Self-management across chronic diseases: Targeting education and support needs

ObjectivesAmong Canadian adults with chronic disease: 1) to identify groups that differ in self-management task frequency and self-efficacy; 2) to compare group characteristics and preferences for self-management support.MethodsUsing data from an online survey, cluster analysis was used to identify groups that differed in self-management task frequency and self-efficacy. Multivariable regression was used to explore relationships with patient characteristics and preferences.ResultsCluster analysis (n = 247) revealed three groups:Vulnerable Self-Managers (n = 55), with the highest task frequency and lowest self-efficacy; Confident Self-Managers (n = 73), with the lowest task frequency and highest self-efficacy; and Moderate Needs Self-Managers (n = 119), with intermediate task frequency and self-efficacy. Vulnerable Self-Managers, when compared with the Confident group, were more often: on illness-related employment disability or unemployed; less well educated; diagnosed with emotional problems or hypertension, and had greater multimorbidity. They participated less often in self-management programs, and differed in support preferences.ConclusionsKnowing the characteristics of vulnerable self-managers can help in targeting those in greater need for self-management support that matches their preferences.Practice ImplicationsDifferent approaches are needed to support self-management in the vulnerable population.     

A peer support intervention in improving glycemic control in patients with type 2 diabetes

Objective

This study aims to assess the effectiveness of a peer support intervention, in which patients with T2DM were provided ongoing self-management support by trained peers with diabetes directed at improving self-care behaviors, self-efficacy and life quality.

Self-management among community-dwelling people with chronic conditions: Adapting evidence-based group programs using intervention mapping

ObjectiveSelf-management is a core theme within chronic care and several evidence-based interventions (EBIs) exist to promote self-management ability. However, these interventions cannot be adapted in a mere copy-paste manner. The current study describes and demonstrates a planned approach in adapting EBI’s in order to promote self-management in community-dwelling people with chronic conditions.MethodsWe used Intervention Mapping (IM) to increase the intervention’s fit with a new context. IM helps researchers to take decisions about whether and what to adapt, while maintaining the working ingredients of existing EBI’s.ResultsWe present a case study in which we used IM to adapt EBI’s to the Flemish primary care context to promote self-management in people with one or more chronic disease. We present the reader with a contextual analysis, intervention aims, and content, sequence and scope of the resulting intervention.ConclusionIM provides an excellent framework in providing detailed guidance on intervention adaption to a new context, while preserving the essential working ingredients of EBI’s.Practice ImplicationsThe case study is exemplary for public health researchers and practitioners as a planned approach to seek and find EBI’s, and to make adaptations.     

Self-management support activities in primary care: A qualitative study to compare provision across common health problems

ObjectiveTo explore the views of primary care teams about the provision of self-management support to patients with common health problems.MethodsSemi-structured interviews were conducted with twenty-one members of the primary care team from thirteen general practices. Interviews were transcribed verbatim, and analysed using the ‘Framework’ approach.ResultsThree categories and six sub-categories illustrating different self-management support activities across common health problems were identified from the analysis of interviews, and contributed to one major theme and one cross-cutting theme. Referral and signposting were frequently used to facilitate patient engagement with external services and resources. Practitioners faced some challenges in balancing medical management and psychosocial support and motivating patients to engage with self-management.ConclusionsPrimary care teams described providing a wide range of self-management support activities, but the pattern of use varied for different types of health problem. These patterns may have been influenced, in part, by general practices focusing upon achieving financially incentivised quality improvement goals.Practice implicationsTo improve self-management support, practitioners need a digital repository of services/resources, motivational interviewing skills, an understanding of the optimum duration and pattern of consultations, and incentivised targets that match a biopsychosocial model of care.     

Effects of an empowerment-based intervention on health-related knowledge and resilience in patients with coronary artery stent implantation

ObjectivesTo examine the effects of an empowerment-based intervention on health-related knowledge and resilience among patients after coronary artery stent implantation.MethodsThis was a randomized controlled trial with a 4-week-long intervention. Participants were randomly allocated to an empowerment-based intervention group (n = 42) or control group (n = 43). Knowledge on CHD and resilience were evaluated and compared between groups.ResultsCompared with the control group, patients in the intervention group showed higher score changes for CHD total knowledge (U = 196.500; P ＜ 0.001) and its 5 dimensions including CHD definition (U = 657.500; P = 0.022), manifestation (U = 245.000; P ＜ 0.001), examination (U = 639.000; P = 0.015), treatment (U = 475.000; P ＜ 0.001), and medication (U = 465.000; P ＜ 0.001), and higher level of resilience (t = 3.235; P = 0.002).ConclusionThe empowerment-based intervention was effective in enhancing the knowledge on CHD and improving resilience for patients with coronary artery stent implantation.Practice implicationsThe structured empowerment-based intervention provides a basis for facilitating the use of this intervention in patients with coronary heart disease.     

