The association between patient activation and self-care practices: A cross-sectional study of an Australian population with comorbid diabetes and chronic kidney disease

Diabetes self-care and its associated factors among type 2 diabetes mellitus with chronic kidney disease patients in the East Coast of Peninsular Malaysia

Introduction

Diabetes self-care among diabetic patients is crucial as it determines how patients care for their illness in their daily routine for better diabetes control. This study aims to calculate the average score for diabetes self-care among patients with type 2 diabetes mellitus and chronic kidney disease and to identify factors that are associated with this score.

Materials and Methods

This cross-sectional study enrols patients over 18 years old with type 2 diabetes mellitus and chronic renal disease with an eGFR of less than 60 mL/min/1.73 m2 in a tertiary hospital in Malaysia. The Malay version of the Summary of Diabetic Self-Care Activities (SDSCA) was used to assess diabetes self-care, the Malay version of the diabetes-related distress questionnaire (DDS-17) was used to assess diabetes distress, and the Malay version of the Patient Health Questionnaire-9 (PHQ-9) was used to assess depression. Data analysis was performed using both simple and multiple linear regression models to determine the associations between variables.

Result

One hundred and seventy-six eligible patients were recruited for this study. The mean score for diabetes self-care is 3.62. The eGFR (p = 0.002) and diabetes distress (p = 0.004) are the significant associated factors for diabetes self-care among type 2 diabetes mellitus patients with chronic kidney disease.

Conclusion

The mean score for diabetes self-care indicated a moderate level of self-care. The eGFR level and diabetes distress were important factors influencing diabetes self-care practices.

Pica is associated with lower willingness to change negative habits of diet and exercise, inadequate lifestyle, and less healthful food consumption in dialysis

Background

In dialysis patients, on the one hand unwillingness to change negative lifestyle patterns is associated with worse nutritional status and unhealthy lifestyle, whereas on the other, pica may be highly prevalent. However, it is not known whether pica is associated with unwillingness to change negative lifestyle behaviors, as well as with consumption of different types of foods. This study aimed to investigate this issue.

Methods

This is a cross-sectional study in dialysis patients. Lifestyle was assessed using the self-administered Instrument to Measure Lifestyle Questionnaire (IMEVID). Pica diagnosis was established according to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. A food frequency questionnaire was performed and self-reported willingness to change was determined by a trans-theoretical model staging inventory.

Results

Compared with patients without pica, those with pica (particularly hard pica) had lower willingness to change unhealthy behavior in the case of diet (22% vs. 46% in precontemplation/contemplation stages, respectively) and exercise (43% vs. 62% in precontemplation/contemplation stages, respectively). Patients with hard pica had significantly (p < 0.05) lower scores in almost all dimensions of the lifestyle questionnaire than those in the no pica group: diet (23.9 vs. 26.8, respectively), physical activity (5.5 vs. 7, respectively), knowledge of disease (5.7 vs. 6.4, respectively), emotion management (6.6 vs. 8, respectively) and adherence to treatment (13.4 vs. 14.7, respectively), but not in the consumption of tobacco and alcohol. Compared to patients with no pica, those with hard pica ate vegetables and fruits less frequently, and dairy products, fried foods and soda more frequently.

Conclusions

Pica was more frequently observed in patients with lower willingness to change negative habits of diet and exercise, in those who had more unhealthy behaviors in diet, exercise and emotion management dimensions and adherence to treatment, as well as in those who ate less frequently healthful foods and more frequently unhealthy foods.

Patient activation in advanced chronic kidney disease: a cross-sectional study

BACKGROUND

Patient activation refers to the knowledge, confidence and skills required for the management of chronic disease and is antecedent to self-management. Greater self-management in chronic kidney disease (CKD) results in improved patient experience and patient outcomes.

AIM

To examine patient activation levels in people with CKD stage 5 pre-dialysis and determine associations with sociodemographic characteristics, treatment adherence and healthcare utilisation.

METHODS/DESIGN

People with CKD stage 5 not receiving dialysis from one Australian kidney care service. Patient activation was measured using the 13-item Patient Activation Measure (PAM-13). Sociodemographic and clinical outcome data (emergency department visits, admissions) were collected from medical records. Morisky Medication Adherence Scale was used to determine self-report medication adherence.

RESULTS

Two hundred and four participants completed the study. The mean PAM-13 score was 53.4 (SD 13.8), with 73% reporting low activation levels (1 and 2). Patient activation scores significantly decreased with increased age (P < 0.001) and significantly increased with higher educational levels (P < 0.001). Higher patient activation level was associated with fewer hospital emergency department visits (P = 0.03) and increased medication adherence (P < 0.001).

CONCLUSION

Patient activation levels are low in people with CKD stage 5 not receiving dialysis suggesting limited ability for self-management and capacity for optimally informed decisions about their healthcare. Efforts to improve patient activation need to consider age and education level.

Health literacy and self-care among patients with chronic kidney disease in a primary care setting

INTRODUCTION

The study objective was to determine the levels of self-care and health literacy (HL) and their associations among patients with chronic kidney disease (CKD).

METHODS

This was a cross-sectional, questionnaire-based study conducted in a public primary care setting in Singapore. A total of 289 participants aged 21-80 years with hypertension were recruited. Self-care profiles were measured using the Hypertension Self-Care Profile (HTN-SCP; range 0-240, domain range 0-80). Health literacy was measured using the Short-Form Health Literacy Scale (HLS-SF12; range 0-50, limited literacy ≤33).

RESULTS

The mean self-care score was 182.7 (standard deviation [SD] 23.2). The median HL score was 34.7 (interquartile range [IQR] 31.9-40.3), and 31.1% of participants had limited HL. Self-care was not associated with age, CKD status, household income and education, but was associated with gender and HL score. In the final regression model, lower HL scores (adjusted β = 1.03, 95% confidence interval [CI] 0.7 to 1.36, P < 0.001) and male gender (adjusted β = -5.29, 95% CI -10.56 to -0.03, P = 0.049) were associated with lower self-care scores. The HL scores were associated with self-care domains of self-efficacy (HL: β = 0.30, 95% CI 0.17 to 0.42, P < 0.001), motivation (HL: β = 0.40, 95% CI 0.26 to 0.53, P < 0.001) and behaviour (HL: β = 0.38, 95% CI 0.26 to 0.50, P < 0.001).

