Using digital interventions for self-management of chronic physical health conditions: A meta-ethnography review of published studies

ObjectivesTo understand the experiences of patients and healthcare professionals (HCPs) using self-management digital interventions (DIs) for chronic physical health conditions.MethodsA systematic search was conducted in 6 electronic databases. Qualitative studies describing users’ experiences of self-management DIs were included, and authors’ interpretations were synthesised using meta-ethnography.Results30 papers met the inclusion criteria, covering a range of DIs and chronic conditions, including hypertension, asthma and heart disease. The review found that patients monitoring their health felt reassured by the insight this provided, and perceived they had more meaningful consultations with the HCP. These benefits were elicited by simple tele-monitoring systems as well as multifaceted DIs. Patients appeared to feel more reliant on HCPs if they received regular feedback from the HCP. HCPs focused mainly on their improved clinical control, and some also appreciated patients’ increased understanding of their condition.ConclusionsPatients using self-management DIs tend to feel well cared for and perceive that they adopt a more active role in consultations, whilst HCPs focus on the clinical benefits provided by DIs.Practice implicationsDIs can simultaneously support patient condition management, and HCPs’ control of patient health. Tele-monitoring physiological data can promote complex behaviour change amongst patients.     

Results of a self-management program added to standard physical therapy in chronic neck pain

ObjectiveTo evaluate the effectiveness of a self-management treatment added to a physical therapy program compared to a physical therapy program in patients with chronic neck pain.MethodsFifty-three patients with chronic neck pain were randomly allocated to a physical therapy intervention (control group) or an individualized self-management combined with physical therapy intervention (experimental group). Both interventions were developed over a four-week period. Outcome measures included were Disability, Fear-Avoidance Beliefs, Health-Related Quality of Life, Pain, and Anxiety and Depression. All outcomes were measured before and after the treatment and at three-month follow-up.ResultsThere were not significant differences between groups at baseline. After the intervention both groups obtained better results in the Neck Disability Index but there were not significant differences between them (p > 0.05). At follow-up, the self-management group obtained significant better results compared to the control group (95 % CI: -5.20(-6.8 to -1.5), p = 0.032).ConclusionsAn individualized self-management program added to a physical therapy program led to a greater improvement in disability at 3 months follow up compared to a physical therapy program alone. Catastrophizing, pain, and health-related quality of life improved significantly after the intervention and at follow-up compared to the standard care alone.Practical implicationsThis study indicates that physical therapy for patients with chronic neck pain preferably should include self-management education.     

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.

Randomized trial of an uncertainty self-management telephone intervention for patients awaiting liver transplant

ObjectiveWe tested an uncertainty self-management telephone intervention (SMI) with patients awaiting liver transplant and their caregivers.MethodsParticipants were recruited from four transplant centers and completed questionnaires at baseline, 10, and 12 weeks from baseline (generally two and four weeks after intervention delivery, respectively). Dyads were randomized to either SMI (n = 56) or liver disease education (LDE; n = 59), both of which involved six weekly telephone sessions. SMI participants were taught coping skills and uncertainty management strategies while LDE participants learned about liver function and how to stay healthy. Outcomes included illness uncertainty, uncertainty management, depression, anxiety, self-efficacy, and quality of life. General linear models were used to test for group differences.ResultsNo differences were found between the SMI and LDE groups for study outcomes.ConclusionThis trial offers insight regarding design for future interventions that may allow greater flexibility in length of delivery beyond our study’s 12-week timeframe.Practice implicationsOur study was designed for the time constraints of today’s clinical practice setting. This trial is a beginning point to address the unmet needs of these patients and their caregivers as they wait for transplants that could save their lives.     

Fatigue self-management education in persons with disease-related fatigue: A comprehensive review of the effectiveness on fatigue and quality of life

ObjectivesTo systematically synthesize the effectiveness of fatigue self-management education (SME) on fatigue and quality of life (QoL) in persons with disease-related fatigue, and to describe the intervention characteristics.MethodsWe systematically reviewed the literature on SMEs in people with disease-related fatigue. We included randomized controlled trials (RCT), which aimed to improve self-management skills for fatigue in daily life. We synthesized the effectiveness and mapped the intervention characteristics.ResultsWe included 26 RCTs studying samples from eight disease groups. At follow-up, 46% studies reported statistically significant improvements on fatigue and 46% on QoL. For persons with cancer 6/8 and multiple sclerosis 8/10 RCTs showed positive evidence in favor of SME. The range of effect sizes was wide (d: 0.0 ->0.8). Delivery modalities (inpatient, outpatient, home), interactions (individual, group, remote), and duration [range (h): 1–17.5] varied.ConclusionsThe overall evidence on the effectiveness of SMEs on fatigue and QoL is limited and inconsistent. For persons with cancer and multiple sclerosis, the evidence provides a positive effect. The RCTs with medium to large effect on QoL indicate the potential benefit of SMEs.Practical implicationDuration and peer interaction should be considered when tailoring SMEs to populations and contexts.     

