be identified. Primary care providers (PCPs) will be contacted to gain 
permission to recruit their patients.  We have successfully used this recruitment method in 
Table 1. Peer Coach Training 
Part 1:  Self-Management 
Knowledge 
Part 2. “How to be a Peer 
Coach” 
Chronic Pain Basics 
What is a Peer? 
-Biopsychosocial Model 
Cultural Competence 
-Gate Control Theory of Pain 
Communication Skills 
Relaxation Skills 
Managing Crisis and 
Emergency Situations 
Motivational Strategies 
Activity Pacing 
Cognitive Behavioral Skills 
Self-Care Skills 
Interpersonal Skills 
 

several past studies, with over 90% of PCPs agreeing to allow access to their patients. For 
IMPPRESS, we successfully recruited 20 patients in 6 weeks using this method, after needing 
permission from only 2 PCPs to achieve our recruitment goal.  Based on this experience, we 
anticipate little difficulty recruiting from multiple PCPs’ panels across 9 clinics.   
Inclusion/Exclusion Criteria:  Once potentially eligible Veterans are identified and PCPs 
have granted permission to recruit, we will contact Veterans to identify those who meet study 
inclusion/exclusion criteria. Potential participants will be told that we are conducting a study to 
learn how Veterans can help other Veterans with chronic pain management, and that they will 
be randomly assigned either to the Veteran peer coach group or to the group receiving a pain 
self-management class.  Eligible patients must 1) have musculoskeletal pain in the low back, 
cervical spine, or extremities (hip, knee, or shoulder) for ≥3 months; 2) have at least moderate 
pain severity, defined by pain ≥ 5 on a 0 (no pain) to 10 (worst pain imaginable) scale; and 3) 
indicate willingness to engage in phone or in-person contact on a regular basis with another 
Veteran.  We have identified approximately 26,000 unique outpatients who meet criteria 1 and 
2. Patients will be excluded if the electronic medical record indicates a diagnosis of a psychotic 
disorder (e.g., ICD-9 codes 295-295.9 for schizophrenia), current substance dependence (e.g., 
ICD-9 codes 304-304.9), severe medical conditions precluding participation (e.g., NY Heart 
Association Class III or IV heart failure, ICD-9 codes 428-428.9 ), or if the eligibility screener 
given to prospective participants reveals active suicidal ideation, severe hearing or speech 
impairment, or pending surgery for a musculoskeletal condition (e.g., back surgery). 
Control Arm 
 
Veterans will be randomized to either the peer coaching arm or a control group 
consisting of a 2-hour class in pain “basics” and pain self-management. In this class, topics 
listed in Part 1 (Self-Management Knowledge) of Table 1 will be reviewed (e.g., chronic pain 
basics, relaxation skills, activity pacing), and Veterans will be given a set of pamphlets related to 
pain self-management. Ms. Kempf will lead the control group class; she has taught similar 
classes in other studies. Control participants will complete baseline assessments just prior to 
the class, to help encourage class attendance. (They receive compensation for assessments, 
see D3). We estimate offering one class per month during the study, with more offered as 
needed during heavier recruitment periods. To maximize attendance, some classes will be 
offered in the evening. 
 
Peer Coach-Veteran Sessions 
 
Method of Contact:  Participants will choose whether they want to meet in person or 
have telephone contacts (or a combination).  In IMPPRESS, most chose to have subsequent 
meetings over the phone for convenience.  Prior peer mentoring studies with Veterans have 
used a mix of in-person and telephone contacts and have had positive results.11,49   
Frequency of Contacts/Meetings:  Peer coaches will be asked to contact/meet with 
Veterans a minimum of two times per month via telephone or in-person. Ms. Kempf, in her 
booster sessions and individual calls with coaches, will monitor and help to encourage contacts 
at this interval.  
Manual:  Veterans will be given a manual identical to Section 1 of the peer coaches’ 
manual (i.e., without the section on being a peer coach).  (See Table 1, Column 1)  
 