CONCLUSION

Thirty-one percent of the participants had limited HL. Self-care was not associated with age, race, CKD status, household income or education. Male gender and limited HL were associated with lower self-care. Self-care was associated with self-efficacy, motivation and behaviour. Future research could focus on more targeted approaches to improve self-care and HL among patients with CKD.

Application value of DSMB-O scale in self-management of elderly patients with type 2 diabetes mellitus

BACKGROUND

To enhance the self-management ability of elderly diabetes mellitus (DM) patients, priority should be given to the accurate evaluation of their current self-management ability, and then provide corresponding guidance.

OBJECTIVE

To explore the application value of Diabetes Self-Management Behaviors among Older Koreans (DSMB-O) in self-management of elderly patients with type 2 diabetes mellitus (T2DM).

METHODS

Using convenient sampling, this study retrospectively collected the clinical data of 215 elderly patients with T2DM who were admitted to our hospital from June 2020 to June 2022. Enrolled patients were divided into an effective-control group (n= 80) and an ineffective-control group (n= 135) based on whether the glycated hemoglobin (HbA1C) was < 7.5% for further comparison of the collected data.

RESULTS

There were statistically significant differences in the comparison of the proportion of diabetes mellitus (DM) course (χ2= 26.000, P< 0.001), DSMB-O score (17.67 ± 4.07 VS 14.67 ± 4.70 points, t= 4.582, P< 0.001), and Summary Diabetes Self Care Activity (SDSCA) score (43.16 ± 11.17 VS 37.58 ± 12.47 points, t= 5.492, P< 0.001) between the two groups. The total score of DSMB-O was negatively correlated with both HbA1c (r=-0.281, P< 0.001) and complications (r=-0.193, P= 0.004); moreover, the total score of SDSCA was also negatively correlated with both HbA1c (r=-0.234, P< 0.001) and complications (r=-0.153, P= 0.025). Among various dimensions of DSMB-O, active exercise (OR= 0.699, 95%CI: 0.541 ∼ 0.902) and blood glucose monitoring (OR= 0.603, 95%CI: 0.431 ∼ 0.817) were protective factors for T2DM patients with HbA1c levels < 7.5%. The area under the curve (AUC) of SDSCA score and DSMB-O score predicting self-management level in elderly T2DM patients was 0.643 (95%CI: 0.611 ∼ 0.756) and 0.716 (95%CI: 0.689∼ 0.774), respectively.

CONCLUSION

DSMB-O exhibits a higher accuracy in predicting the self-management level of elderly patients with T2DM than that of SDSCA. Regular exercise, medication, blood glucose monitoring, and reducing the risk of complications are all intimately associated with the control of blood glucose.

A codesigned integrated kidney and diabetes model of care improves patient activation among patients from culturally and linguistically diverse backgrounds

BACKGROUND

Little is known about the relationship between patients' cultural and linguistic backgrounds and patient activation, especially in people with diabetes and chronic kidney disease (CKD). We examined the association between culturally and linguistically diverse (CALD) background and patient activation and evaluated the impact of a codesigned integrated kidney and diabetes model of care on patient activation by CALD status in people with diabetes and CKD.

METHODS

This longitudinal study recruited adults with diabetes and CKD (Stage 3a or worse) who attended a new diabetes and kidney disease service at a tertiary hospital. All completed the patient activation measure at baseline and after 12 months and had demographic and clinical data collected. Patients from CALD backgrounds included individuals who spoke a language other than English at home, while those from non-CALD backgrounds spoke English only as their primary language. Paired t-tests compared baseline and 12-month patient activation scores by CALD status.

RESULTS

Patients from CALD backgrounds had lower activation scores (52.1 ± 17.6) compared to those from non-CALD backgrounds (58.5 ± 14.6) at baseline. Within-group comparisons showed that patient activation scores for patients from CALD backgrounds significantly improved by 7 points from baseline to 12 months follow-up (52.1 ± 17.6-59.4 ± 14.7), and no significant change was observed for those from non-CALD backgrounds (58.5 ± 14.6-58.8 ± 13.6).

CONCLUSIONS

Among patients with diabetes and CKD, those from CALD backgrounds report worse activation scores. Interventions that support people from CALD backgrounds with comorbid diabetes and CKD, such as the integrated kidney and diabetes model of care, may address racial and ethnic disparities that exist in patient activation and thus improve clinical outcomes.

PATIENT OR PUBLIC CONTRIBUTION

Patients, caregivers and national consumer advocacy organisations (Diabetes Australia and Kidney Health Australia) codesigned a new model of care in partnership with healthcare professionals and researchers. The development of the model of care was informed by focus groups of patients and healthcare professionals and semi-structured interviews of caregivers and healthcare professionals. Patients and caregivers also provided a rigorous evaluation of the new model of care, highlighting its strengths and weaknesses.

Exploring factors influencing patient activation in Saudi rheumatoid arthritis patients: A Nationwide Cross-Sectional Survey-Results from the COPARA study

OBJECTIVES

To evaluate patient activation in rheumatoid arthritis (RA) patients using patient activation measure 13 (PAM-13) on a national level in Saudi Arabia.

METHOD

A national survey was administered across multiple centers in Saudi Arabia. Patient activation was assessed using the PAM-13. The Compliance Questionnaire for Rheumatology (CQR) and the RA Impact of Disease (RAID) tool were also administered. The data from the survey were analyzed, and the results were stratified based on activation level. All factors affecting patient activation were explored and reported.

RESULTS

A total of 1241 participants were included. Most of the patients were females (85%), the mean age was 47 (±14), and most patients lived in the central region (47%). The mean (±standard deviation) patient activation score was 578.7 (±13.0). Patient activation was affected by multiple factors: demographic characteristics, such as education, with a beta value of 1.11 (95% confidence interval [CI] 0.64 ̶1.58, p < .001). Higher CQR scores were associated with higher activation levels, with a beta value of 2.61 (95% CI 0.80 ̶4.44, p = .005), and higher RAID scores were associated with lower activation levels, with a beta value of 3.13 (95% CI 1.36 ̶4.91, p = .001).