5例注意缺陷多动障碍患儿自我管理技能训练的干预研究

目的：探索注意缺陷多动障碍患儿自我管理技能训练的方法，评估自我管理技能训练用于多动症患儿的治疗效果。方法：对5名多动症男孩进行为期6周的以自我管理技能训练为主的综合治疗，以Conners父母症状问卷、Achenbach儿童行为调查表作为治疗效果的评价工具。结果：治疗后．除1名儿童未见明显疗效外，其余4名儿童的行为问题均获得不同程度的改善。结论：本研究所采用的自我管理技能训练计划切实可行，用于注意缺陷多动障碍患儿行为问题的治疗有效。     

Self-management support in primary care is associated with improvement in patient activation

Objectives

To examine: 1) whether patient characteristics predict perceived self-management support (usefulness of information and collaborative care planning) by primary care providers after six months, and 2) the association between perceived self-management support and patient activation at 6 months

Self-management: One size does not fit all

Self-management for people with chronic diseases is now widely recognized as an essential part of treatment. Despite the high expectations and the growing body of evidence in terms of its effectiveness, a wide application of self-management programs is inhibited due to several challenges. Worldwide, a variety of complex and multifactorial interventions have been evaluated in very heterogeneous patient populations leaving healthcare professionals in doubt about what works best and what works in whom. In this letter to the editor the authors systematically reflect on the current evidence of patient-specific determinants of success of self-management and argument the urge for increased scientific efforts to establish tailored self-management in patients with chronic disease.     

Differential effects of health knowledge and health empowerment over patients’ self-management and health outcomes: A cross-sectional evaluation

Objective

The role of health knowledge and empowerment in explaining behavioral and health outcomes was treated in depth in the literature, but the combined effect of these constructs has been somehow neglected. This study presents an empirical, a priori, cross-sectional evaluation of the differential effects of health knowledge and empowerment on patients’ self-management and health outcomes.

Methods

This study relies on a cross-sectional design involving a total of 209 Fibromyalgia patients. Structural Equation Modeling techniques were employed to analyze the model relationships.

Results

Knowledge and three empowerment dimensions were found to positively impact health outcomes. However, these relationships were not mediated by self-management. Self-management, operationalized in terms of physical exercise and drug intake, was found to be a strong predictor of health outcomes.

Conclusion

Despite the lack of support for the mediating role of self-management, a strong impact of knowledge and empowerment over health outcomes was observed. Theories of health literacy and empowerment may benefit from this result by integrating both dimensions in an overall model of behavioral and health outcomes change.

Practice implications

Results from this study suggest that health interventions targeted to chronic patients should focus simultaneously on knowledge and empowerment, rather than favoring one of these individual constructs.     

Self-management support provided by trained asthma educators result in improved quality of life and asthma control compared to usual care: A systematic review and meta-analysis

ObjectivesWe sought to describe training activities on self-management support (SMS) for asthma educators and the effects of SMS provided by trained educators on asthma patient outcomes.MethodsWe conducted a systematic review of six medical databases and sought for trials assessing SMS provided for adults with asthma by trained educators. Two reviewers independently selected and extracted data on asthma educators’ training activities and patient outcomes. We performed meta-analyses for asthma-related quality of life (QoL) and asthma control.ResultsWe screened 3217 records and included 16 trials. Learning activities and assessments were reported in 8/16 and 4/16 trials, respectively. Compared to usual care, trained asthma educators provided SMS that resulted in clinically important improvements in QoL (pooled mean difference [MD] = 0.52; 95% confidence interval [95%CI]: 0.19 to 0.83) and asthma control (pooled MD= −0.68; 95%CI: −0.99 to −0.38).ConclusionAlthough asthma-specific SMS provided by trained educators had a beneficial effect over the current care, our results highlight the need to better describe training activities for asthma educators.Practice implicationsThis systematic review provides key elements of efficient training activities for asthma educators and reaffirms the importance of training educators to provide SMS in order to improve asthma patients’ QoL and asthma control.     