Supporting cancer patients to self-manage: Extent of use and perceptions of “trusted” online self-management resources

ObjectivesOnline resources can support patient self-management practices, but are not systematically used in routine clinical practice. We evaluated cancer patients' satisfaction with, and use of, tailored online resources.MethodsPatients completed monthly validated electronic patient reported outcome measures (ePROMs) of distress, unmet needs and symptoms. Patients with ePROM scores above pre-determined thresholds received an email directing them to relevant online self-management resources. Perceptions and experiences with these resources were evaluated via an online survey 3, 6 and 9 months after their initial monthly ePRO; and a subset of patients was also interviewed. Webpage use was monitored through Google Analytics and ClickMeter.ResultsOverall, 221 patients completed evaluation surveys and 31 completed interviews. Patients spent 0–10 min on average accessing resources, with 93% indicating they would reuse them. The most viewed page was physical wellbeing (n = 680); exercise and nutrition resources were most popular; and 69% of patients were satisfied with information content, reporting resources were easy to understand and navigate.ConclusionsOnline resources are perceived as acceptable and useful. Design and delivery recommendations can improve their support of self-management.Practice implicationsIncorporating automated online self-management resources into routine clinical workflows is a viable model to support routine follow up care.     

Acid-base balance and subjective feelings of fatigue during physical exercise

Six trained male subjects performed exercise on a bicycle ergometer. The external load was increased every minute by 10 watt until exhaustion. The subjects quantified their subjective feeling of fatigue by means of a rating scale.Parameters of acid-base balance (pH, ) were determined in arterial blood from the a. brachialis.Correction of the acidaemia by infusion of NaHCO₃ (8%) during exercise had no effect upon the subjective feeling of fatigue, and except for carbon dioxide output no effect upon some important physiological functions (heart rate, blood pressure, ventilation, and oxygen consumption) during submaximal and maximal exercise.     

The Look After Yourself (LAY) intervention to improve self-management in stroke survivors: Results from a quasi-experimental study

ObjectiveTo test the efficacy of a self-management intervention for stroke survivors vs. usual care.MethodsUsing a quasi-experimental study, participants were recruited from three public Italian hospitals. Questionnaires assessing self-efficacy (SSEQ), quality of life (SF-12), physical performance (SPPB), depression (GDS) and activities of daily living (MBI) were administered at baseline, discharge and two months after discharge. Mixed models with a propensity score were used between experimental group (EG) and control group (CG). Logistic models were used to compare the use of health services.ResultsEighty-two stroke survivors were enrolled in the EG and 103 in the CG. Self-efficacy in self-management improved in the EG compared to the CG during hospitalization. Improvements from baseline to discharge were found in the EG in the mental component of SF-12 and in MBI. The EG were 8.9 times more likely to contact general practitioners after discharge and 2.9 times to do regular exercise than CG. Notably, EG with higher education benefitted more from the intervention.ConclusionThe intervention was efficacious in improving self-efficacy, mental health and activities of daily living.Practice implicationsStructured educational interventions based on problem-solving and individual goal setting may improve self-management skills in stroke survivors.     

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.     

A secondary analysis of the moderating effects of depression and multimorbidity on the effectiveness of a chronic disease self-management programme

Objective

Patients accessing the chronic disease self-management programme (CDSMP) often report multiple long-term conditions (multimorbidity). Although multimorbidity often predicts poor outcomes, CDSMP effectiveness may be enhanced in multimorbidity via synergies between self-management for different conditions. This study assessed whether CDSMP benefits varied by patterns of multimorbidity.

Methods

The study was based on a secondary analysis of an RCT. Patients with long-term conditions (n = 629) were randomised to CDSMP or wait-list and completed baseline and 6 month assessments. We identified four multimorbidity groups: (1) single physical condition; (2) multiple physical conditions; (3) single physical condition plus ‘probable depression’; (4) multiple physical conditions plus ‘probable depression’.

Results

Multimorbidity group significantly moderated the effect of CDSMP on vitality, health-related quality of life, and mental well-being, with the greatest benefit found for patients with multiple physical conditions plus ‘probable depression’.