CONCLUSIONS

Patient activation was affected by several demographic characteristics and the impact of RA. A higher activation may improve compliance. Future longitudinal studies are required to confirm these findings and should explore the underlying mechanism of these effects.

The mediating effect of self-efficacy on the relationship between diabetes self-management ability and patient activation in older adults with type 2 diabetes

OBJECTIVE

The aim of this study was to investigate the level of diabetes self-management ability in older patients with type 2 diabetes and analyse its relationship with patient activation. Besides, the mediating effect of self-efficacy on the relationship between the two was assessed in the study.

METHODS

Using a cross-sectional design, 200 elderly patients with type 2 diabetes were recruited from the community of Yangzhou, China. The Patient Activation Measure (PAM), The Self-efficacy for Diabetes (SED), and The Summary of Diabetes Self-Care Activities Measure (SDSCA) were used in the questionnaires. Data analysis was performed using SPSS 27.0 and PROCESS macro.

RESULTS

Pearson correlation analysis revealed a significant positive correlation (p< 0.01) between diabetes self-management ability and patient activation (r=0.312) and self-efficacy (r=0.367). Self-efficacy partially mediated the effect between patient activation and self-management ability in older patients with type 2 diabetes, and the mediating effect accounted for 49.33% of the total effect (p< 0.001).

CONCLUSIONS

Older patients with type 2 diabetes in the community have a moderate level of self-management ability. Patient activation can improve patients' self-management ability through self-efficacy.

Factors related to recruitment and retention of patients into diabetes group visits in Federally Qualified Health Centers

RATIONALE, AIMS AND OBJECTIVES: To examine factors related to recruitment of eligible patients and retention of enrolled patients in diabetes group visits (GVs).

METHOD

As part of a cluster randomized trial, 272 eligible patients were contacted and 75 patients were eventually enrolled in GVs at six community health centers (CHC). Fisher's exact tests and χ² tests were used to compare enrolled and nonenrolled patients by patient recruitment method, gender and preferred language. Linear mixed models were used to evaluate characteristics associated with GV attendance such as diabetes self-empowerment and diabetes-associated distress. Content analysis was used to analyse patients' open-ended survey responses, and template analysis was used to analyse CHC staff interviews.

RESULTS

In terms of recruitment and enrollment analysis, patients who received in-person contact only and both phone and in-person contact comprised a greater fraction of the enrolled than unenrolled group, while those who received phone only and both phone and mail comprised a smaller fraction of the enrolled than unenrolled group (p = 0.004). In terms of retention analysis, 70 of the 75 enrolled patients attended at least one GV (93%). The average number of GVs was 3.2 out of 6 visits. Higher GV attendance was associated with lower baseline diabetes empowerment (p = 0.03). Patients' most common self-reported motivating factors to attend GVs were to learn more about diabetes, gain improved blood glucose control and find support from peers.

CONCLUSION

In-person recruitment for GVs at CHCs was more effective than recruitment by telephone/mail. Patients who felt less empowered to manage their diabetes were most motivated to attend GVs. These findings could help clinicians implement targeted recruitment of patient populations who are more likely to attend diabetes GVs and tailor self-management education interventions to their patient populations, particularly for underserved patients who face disparate clinical outcomes.

Preoperative patient activation predicts minimum clinically important difference for PROMIS pain and physical function in patients undergoing elective spine surgery

BACKGROUND CONTEXT

Patient activation is a patient's willingness to take independent actions to manage their own health care.

PURPOSE

The goal of this study is to determine whether preoperative patient activation measure (PAM) predicts minimum clinically important difference (MCID) for Patient-Reported Outcomes Measurement Information System (PROMIS) pain, physical function, depression, and anxiety for patients undergoing elective spine surgery.

STUDY DESIGN/SETTING

Retrospective review.

PATIENT SAMPLE

A single-institution, academic database of patients undergoing elective spine surgery.

OUTCOME MEASURE

MCID at 1-year follow-up for PROMIS pain, physical function, depression and anxiety.

METHODS

We retrospectively reviewed a single-institution, academic database of patients undergoing elective spine surgery. Preoperative patient activation was evaluated using the PAM-13 survey, which was used to stratify patients into four activation stages. Primary outcome variable was achieving MCID at 1-year follow-up for PROMIS pain and physical function. Multivariable logistic regression analysis was used to determine impact of patient activation on PROMIS pain and the physical function.

RESULTS

Of the 430 patients, 220 (51%) were female with a mean age of 58.2±16.8. Preoperatively, 34 (8%) were in activation stage 1, 45 (10%) in stage 2, 98 (23%) in stage 3, and 253 (59%) in stage 4. At 1-year follow up, 248 (58%) achieved MCID for PROMIS physical function, 256 (60%) achieved MCID for PROMIS pain, 151 (35.28%) achieved MCID for PROMIS depression, and 197 (46%) achieved MCID for PROMIS anxiety. For PROMIS physical function, when compared to patients at stage 1 activation, patients at stage 2 (aOR:3.49, 95% CI:1.27, 9.59), stage 3 (aOR:3.54, 95% CI:1.40, 8.98) and stage 4 (aOR:7.88, 95% CI:3.29, 18.9) were more likely to achieve MCID. For PROMIS pain, when compared against patients at stage 1, patients at stage 3 (aOR:2.82, 95% CI:1.18, 6.76) and stage 4 (aOR:5.44, 95% CI:2.41, 12.3) were more likely to achieve MCID. For PROMIS depression, when compared against patients at stage 1, patients at stage 4 were more likely to achieve MCID (Adjusted Odds Ratio (aOR):2.59, 95% CI:1.08-6.19). For PROMIS anxiety, when compared against patients at stage 1, stage 3 (Adjusted Odds Ratio (aOR):3.21, 95% CI:1.20-8.57), and stage 4 (aOR:5.56, 95% CI:2.20-14.01) were more likely to achieve MCID.

CONCLUSION

Patients at higher stages of activation were more likely to achieve MCID for PROMIS pain, physical function, depression, and anxiety at 1-year follow-up. Routine preoperative assessment of patient activation may help identify patients at risk of poor outcomes.