Self-management problem solving for adolescents with type 1 diabetes: intervention processes associated with an Internet program

Objective

Describe intervention processes associated with an Internet self-management problem solving program for adolescents with type 1 diabetes, and relate participant characteristics to program use.

Methods

Forty-one adolescents with type 1 diabetes, aged 13–17, participated in an Internet intervention.

Results

Participants reported psychosocial self-management barriers related to social issues (45%), time pressures (22%), and emotions (25%). Most adolescents (76%) completed the two guided problem solving cycles, and most (97%) problems were appropriate and specific to diabetes. Of the 61 diabetes problems reported, 92% were mostly or completely solved. Baseline hemoglobin A1c, diabetes duration, and age were not related to online activities, however females posted more often to the forum (U = 130.0, Z = 2.13, p = .033). The majority of parents (87%) interacted with their child about the website.

Conclusion

Adolescents experience psychosocial barriers to self-management that can be addressed by teaching problem solving via the Internet.

Practice implications

An Internet self-management problem solving program with minimal external support provides a viable option for diabetes clinics to improve pediatric diabetes outcomes.     

Self-management of chronic low back pain: An exploration of the impact of a patient-centered website

Objective

This paper examines from a qualitative approach the role of a patient-centered website – named “Oneself” – on patients’ chronic low back pain self-management attitudes and behaviors in the Italian part of Switzerland.

Methods

In-depth interviews have been conducted with a purposive and convenient sample of 18 chronic low back pain sufferers who had used Oneself during 6 months. Data collection and analysis were driven by grounded theory.

Results

Reported positive effects of the use of Oneself on self-management attitudes and behaviors include self-comprehension, improvement of argumentative abilities, orientation, development of self-confidence and maintenance of a high level of attention. In some cases, participants affirm to have experienced negative effects such as confusion and discouragement. The individual's previous awareness of cLBP and level of self-management plays a main role in the way people use the website and in its impact. Based on this criterium, a typology of four patterns of use is drawn.

Conclusion

Patient-centered websites are useful for enhancing self-management of chronic low back pain. However, individuals take advantage of this means differently, based on their stage of advancement in the self-management process.

Practice implications

Information and supports provided online should be tailored according to people's stage of advancement.     

Mastery and perceived autonomy support are correlates of Dutch diabetes patients’ self-management and quality of life

Objective

The aim of this study was to assess the associations between type 2 diabetes patients’ mastery and perceived autonomy support and their self-management skills and health-related quality of life (HRQOL).

Methods

A cross-sectional questionnaire survey was conducted among 3352 patients with type 2 diabetes. Key variables were assessed with validated questionnaires.

Results

Patients’ mastery and perceived autonomy support correlated positively with their self-management skills (r = 0.34, p < 0.001; r = 0.37, p < 0.001) and HRQOL (r = 0.37, p < 0.001; r = 0.15, p < 0.001). In the linear regression analysis, mastery and perceived autonomy support were positive correlates of self-management (β = 0.23; p < 0.001; β = 0.25; p < 0.001). Patients with more physical or psychological complications had significantly lower scores on mastery, perceived autonomy support, self-management and HRQOL.

Conclusion

Our results indicate the importance of mastery in relation to diabetes patients’ perceived autonomy support, self-management skills and HRQOL.

Practice implications

Since a greater sense of mastery is likely to increase patients’ autonomous motivation to cope with their disease, interventions can aim to influence patients’ motivational regulation. In addition, we confirmed the need for autonomy support to improve patients’ self-management skills. Professionals can be trained to be autonomy-supportive, which relates to person-centered approaches such as motivational interviewing (MI).     

Patient empowerment: Myths and misconceptions

Objective

The purpose of this article is to clarify the concept of empowerment and to correct common misconceptions about its use in diabetes care and education.

Methods

The patient empowerment approach is well suited to helping patients make self-selected changes related to weight, nutrition, and physical activity. Although the concept of patient empowerment has become an integral part of diabetes education, an accurate understanding and authentic application of empowerment has not occurred as readily. The empowerment approach is clarified and common misconceptions have been corrected.

Results

Embracing empowerment means making a paradigm shift that is often difficult because the traditional approach to care is embedded in the training and socialization of most health care professionals (HCPs).