Content of Contacts:  As we have learned from our other pain self-management studies 
and IMPPRESS, the content of each meeting is variable depending on a Veteran’s particular 
needs.23-25  However, regardless of specific content (i.e., the specific self-management 

strategies discussed), coaches will be asked to 1) review self-management strategies/exercises 
(based on manual, See Table 1, Column 1), 2) help the Veteran to make adjustments if 
strategies are not working, 3) help the Veteran to set, follow up on, and be accountable to goals, 
4) and motivate and listen to the Veteran.  As part of this motivation, coaches will be 
encouraged to discuss their personal experiences with pain self-management and how they 
overcame obstacles or handled setbacks and frustrations, and to feel free to engage in 
conversation that is social in nature if comfortable and appropriate for the situation. Coaches will 
not advise on medications or medical questions, but will recommend Veterans see their 
physicians.    
 
Record of Contacts: Peer coaches will be asked to log their sessions with each Veteran, 
including, date, length, format (phone, in-person), brief notes on content, and any other 
pertinent information, to allow us to track number and content of contacts. Study staff will 
maintain regular contact with the peer coaches to ensure logs are being completed, to facilitate 
collection of logs, and to offer feedback (i.e., if details are missing, or if the peer coach is doing 
an exceptional job with logs).  Logs are simple, straightforward, and typically take less than 5 
minutes to complete.  
Optimizing Intervention Fidelity:  We will employ the following facilitation strategies to 
optimize fidelity to the intervention: 1) a detailed intervention manual; 2) peer coach training; 3) 
regular peer coach booster sessions; 4) observer-rated fidelity assessment with feedback to 
coaches during intervention (which reinforces the importance of protocol adherence and 
provides constructive feedback to maintain strengths and identify areas for improvement).50,51   
Data Collection Protocol for Primary and Secondary Measures (Aims 1 and 2) 
 
 
Assessments will be given at baseline, 6 and 9 months.  Participants (intervention and 
control) will receive $30 per assessment.  We will administer the same measures to peer 
coaches and Veterans, because research suggests peer coaches also benefit from peer 
interventions.  Moreover, we want to determine whether the peers experience any negative 
effects related to their participation.52  
After obtaining informed consent, a research assistant will administer a baseline 
assessment to gather socio-demographic data, review the Veteran’s history with an emphasis 
on previous and current pain treatments, and administer measures of primary and secondary 
outcomes.  These assessments will take approximately 30 minutes each.   
Aim 1 (Primary Outcome): To compare 6- and 9-month effects of peer-supported chronic 
pain self-management versus controls on overall pain.  Overall pain will be measured with 
the Brief Pain Inventory (BPI) total score.  The BPI was developed to assess the severity of pain 
and the impact of pain on daily functioning, and has been validated in primary care studies.6,53  
The BPI is the average of two scores: pain intensity and pain interference.  The pain intensity 
score is an average of 4 ratings of 0 (no pain) to 10 (pain as bad as you can imagine) for 
current, least, worst, and average pain in the past week.  The BPI pain interference score 
averages seven ratings, 0 (does not interfere) to 10 (interferes completely), of interference with 
general activity, mood, walking ability, normal work, relations with other people, sleep, and 
enjoyment of life. The BPI total score will be used as the primary outcome measure because 
BPI total has been shown to be highly responsive to change in clinical trials.54,55  The BPI has 
been shown to have strong internal consistency in its original validation study (Cronbach’s α = 
0.77),53 the SCAMP study (α = .83),6 and IMPPRESS (α = .88); and the BPI assesses the two 
most important domains—severity and interference—recommended for pain studies.56  
Aim 2 (Secondary Outcome Measures):  To compare 6- and 9-month effects of peer-
supported chronic pain self-management versus controls on self-efficacy, pain coping, 