Patient engagement in decision making and associated factors among outpatients with selected non-communicable chronic diseases in public hospitals of West Shoa, Ethiopia

BACKGROUND

Despite the importance of patient engagement in health care decision-making in the care of patients with chronic diseases, there is limited information about it and the factors affecting it in Ethiopia and in the Public Hospitals of West Shoa in particular. Thus, this study was designed to assess the engagement of patients with selected chronic non-communicable diseases in health care decision-making and associated factors in public hospitals of West Shoa Zone, Oromia, Ethiopia.

METHODS

We used an institution -based cross-sectional study design. We used systematic sampling for the selection of study participants from June 7-July 26, 2020. Standardized, pretested, and structured Patient Activation Measure was used to measure patient engagement in healthcare decision-making. We did descriptive analysis to determine the magnitude of patient engagement in health care decision-making. Multivariate logistic regression analysis was used to determine factors associated with patients' engagement in the health care decision-making process. Adjusted odds ratio with a 95% confidence interval was calculated to measure the strength of association. We declared statistical significance at p<0.05. we presented the results in tables and graphs.

RESULTS

406 patients with chronic diseases took part in the study, yielding a response rate of 96.2%. Less than a fifth [19.5% (95% CI: 15.5, 23.6)] of participants in the study area had a high engagement in their health care decision-making. Educational level (college or above) [AOR = 5.2, 95% CI (1.76-15.46)], duration of diagnosis >5 years [AOR = 1.8, 95% CI (1.03-3.2)], health literacy [AOR = 1.15, 95% CI (1.06-1.24)], autonomy preference in decision making [AOR = 1.35, 95% CI (1.03-1.96)] were factors significantly associated with participants' engagement in health care decision making among patients with chronic diseases.

CONCLUSION

A high number of respondents had a low engagement in their health care decision-making. Preference for autonomy in decision making, educational level, health literacy, duration of diagnosis with the disease were factors associated with patient engagement in health care decision making among patients with chronic diseases in the study area. Thus, patients should be empowered to be involved in decision making to increase their engagement in the care.

The Patient Activation Measure in Patients with Rheumatoid Arthritis: A Systematic Review and Cross-Sectional Interview-Based Survey

Introduction/Objective

The patient activation measure (PAM) is considered a reliable tool for measuring patient activation. This study aimed to systematically review the scientific literature regarding the use of PAM -13 in rheumatology patients and to compare PAM scores in patients with rheumatoid arthritis (RA) following two different practices at a single institution with previously published studies.

Methods

The study consisted of a systematic review of articles reporting the PAM-13 in patients with RA, followed by a cross-sectional study evaluating PAM scores between standard rheumatology clinics and specialized rheumatology clinics (SRCs). The correlation between PAM levels and other variables, such as demographics, disease characteristics, and treatment, was assessed.

Results

Nineteen studies, published between 2012 and 2022, met the inclusion criteria. The studies in this review had inconsistent results and quality, with patient activation in RA ranging from 29 to 76. A total of 197 patients with confirmed RA diagnoses were interviewed (response rate, 88%). Most were female (n=173, 88%) and older than 40 years (n=150, 76%). The average patient activation score was 64.9 (standard deviation, 15.7). Most participants had level 3 and 4 patient activation measures (n=71 [36%] and n=72[37%], respectively). Patients who were attending SRCs also had borderline higher PAM levels. Patients with high PAM scores tended to be older, have active disease, and were taking corticosteroids.

Conclusion

Adequate activation of patients was observed from our center, which was higher than that reported in most published literature. The PAM of patients with RA was variable according to the systematic review. Longitudinal interventional studies should be considered to improve activation in patients with low scores.

Patient activation and its association with health indices among patients with inflammatory bowel disease

BACKGROUND

Patient activation refers to patients' independence in daily activities, involvement in the therapeutic process, and ability to manage their health. This study examined the association between the activation of patients with inflammatory bowel disease (IBD) and its effect on health indices.

OBJECTIVES

To evaluate the association between the activation of patients with IBD measured by patient activation measure (PAM-13) questionnaire with disease activity and quality of life in IBD.

DESIGN

A retrospective cross-sectional study.

METHODS

This study included patients with Crohn's Disease (CD) or ulcerative colitis (UC) followed at a large medical center in Israel, who were recruited during routine visits. They answered weekly questionnaires using a mobile smartphone application that included clinical and emotional disease parameters, including IBD control, quality of life [short IBD quality of life questionnaire (SIBDQ)], patient-reported outcomes measurement information system (PROMIS-10) and PAM-13. Additional clinical parameters were collected from electronic medical records.

RESULTS

Among 201 patients (113 females) who responded to the questionnaires, 152 (75.6%) had CD and 49 (24.4%) UC. For PAM-13, 158 (79%) patients were at PAM-13 levels 3-4 (mean score: 68.5, range: 60.0-73.1) and 43 (21%) were at levels 1-2 (mean score: 45.2, range: 40.9-49.9). PAM-13 levels were correlated with IBD control (r = 0.19, p = 0.023), SIBDQ (r = 0.20, p = 0.010), and PROMIS-10 score (r = 0.24, p = 0.017).

CONCLUSIONS

Our findings demonstrate the importance of patient activation and engagement in IBD. Knowledge of patient activation may enable caregivers to predict levels of self-care and the likelihood of compliance with health behavior recommendations.

Relationship between patient activation and self-efficacy among patients undergoing hemodialysis: a cross-sectional study

Background

Patient activation in chronic kidney disease (CKD) is increasingly being prioritized and considered a quality metric in CKD. Given the importance of patients’ activation in improving the quality of chronic disease care, this study aimed to assess patients’ activation levels and its relationship with self-efficacy among patients undergoing hemodialysis.

Methods

In this cross-sectional study, a total of 180 patients undergoing maintenance hemodialysis were selected by random sampling from the largest hemodialysis center (dialysis center of Emam Reza hospital, Tabriz) in Iran. Data were collected by demographics, patient activation measure, and chronic kidney disease self-efficacy (CKD-SE) scale from March to May 2021. Collected data were analyzed using SPSS software (ver. 26) using ANOVA, t-test, Pearson correlation coefficient, and multiple regression tests.