Conclusion

The coexistence of depression and multiple physical conditions is associated with increased illness burden, but such patients benefit more from the CDSMP. The mechanisms underlying this effect are unclear, but it does not appear to be through self-management or self-efficacy.

Practice implications

The presence of multimorbidity in combination with depression may be a useful criteria for referral to the CDSMP.     

Treatment-related and psychosocial variables in explaining physical activity in women three weeks to six months post-treatment of breast cancer

Objective

This study examined treatment-related and psychosocial variables in explaining total and leisure time physical activity in breast cancer survivors three weeks to six months post-treatment.

Methods

A questionnaire was used to measure total and leisure time physical activity and relevant determinants among 464 breast cancer survivors (aged 18–65 years).

Results

Personal control was an important overall determinant in explaining physical activity in breast cancer survivors. The impact of treatment-related variables and psychological functioning depended on the working status of the women. Fatigue and poor body image prevented non-working women from being sufficiently physically active. In working women, chemotherapy and arm problems negatively influenced physical activity, whereas therapy side-effects (headaches, hot flashes, feeling unwell) and poor body image positively influenced physical activity. Social support and coping strategies could not explain post-treatment physical activity levels.

Conclusion

Personal control, treatment-related variables and psychological functioning influenced physical activity after cancer treatment. Relations depended on the working status of the women.

Practice implications

Incorporating self-control methods in physical activity interventions after breast cancer could be helpful. Furthermore, interventions should be tailored to the experienced symptoms (fatigue, arm-problems, body image) and working status of women.     

A randomised controlled trial of lay-led self-management for people with multiple sclerosis

Objective

To determine the impact of the Chronic Disease Self-Management Course (CDSMC) on people with multiple sclerosis (MS).

Methods

2-group, randomised, controlled trial with Intervention Group (IG) and Waiting-List Control Group (WLCG). Additional data were collected from a Comparison Group (CG) who chose not to attend the CDSMC. Participants completed baseline questionnaires; IG participants attended the CDSMC immediately; all participants were assessed at 4-months and 12-months.

Results

216 baseline questionnaires were returned; 73% were female, mean age 51.1 years, mean disease duration 12.0 years. Results showed that the CDSMC had an impact on self-management self-efficacy (ES 0.30, p = 0.009 for the IG) and MSIS physical status (ES 0.12 for the IG, p = 0.005). There were no other statistically significant changes. However, trends towards improvement on depression (ES 0.21 for the IG, p = 0.05) and MS self-efficacy (ES 0.16 for the IG, p = 0.04) were noted. All improvements were maintained at 12-months. At baseline, CG participants were older, had longer disease duration (p < 0.01) and less anxiety (p = 0.009) compared to RCT participants.

Conclusion

The CDSMC provides some small positive effects for people with MS. Motivation to attend may be linked to psychological distress and disease duration.

Practice implications

The CDSMC may be of value for those with mild anxiety/depression who need extra support. Attendance early in the disease course is recommended.     

Nanoscale theranostics for physical stimulus-responsive cancer therapies

Physical stimulus-responsive therapies often employing multifunctional theranostic agents responsive to external physical stimuli such as light, magnetic field, ultra-sound, radiofrequency, X-ray, etc., have been widely explored as novel cancer therapy strategies, showing encouraging results in many pre-clinical animal experiments. Unlike conventional cancer chemotherapy which often accompanies with severe toxic side effects, physical stimulus-responsive agents usually are non-toxic by themselves and would destruct cancer cells only under specific external stimuli, and thus could offer greatly reduced toxicity and enhanced treatment specificity. In addition, physical stimulus-responsive therapies can also be combined with other traditional therapeutics to achieve synergistic anti-tumor effects via a variety of mechanisms. In this review, we will summarize the latest progress in the development of physical stimulus-responsive therapies, and discuss the important roles of nanoscale theranostic agents involved in those non-conventional therapeutic strategies.     

Development of a motivation-based tool to facilitate individualized self-management interventions for adolescents with asthma

ObjectiveTo develop a questionnaire for segmenting adolescents with asthma into archetypes based on their motivations for individualized self-management interventions.MethodsA prospective observational study using segmentation methodology. First, adolescents created photo diaries followed by in-person semi-structured interviews to develop a pool of candidate items for identifying and describing archetypes. Second, quantitative methods were used to test the pool of items to determine which ones best identified each archetype.ResultsSix archetypes based on motivations were identified and described: goal oriented visionaries; mentors and helpers; influencers; discouraged adolescents; dependent adolescents; and shame avoiders. A questionnaire with 63 candidate items was administered to 201 adolescents. Confirmatory factor analysis resulted in a 17-item questionnaire that identified the archetypes.ConclusionThis study is the first step towards applying a segmentation methodology to facilitate the application of interventions during a clinic visit to increase adherence. It has shown that a relatively short questionnaire can be used to identify archetypes based on motivations.Practice ImplicationsThe 17-item questionnaire could provide a framework and direction for healthcare professionals to customize existing adherence interventions, such as motivational interviewing, to different segments of adolescents. It would be especially helpful in primary care settings where time is limited.     