patient activation, social support, health-related quality of life, and health service 
utilization.  We will measure self-efficacy with the Arthritis Self-Efficacy Scale,57 a 6-item 
measure that our team has used in prior studies.5,58 Patients respond to each item with their 
degree of certainty on a scale ranging from 1 (very uncertain) to 10 (very certain).  In the 
SCAMP study (with primary care patients, including 40% Veterans, with pain and depression), 
this scale had high internal consistency (Cronbach’s α=.88).58  
Pain coping will be measured with the Pain Catastrophizing Scale, a 13-item scale that 
assesses catastrophizing—a pain belief that has been found to be a strong predictor of poor 
treatment response.  Validation studies have found strong evidence of criterion-related, 
concurrent, and discriminant validity.59 In IMPPRESS this scale had high internal consistency 
(Cronbach’s α=.95). 
Patient activation will be measured with the Patient Activation Measure (PAM) Short Form, a 13-
item scale that assesses patient knowledge, skill, and confidence for self-management of one’s 
chronic health condition.60 The PAM has been demonstrated reliable and valid in a variety of 
studies, including IMPPRESS and other work by our team, with reliability ranging from α =.87-
.88.13,34,60,61 
Social support will be assessed through the Multidimensional Scale of Perceived Social 
Support. The MSPSS includes 12, 7-point Likert scale items. The test-retest reliability and 
internal consistency is high, ranging from α=.84-.95 across a variety of studies, including 
IMPPRESS.62,63 
Health-related quality of life will be measured with the RAND SF-36, developed as part of the 
Medical Outcomes Study. 64  
Health care utilization will be assessed using procedures similar to those we have used in prior 
studies.6 Our Data Management group will run CPRS queries for each participant over the 9-
month intervention period to identify the following: outpatient visits, ED visits, phone visits, non-
opioid and opioid analgesic prescriptions.   
Other Measures 
1) Sociodemographics:  age, sex, race, education, marital and job status, income 
2) Pain Treatment History questionnaire (includes current therapy for pain) 
Because depression, anxiety, and pain are common comorbid conditions,68,69 we will also 
administer the following measures: 
3) Depression:  PHQ-870;  4) Anxiety:  GAD-771 
Data Analysis  
Sample Size Determination. Our sample size is calculated based on estimated intervention 
effect on the primary outcome, the Brief Pain Inventory (BPI) total score, a continuous measure. 
Effect sizes for the BPI in past studies by our team have ranged from .4 to .6.  Because this is 
our first large-scale trial with peer coaches, we will conservatively power the study based on an 
effect size of .4. To test for a significant difference between the BPI change from baseline to the 
primary 6-month endpoint between the treatment and control arm, will use a linear mixed 
model.72 With a two-sided test and a Type I error of .05, we will have 80% power to detect a .4 
effect size with 102 Veterans and 34 peer coaches in the treatment group and 80 Veterans in 
the control arm, assuming equal variance across the two treatment arms, 3 Veterans per peer 
coach, and an intra-class correlation (ICC) in the treatment group of .3, which was observed in 
IMPRESS.73  (A smaller N is required in the control group because they are not nested within 
peer coaches.)  In our prior chronic pain trials at RVAMC, retention rates were >90%. With a 
conservative 15% attrition rate, we will need 120 (102/.85) Veterans in the treatment arm, 40 