Results

The majority of the participants (35%) were at level 1 of activation and only 28.9% of the individuals were at level 4. According to the results, the mean score of self-efficacy in patients undergoing hemodialysis (in a possible range of 0–10) was 5.50 ± 1.45. Multiple regression analysis showed that factors including self-efficacy, educational level, and marital status were significant predictors of change in patient activation (R2 = 0.85, adjusted R2 = 0.66, p < 0.001). The results showed that self-efficacy was the main predictor of patient activation (β = 0.49, p < 0.001).

Conclusion

According to the result, improving the patients' self-efficacy could improve the patient's activation. Moreover, patients with lower educational level reported the lower activation score; therefore, health care providers should improve the knowledge of patients with lower educational level, encourage them to be more active in their health care, and help them in providing more tailored strategies to improve the quality of care more efficiently. Furthermore, Measuring patients' activation level at admission to the dialysis unit is recommended for all patients undergoing hemodialysis.

Patient activation for self-management among adult patients with multimorbidity in primary healthcare settings

Background and Aims

Multimorbidity is a major public health and healthcare challenge around the world, including in Finland. As multimorbidity necessitates self-management in everyday life, the effects of patient activation - a patient's knowledge, skills, and confidence in managing own health - on the capacity for self-management warrant study, especially in primary healthcare settings. This study aimed to assess patient activation among multimorbid primary healthcare patients, identify factors associated with patient activation, and determine whether patients with low and high activation differ in terms of health and self-management behavior, related perceptions, and health-related quality of life (HRQoL).

Methods

A cross-sectional survey was conducted among multimorbid patients who attended Finnish primary healthcare consultations (November 2019 to May 2020). The main outcome, patient activation, was assessed using the patient activation measure, PAM-13®. Responses from 122 patients were analyzed using descriptive statistics, t-tests, analysis of variance, linear modeling, the χ 2 test, and binary regression analysis.

Results

The mean score of patient activation was 56.12 (SD 12.82) on a scale 0-100 where ≤55.1 indicate low activation. The lower activation scores were significantly associated with old age, obesity, loneliness, and lower perceived health, functional ability, and vitality. Patients with low activation (47%) had significantly poorer physical activity, diets, adherence to care, and HRQoL, and significantly worse perceptions related to self-management including motivation and energy, sense of normality, and support from physicians, nurses, and close people.

Conclusion

Patient activation among multimorbid outpatients was rather low. Findings indicate that patients' perceptions of their health and psychosocial factors may be important for activation and that patients with low and high activation differ with respect to several health variables. Determining patient activation in multimorbid patients may facilitate adaptation of care to better meet patient capabilities and needs in clinical settings. Knowledge of a patient's activation level may also be useful when developing interventions and care strategies for this patient group.

The Brave Patient after 80-Satisfaction with Visit and Individual Determinants of Proactive Patient Attitude among the Oldest General Practice Users

Background. A patient’s adherence to a course of treatment depends on the individual’s activation, the quality of patient–clinician relations, attitudes, self-efficacy, or positive emotions. Patient proactive attitude (PAA) is seldom researched among the oldest healthcare users. This study was designed to identify predictors of PAA toward health and treatment among community-dwelling general practice patients aged 80+, and was based on a PRACTA (PRomoting ACTive Aging) project. Methods. Patients (n = 658), aged 80+ visiting a general practitioner (GP) filled in the PRACTA attitude toward treatment and health scale and the PRACTA self-efficacy scale questionnaires. Sociodemographic factors, self-reported health status, and satisfaction with the visit were analyzed as independent factors. Results. Attitudes toward treatment and health scores were predicted by marital status, living alone or not alone, hospitalization the prior year, level of impairment, and satisfaction with visit. However, some differences were observed depending on the device’s subscale. Self-efficacy score was determined by marital status, living alone or not alone, prior hospitalization, and satisfaction with visit. We did not find an effect of age or gender on PAA. Patient satisfaction with visit was the strongest predictor of all PAA dimensions. Conclusion. Higher visit satisfaction helps to retain a PAA among seniors 80+. Screening questions about living situation, marital and functional status, emotional state, and recent history of hospitalization might help GPs additionally anticipate PAA level and adjust their actions accordingly.

Patient Activation: The Cornerstone of Effective Self-Management in Chronic Kidney Disease?

The importance of patient activation (i.e., the knowledge, skills, and confidence one has in managing one's own healthcare) in people with long-term conditions, including kidney disease, is growing. Enabling and empowering patients to take a more active role in their health and healthcare is the focus of person-centred care. Patient activation is recognised as a key construct of self-management, as to effectively self-manage a long-term condition, it is required to enable individuals to actively participate in treatment decisions, prevent complications, and manage risk factors. Identifying an individual's level of activation can help guide and tailor care, and interventions aimed at increasing patient activation may improve patient engagement and health outcomes. In this review, we explore the concepts of patient activation and self-management, the relationship between patient activation and self-management, interventions aimed at improving these, and what these mean to people living with kidney disease.

Psychometric evaluation of the 8-item Altarum Consumer Engagement (ACE) Measure™ in community-dwelling adults in Singapore

BACKGROUND

A valid and reliable measure is essential to assess patient engagement and its impact on health outcomes. This study aimed to examine the psychometric properties of the 8-item Altarum Consumer Engagement Measure™ (ACE Measure) among English-speaking community-dwelling adults in Singapore.

METHODS

This cross-sectional study involved 400 randomly selected community-dwelling adults (mean age: 49.7 years, 50.0% were female, 72.3% were Chinese) who completed the English version of the 8-item ACE Measure independently. The item-level statistics were described. The internal consistency of the measure was measured by Cronbach alpha and item-rest correlations. Validity of the tool was assessed by 1) factorial validity using confirmatory factor analysis (CFA), 2) hypothesis-testing validity by correlating ACE subscales (Commitment and Navigation) with health-related outcomes, and 3) criterion validity against the Patient Activation Measure and Health Confidence Measure.