Preferences for patient-centered care among cancer survivors 5 years post-diagnosis

ObjectiveOur primary objective was to identify predictors associated with preferences for patient-centered care among cancer survivors and the association between cancer health literacy and patient-centered care preferences.MethodsCross sectional analyses of N = 345 adult cancer survivors (5 years post cancer diagnosis) attending follow-ups at University Malaya Medical Centre, Malaysia. Face-to face-interviews were conducted using the 30-item Cancer Health Literacy Test and the Patient-Practitioner Orientation Scale to determine preference for patient-centered care.ResultsCancer survivors’ preference for patient-centered care was associated with a higher cancer health literacy score, higher educational level, being employed, breast cancer diagnosis, and not desiring psychological support [F (14, 327) = 11.25, p < 0.001, R² = 0.325].ConclusionFindings from this study provide insights into preferences for patient-centered care among cancer survivors during receipt of follow-up care, which remains an understudied phase of cancer care delivery.Practice implicationsEfforts are needed to ensure different preferences for care are taken into account particularly in the setting of variable cancer health literacy.     

The influence of diabetes psychosocial attributes and self-management practices on change in diabetes status

Objective

To examine the influence of diabetes psychosocial attributes and self-management on glycemic control and diabetes status change.

Methods

Using data from the Health and Retirement Study, a nationally representative longitudinal study of U.S. adults >51 years, we examined cross-sectional relationships among diabetes psychosocial attributes (self-efficacy, risk awareness, care understanding, prioritization of diabetes, and emotional distress), self-management ratings, and glycemic control. We then explored whether self-management ratings and psychosocial attributes in 2003 predicted change in diabetes status in 2004.

Results

In multivariate analyses (N = 1834), all diabetes psychosocial attributes were associated with self-management ratings, with self-efficacy and diabetes distress having the strongest relationships (adj coeff = 8.1, p < 0.01 and −4.1, p < 0.01, respectively). Lower self-management ratings in 2003 were associated cross-sectionally with higher hemoglobin A1C (adj coeff = 0.16, p < 0.01), and with perceived worsening diabetes status in 2004 (adj OR = 1.36, p < 0.05), with much of this latter relationship explained by diabetes distress.

Conclusion

Psychosocial attributes, most notably diabetes-related emotional distress, contribute to difficulty with diabetes self-management, poor glycemic control, and worsening diabetes status over time.

Practice implications

Self-management and adherence interventions should target psychosocial attributes such as disease-related emotional distress.     

The effect of an education programme (MEDIAS 2 ICT) involving intensive insulin treatment for people with type 2 diabetes

Objective

In a randomized, multi-centre trial, the effect of an education programme (MEDIAS 2 ICT) involving intensive insulin treatment for people with type 2 diabetes was compared with an established education programme as an active comparator condition (ACC).

Methods

We investigated whether MEDIAS 2 ICT was non-inferior to ACC in overall glycaemic control. Secondary outcomes were the diabetes-related distress, diabetes knowledge, quality of life, self-care behavior, lipids, blood pressure and weight.

Results

186 subjects were randomized. After a six month follow-up the mean HbA1c decrease was 0.37% (from 8.2 ± 1.1% to 7.8 ± 1.5%) in the ACC and 0.63% (from 8.5 ± 1.5% to 7.9 ± 1.2%) in MEDIAS 2 ICT. The mean difference between both groups was −0.26% (95% CI −0.63 to −0.14) in favor of MEDIAS 2 ICT. This result was within the predefined limit for non-inferiority. Diabetes-related distress was significantly more reduced in MEDIAS 2 ICT (−3.4 ± 7.1) than in ACC (0.4 ± 9.0; p = 0.31).

Conclusion

MEDIAS 2 ICT is as effective in lowering HbA1c as previously established education programmes, but showed superiority in reducing diabetes-related distress.

Practical implications

MEDIAS 2 ICT provides an alternative for education of people with type 2 diabetes treated by multiple injection therapy.