coaches, and 95 (80/.85) Veterans in the control arm, for a total N = 215 Veterans and N = 40 
coaches. We plan an intent-to-treat analysis approach.  
Consistent with previous studies at RVAMC, the sample will include at least 15% minorities, 
reflecting the demographics of our medical center. In our SCAMP study, Blacks comprised 16% 
of the Veteran sample and 13% in ESCAPE.  We do not plan to over-sample minorities or 
power sufficiently to explore racial differences in treatment response. The racial/ethnic 
composition of RVAMC and participating CBOCs makes exploring racial differences in 
treatment response impractical unless we employed special efforts to recruit minorities other 
than Blacks. 
Randomization. Veterans will be randomly assigned to one of the two study arms using a table 
of random numbers generated by our statistician, Dr. Daggy. To obtain the random treatment 
assignment for the 215 Veterans, five blocks of 43 Veterans will be used, and random treatment 
allocation will occur within each block to maintain the allocation ratio consistently across blocks. 
This block size is large enough to prevent investigators and research staff from guessing which 
treatment comes next in the sequence, while still allowing the allocation ratio to remain 
consistent.   
Data Analysis: Baseline Comparability. Because of the size of this study, it is expected that 
randomization will produce treatment groups that are comparable and balanced.  To test this 
assumption, we will tabulate baseline characteristics of participants and assess for potential 
imbalance in variables such as sociodemographics, depression, and anxiety across study arms. 
Additionally, descriptive statistics for baseline characteristics of peer coaches will be assessed 
(e.g., treatment history, including opioid use). Continuous variables will be assessed with 
graphical displays and summary statistics (means, standard deviation, range, etc.). Frequency 
distributions and percentages will be calculated for categorical data.  
Data Analysis for Aim 1. We will summarize total BPI score at each time point (baseline, 6, 
and 9 months) for both study arms. To compare the primary outcome of total BPI score at each 
time point relative to baseline between two treatment arms, we will use a linear mixed-effects 
model fit to all time points.  This model will allow us to compare the change in BPI from baseline 
to 6 months (primary endpoint) between treatment groups, while accounting for the correlation 
of measurements from the same Veteran/peer coach and adjusting for confounding factors. 
Fixed effects in the model will include an indicator for treatment group, time (baseline, 6, and 9 
months.), treatment group by time interaction, and covariates found to differ significantly 
between treatment and control arm.  Random effects will include a random patient-specific 
intercept and a random effect for peer coach within the treatment arm only.  Additionally, the 
variance may be allowed to differ between treatment and control arms. Because this is a 
randomized trial design we do not expect covariates to significantly differ between the two 
groups.  However, if there are statistically significant differences, these covariates will be 
included in the model.  The linear mixed model for subject i in therapy group j at time k is 
 
 
where 
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covariates, 
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is the indicator for the 9-month time 
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 is the random effect due to peer 
coach j, 
 and 
 are the residual errors for each treatment group. All 
analyses will include checking of assumptions and model fit.  Our statistical model, which 
accounts for nesting of Veterans within peer coaches, will allow us to calculate the intra-class 
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correlation (ICC) in the treatment group to evaluate whether there are substantial variations 
among peer coaches.  In secondary analyses, we will also look at the BPI subscales of pain 
intensity and interference separately, using a similar mixed-model approach and adjusting for 
multiple comparisons using the Šidák method to maintain the overall confidence at 95% and to 
adjust for multiple comparisons. To determine if fidelity moderates patient outcomes, we will 
include the peer coach fidelity score by treatment group interaction and the interaction (fidelity 
score by time by treatment group) for the 9-month time point in the model above. 
Data Analysis for Aim 2. Secondary measures of self-efficacy, pain coping, patient activation, 
social support, and health-related quality of life are continuous measures; thus the linear mixed-
effects model described above will also be appropriate to analyze these measures.  If a linear 
mixed model does not seem appropriate for a given scale, then a generalized linear mixed-
effects model will be used. Since there will be a number of secondary outcomes, we will use the 
Šidák method. Health care utilization (number of ED visits, hospitalizations, outpatient visits, 
telephone visits, and analgesic prescriptions, including opioids) over the 9-month intervention 
will be analyzed using a generalized linear mixed model, assuming the counts follow a Poisson 
or negative binomial distribution. Explanatory variables in the model will include treatment 
indicator and, if necessary, a random effect for peer coach within the treatment group only. 
Covariates that significantly differ between groups will be included.  If counts include a high 
proportion of zeros, a zero-inflated count model may be required.74   
Missing Data. We conservatively anticipate 10-15% attrition based on our prior studies, which 
had attrition rates <10%.  Attrition is reflected in the sample size calculation.  We will compare 
patient demographic characteristics between those who withdraw and those who do not to verify 
whether there are characteristics that discriminate dropouts.  If the dropout mechanism appears 
to be Missing At Random,75 we will simply use all observed outcomes for the analysis. Under 
circumstances where power loss is of concern, we will use multiple imputation procedures to 
make use of all relevant observed variables. If data are found to be Missing Not At Random 
(MNAR), we will use appropriate models (i.e., selection models,76 pattern mixture models77) to 
account for the missing data mechanism.   
 
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