RESULTS

There was no floor or ceiling effect for Commitment and Navigation subscales, and the Cronbach alpha for each subscale was 0.76 and 0.54, respectively. The two-factor structure was confirmed by CFA. In general, Commitment and Navigation subscales were positively correlated with frequency of activity participation (rho = 0.30 - 0.33) and EQ-5D visual analog scale (rho = 0.15 - 0.30). Individuals who perceived better health than peers had higher subscale scores (p < 0.01). Each subscale score had moderate and positive correlations with activation score (rho = 0.48 - 0.55) and health confidence score (rho = 0.35 - 0.47).

CONCLUSIONS

The two-subscale ACE Measure demonstrated good construct validity in English-speaking Singapore community-dwelling adults. Evidence in internal consistency was mixed, indicating further investigation.

Effect of patient activation interventions on health-related behavioral outcomes in adults with chronic kidney disease: a systematic review protocol

OBJECTIVE

This review aims to examine the effect of patient activation interventions compared with usual care on health-related behavioral outcomes in adults with chronic kidney disease stages 3-5.

INTRODUCTION

Chronic kidney disease is a global health problem associated with a high mortality, reduction of health-related quality of life, and high health care costs. The chronic nature requires active involvement and self-management of the person with chronic kidney disease. Patient activation is a self-management approach that refers to the knowledge, confidence, and skills of people to enable them to manage their own health needs. However, the effectiveness of patient activation interventions on health-related behavioral outcomes in this population have not yet been systematically evaluated.

INCLUSION CRITERIA

This systematic review will include primary research studies measuring the effect of behavioral change interventions addressing beliefs, knowledge, confidence, and/or skills to optimize self-management in adult patients with chronic kidney disease stages 3-5 who are not receiving dialysis. Studies included in this review will be randomized controlled trials.

METHODS

Published studies will be searched in MEDLINE, Embase, Emcare, and PsycINFO. Unpublished studies and gray literature sources will also be searched. Titles and abstracts of search results published in English from 2005 onward will be screened, and the full text of potentially relevant studies will be assessed in detail. Studies selected for inclusion will undergo critical appraisal. Data extracted will include specific details about population, study methods, interventions, and outcomes. Studies will be pooled in statistical meta-analysis, if possible.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD42020205084.

Social support as a mediator between depressive symptoms and self-care activities in adults patient with type 2 diabetes mellitus

BACKGROUND

People with type 2 DM are at risk of experiencing depression, which in turn can affect their self-care activities. Recent evidence has shown that social support is beneficial in reducing the risk of depression and positively affecting increases in self-care activities. However, the role of social support in the relationship between depressive symptoms and self-care activities has not been studied. This study aims to determine the mediating effects of social support on the relationship between depressive symptoms and self-care activities of people with type 2 DM.

DESIGN AND METHODS

A cross-sectional consecutive sampling approach was used with 94 respondents with type 2 diabetes in East Jakarta, Indonesia, who were undergoing diabetes treatments during May-June 2020. The instruments used were the Centre for Epidemiologic Studies-Depression Scale (CES-D), Summary of Diabetes Self Care Activities (SDSCA), and Duke-UNC Functional Social Support Questionnaire (DUFSSQ). All three questionnaires have been tested for validity and reliability. Data analysis was carried out using multiple linear regression, path analysis, and the Sobel test.

RESULTS

The results of multiple linear regression analysis on the variables age, sex, education level, socioeconomic status, duration of type 2 DM, and complications of type 2 DM showed that only complications of type 2 diabetes affected self-care activities (p = 0,000; R2 = 0.515). The results of the path analysis and Sobel test showed that social support significantly mediated the effects of the relationship between depressive symptoms and self-care activities (z = -0,162 > table 1.96; direct effect = -0,499; indirect effect = -0,0789; total effect = 40, 3%).

CONCLUSIONS

Screening for depressive symptoms and interventions involving social support are strongly suggested for patients with type 2 DM who are suspected of showing a decline in self-care activities.

Applying A Biopsychosocial Framework to Achieve Durable Behavior Change in Kidney Disease

Chronic disease self-management is the establishment and maintenance of behaviors needed to be an active participant in one's health care and experience the best health outcomes. Kidney disease self-management behaviors to slow disease progression include engaging in exercise or physical activity; adhering to a diet low in sodium, potassium, and phosphorus; monitoring laboratory parameters; managing complex medication regimens; coping with disease-related emotional distress; and communicating effectively with providers. Durable behavior change has been difficult to achieve in kidney disease, in part because of an incomplete understanding of the multilevel factors determining chronic disease self-management in this patient group. The biopsychosocial model of chronic illness care posits that an individual's health outcomes result from biological, psychological, social, and environmental factors as part of a multilevel systems hierarchy. Although this theoretical model has been used to comprehensively identify factors driving self-management in other chronic conditions, it has been applied infrequently to behavioral interventions in kidney disease. In this scoping review, we apply the biopsychosocial model of health to identify individual, interpersonal, and systems-level drivers of kidney disease self-management behaviors. We further highlight factors that may serve as novel, impactful targets of theory-based behavioral interventions to understand and sustain behavior change in kidney disease.

A co-designed integrated kidney and diabetes model of care improves mortality, glycaemic control and self-care

BACKGROUND

Current health-care models are ill-equipped for managing people with diabetes and chronic kidney disease (CKD). We evaluated the impact of a new diabetes and kidney disease service (DKS) on hospitalisation, mortality, clinical and patient relevant outcomes.

METHODS

Longitudinal analyses of adult patients with diabetes and CKD (stages 3a to 5) were performed using outpatient and hospitalisation data from January 2015 to October 2018. Data was handled according to whether patients received the DKS intervention (n = 196) or standard care (n = 7511). The DKS provided patient-centered, coordinated multi-disciplinary assessment and management of patients. Primary analyses examined hospitalisation and mortality rates between the two groups. Secondary analyses evaluated the impact of the DKS on clinical target attainment, changes in eGFR, HbA1c, self-care and patient activation at 12 months.