Conclusion

Unlike the traditional approach, empowerment is not something one does to patients. Rather, empowerment begins when HCPs acknowledge that patient are in control of their daily diabetes care.Empowerment occurs when the HCPs goal is to increase the capacity of patients to think critically and make autonomous, informed decisions. Empowerment also occurs when patients are actually making autonomous, informed decisions about their diabetes self-management.

Practice Implications

Clarity about all aspects of the empowerment approach is essential if it is to be used effectively.     

Self-management education for rehabilitation inpatients: A cluster-randomized controlled trial

Objective

To evaluate generic self-management modules (SelMa) as an adjunct to disease-specific educational programs during inpatient medical rehabilitation.

Depression self-management support: A systematic review

Objective

To systematically review empirical evidence regarding the efficacy of depression self-management support (SMS) interventions for improving depression symptomatology and preventing relapse.

Methods

Pubmed and PsycINFO databases were searched for relevant articles on depression SMS interventions. Scanning of references in the articles and relevant reviews and communications with field experts yielded additional articles. Two independent reviewers analyzed the articles for inclusion and data was extracted from the selected articles.

Results

13 papers met the inclusion criteria and reported the results of six separate studies, including three pilot studies. The results were mostly positive. A majority of the trials assessing depression severity changes found SMS to be superior to care as usual. SMS interventions were found to improve self-management behaviors and self-efficacy. Mixed results were found concerning relapse rates. Promising results were found on assessments of functional status. Based on the findings, cost-effectiveness remains unclear.

Conclusion

SMS has been mostly examined through pilot studies with insufficient power. The results are promising, but larger randomized controlled trials are needed.

Practice implications

SMS interventions can be administered by non-physician professionals and are well accepted by patients, but more research is needed before we can recommend implementing specific depression SMS approaches in primary care.     

Twelve-month outcomes of an Internet-based diabetes self-management support program

Objective

Internet-based programs offer potential for practical, cost-effective chronic illness self-management programs.

Methods

We report 12-month results of an Internet-based diabetes self-management program, with and without additional support, compared to enhanced usual care in a 3-arm practical randomized trial. Patients (n = 463) were randomized: 77.3% completed 12-month follow-up. Primary outcomes were changes in health behaviors of healthy eating, physical activity, and medication taking. Secondary outcomes were hemoglobin A1c, body mass index, lipids, blood pressure, and psychosocial factors.

Results

Internet conditions improved health behaviors significantly vs. usual care over the 12-month period (d for effect size = .09–.16). All conditions improved moderately on biological and psychosocial outcomes. Latinos, lower literacy, and higher cardiovascular disease risk patients improved as much as other participants.

Conclusions

The Internet intervention meets the reach and feasibility criteria for a potentially broad public health impact. However, 12-month magnitude of effects was small, suggesting that different or more intensive approaches are necessary to support long-term outcomes. Research is needed to understand the linkages between intervention and maintenance processes and downstream outcomes.

Practice implications

Automated self-management interventions should be tailored and integrated into primary care; maintenance of patient self-management can be enhanced through links to community resources.     

Communicating with older diabetes patients: self-management and social comparison

OBJECTIVE: The health status and life experiences of older diabetes patients may be highly heterogeneous, thus making their perspectives particularly relevant for developing individualized self-management plans for this population. Our earlier research showed older diabetes patients' healthcare goals and self-management behaviors are frequently shaped through social comparisons with peers/family members. The present paper explores this role of social comparison in their self-management practices and develops a conceptual model depicting the process. METHODS: Data were collected using open-ended, semi-structured interviews to elicit 28 older, type 2 diabetes patients' healthcare goals and self-management practices. Qualitative techniques were used to extract salient themes. RESULTS: Social comparison plays a salient role in routinizing older patients' self-management practices. Almost all patients assess their self-management by making "downward" comparisons with individuals doing worse than them; "upward" comparisons are rarely invoked. Occasionally patients' social comparisons lead them to adopt "normalizing" behaviors resulting in deviations from medically recommended self-care. CONCLUSION: The findings formed the basis for developing a conceptual model delineating the role of social comparison in self-management that can be beneficial for providers in tailoring educational interventions for self-management. PRACTICE IMPLICATIONS: Fostering these comparisons can help providers enhance communication on initiating and sustaining self-management practices.