RESULTS

Patients who received the intervention had a higher hospitalisation rate (incidence rate ratio (IRR), 1.20; 95% CI, 1.13 to 1.30; P < 0.0001), shorter median length of stay (2 days [interquartile range (IQR), 6-1] versus 4 days [IQR 9-1]; P < 0.0001) and lower all-cause mortality rate (IRR 0.4; 95% CI, 0.29 to 0.64; P < 0.0001) than those who received standard care. Improvements in overall self-care (MD 2.26, 95% CI 0.83, 3.69; P < 0.001) and in statin use, foot and eye examination were observed. Mean eGFR did not significantly change after 12 months (MD 1.30, 95% CI -4.17, 1.67; P = 0.40) mls/min per 1.73 m2. HbA1c levels significantly decreased by 0.40, 0.35, 0.34 and 0.23% at 3, 6, 9 and 12 months follow-up respectively.

CONCLUSIONS

A co-designed, person-centred integrated model of care improved all-cause mortality, kidney function, glycaemic control and self-care for patients with diabetes and CKD.

Reliability and Validity of the Patient Activation Measure in Kidney Disease: Results of Rasch Analysis

BACKGROUND AND OBJECTIVES

Despite the increasing prioritization of the promotion of patient activation in nephrology, its applicability to people with CKD is not well established. Before the Patient Activation Measure is universally adopted for use in CKD, it is important to critically evaluate this measure. The aim of this study was to describe the psychometric properties of the Patient Activation Measure in CKD.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

A survey containing the 13-item Patient Activation Measure was completed by 942 patients with CKD, not treated with dialysis. Data quality was assessed by mean, item response, missing values, floor and ceiling effects, internal consistency (Cronbach's alpha and average interitem correlation), and item-rest correlations. Rasch modeling was used to assess item performance and scaling (item statistics, person and item reliability, rating scale diagnostics, factorial test of residuals, and differential item functioning).

RESULTS

The item response was high, with a small number of missing values (<1%). Floor effect was small (range 1%-5%), but the ceiling effect was above 15% for nine items (range 15%-38%). The Patient Activation Measure demonstrated good internal consistency overall (Cronbach α=0.925, and average interitem correlation 0.502). The difficulty of the Patient Activation Measure items ranged from -0.90 to 0.86. Differential item functioning was found for disease type (item 3) and age (item 12). The person separation index was 9.48 and item separation index was 3.21.

CONCLUSIONS

The 13-item Patient Activation Measure appears to be a suitably reliable and valid instrument for assessing patient activation in CKD. In the absence of a kidney-specific instrument, our results support the 13-item Patient Activation Measure as a promising measure to assess activation in those with CKD, although consideration for several items is warranted. The high ceiling effect may be a problem when using the 13-item Patient Activation Measure to measure changes over time.

Evaluation of the My Diabetes Care Patient Portal Intervention: Protocol for a Pilot Randomized Controlled Trial

Background

My Diabetes Care (MDC) is a multi-faceted intervention embedded within an established patient portal, My Health at Vanderbilt. MDC is designed to help patients better understand their diabetes health data and support self-care. MDC uses infographics to visualize and summarize patients’ diabetes health data, incorporates motivational strategies, provides literacy-level appropriate educational resources, and links to a diabetes online patient support community and diabetes news feeds.

Objective

This study aims to evaluate the effects of MDC on patient activation in adult patients with type 2 diabetes mellitus. Moreover, we plan to assess secondary outcomes, including system use and usability, and the effects of MDC on cognitive and behavioral outcomes (eg, self-care and self-efficacy).

Methods

We are conducting a 6-month, 2-arm, parallel-design, pragmatic pilot randomized controlled trial of the effect of MDC on patient activation. Adult patients with type 2 diabetes mellitus are recruited from primary care clinics affiliated with Vanderbilt University Medical Center. Participants are eligible for the study if they are currently being treated with at least one diabetes medication, are able to speak and read in English, are 21 years or older, and have an existing My Health at Vanderbilt account and reliable access to a desktop or laptop computer with internet access. We exclude patients living in long-term care facilities, patients with known cognitive deficits or severe visual impairment, and patients currently participating in any other diabetes-related research study. Participants are randomly assigned to MDC or usual care. We collect self-reported survey data, including the Patient Activation Measure (R) at baseline, 3 months, and 6 months. We will use mixed-effects regression models to estimate potentially time-varying intervention effects while adjusting for the baseline measure of the outcome. The mixed-effects model will use fixed effects for patient-level characteristics and random effects for health care provider variables (eg, primary care physicians).

Results

This study is ongoing. Recruitment was closed in May 2020; 270 patients were randomized. Of those randomized, most (214/267, 80.1%) were non-Hispanic White, and 13.1% (35/267) were non-Hispanic Black, 43.7% (118/270) reported being 65 years or older, and 33.6% (90/268) reported limited health literacy. We obtained at least 95.6% (258/270) completion among participants through the 3-month follow-up assessment.

Conclusions

This randomized controlled trial will be one of the first to evaluate a patient-facing diabetes digital health intervention delivered via a patient portal. By embedding MDC into Epic’s MyChart platform with more than 127 million patient records, our intervention is directly integrated into routine care, highly scalable, and sustainable. Our findings and evolving patient portal functionality will inform the continued development of MDC to best meet users’ needs and a larger trial focused on the impact of MDC on clinical end points.

Trial Registration

ClinicalTrials.gov NCT03947333; https://clinicaltrials.gov/ct2/show/NCT03947333

International Registered Report Identifier (IRRID)

DERR1-10.2196/25955

The My Diabetes Care Patient Portal Intervention: Usability and Pre-Post Assessment

BACKGROUND

My Diabetes Care (MDC) is a novel, multifaceted patient portal intervention designed to help patients better understand their diabetes health data and support self-management. MDC uses infographics to visualize and summarize patients' diabetes health data, incorporates motivational strategies, and provides literacy level-appropriate educational resources.

OBJECTIVES

We aimed to assess the usability, acceptability, perceptions, and potential impact of MDC.

METHODS

We recruited 69 participants from four clinics affiliated with Vanderbilt University Medical Center. Participants were given 1 month of access to MDC and completed pre- and post-questionnaires including validated measures of usability and patient activation, and questions about user experience.

RESULTS

Sixty participants completed the study. Participants' mean age was 58, 55% were females, 68% were Caucasians, and 48% had limited health literacy (HL). Most participants (80%) visited MDC three or more times and 50% spent a total of ≥15 minutes on MDC. Participants' median System Usability Scale (SUS) score was 78.8 [Q1, Q3: 72.5, 87.5] and significantly greater than the threshold value of 68 indicative of "above average" usability (p < 0.001). The median SUS score of patients with limited HL was similar to those with adequate HL (77.5 [72.5, 85.0] vs. 82.5 [72.5, 92.5]; p = 0.41). Participants most commonly reported the literacy level-appropriate educational links and health data infographics as features that helped them better understand their diabetes health data (65%). All participants (100%) intended to continue to use MDC. Median Patient Activation Measure® scores increased postintervention (64.3 [55.6, 72.5] vs. 67.8 [60.6, 75.0]; p = 0.01).

CONCLUSION

Participants, including those with limited HL, rated the usability of MDC above average, anticipated continued use, and identified key features that improved their understanding of diabetes health data. Patient activation improved over the study period. Our findings suggest MDC may be a beneficial addition to existing patient portals.

Determinants of patient activation and its association with cardiovascular disease risk in chronic kidney disease: A cross-sectional study

Background

Patient activation describes the knowledge, skills and confidence in managing one's own health. Promoting patient activation is being prioritized to reduce costs and adverse outcomes such as cardiovascular disease (CVD). The increasing prevalence of chronic kidney disease (CKD) presents a need to understand the characteristics that influence patient activation and the effect on health outcomes.

Design

Cross‐sectional study.

Setting and participants

Patients with non‐dialysis CKD recruited from 14 sites (general nephrology and primary care) in England, UK.

Outcome measures

Patient activation was measured using the PAM‐13. Demographic and health‐related variables, self‐reported symptom burden, health‐related quality of life (HRQOL), socioeconomic status (SES), were assessed as determinants of patient activation. Major CVD risk factors included hypertension, dyslipidaemia, obesity and hyperkalaemia.

Results

743 patients were included (eGFR: 32.3 (_SD17.1) mL/min/1.73 m², age 67.8 (_SD13.9) years, 68% male). The mean PAM score was 55.1 (_SD14.4)/100. Most patients (60%) had low activation. Those with low activation were older (P<.001), had lower eGFR (P = .004), greater number of comorbidities (P = .026) and lower haemoglobin (P = .025). Patients with low activation had a 17% greater number of CVD risk factors (P < .001). Risk factors in those with low activation were being older (P < .001) and having diabetes (P < .001).

Conclusion

This study showed that only a minority of CKD patients are activated for self‐management. Our findings help better understand the level of activation in these patients, particularly older individuals with multimorbidity, and further the knowledge regarding the characteristics that influence activation.

Patient or Public Contribution

Patients were involved in the design of main study.

Patient Activation and Glycemic Control Among Filipino Americans

Purpose: Increasing patient activation facilitates self-management of health, improves health outcomes, and lowers health care expenditures. Extant research notes mixed findings in patient activation by race/ethnicity. The purpose of the study was to examine the relationships among patient activation, select patient characteristics, and glycemic control among Filipino Americans.

Methods: A cross-sectional study was conducted with a convenience sample of Filipino Americans (n=191), with a diagnosis of diabetes mellitus type 1 or type 2, recruited from a southern California adult primary care clinic between December 2017 and March 2018. Patient activation, select characteristics, and hemoglobin A1c (HbA1c) levels were assessed. Bivariate and logistic regression analyses were used to identify correlates of glycemic control. The Strengthening the Reporting of Observational studies in Epidemiology (STROBE) checklist was used to develop the study.

Results: Participants with HgbA₁C≤7.0% reported statistically higher patient activation measure (13 items) (PAM-13) natural log score (mean [M]=60.32, standard deviation [SD]=13.50) compared to those with an HgbA₁C>7.0%, M=52.58, SD=10.19, F(1)=11.05, p<0.001. Multivariate logistic regression using age, low-density lipoprotein, and PAM-13 natural log was statistically reliable distinguishing between A₁C≤7.0 and A₁C>7.0, −2 LogLikehood=1183.23, χ²(3)=15.44, p<0.001.

Conclusions: Patient activation is an important factor in supporting glycemic control. Findings support interventions to target patient activation. Providers are encouraged to use racial/ethnic-centered engagement strategies in resolving health disparity with racial and ethnic minorities to facilitate patient activation and improve health outcomes in patients with diabetes.

Autonomy support from informal health supporters: links with self-care activities, healthcare engagement, metabolic outcomes, and cardiac risk among Veterans with type 2 diabetes

This study examined the role of autonomy support from adults' informal health supporters (family or friends) in diabetes-specific health behaviors and health outcomes. Using baseline data from 239 Veterans with type 2 diabetes at risk of complications enrolled in behavioral trial, we examined associations between autonomy support from a support person and that support person's co-residence with the participant's diabetes self-care activities, patient activation, cardiometabolic measures, and predicted risk of a cardiac event. Autonomy support from supporters was associated with significantly increased adherence to healthy lifestyle behaviors (diet, p < .001 and exercise, p = .003); higher patient activation (p < .001); greater patient efficacy in interacting with healthcare providers, and lower 5-year (p = .044) and 10-year (p = .027) predicted cardiac risk. Autonomy support was not significantly associated with diabetes-specific behaviors (checking blood glucose, foot care, or medication taking); or hemoglobin A1c, systolic blood pressure, or non-HDL cholesterol. There was a significant interaction of autonomy support and supporter residence in one model such that lack of autonomy support was associated with lower patient activation only among individuals with in-home supporters. No other interactions were significant. Findings suggest that autonomy support from family and friends may play a role in patient self-management, patient activation, and lower cardiac risk.

Ativação do paciente com diagnóstico de doença renal crônica: uma revisão integrativa

Objetivo: Estabelecer a medida de ativação de pacientes com doença renal crônica e seus fatores associados. Metodologia: Revisão integrativa de literatura realizada nas seguintes bases de dados: Pubmed, Lilacs, Scielo, Scopus, Science Direct e Insignia Health. Foram utilizados os descritores: Patient Activation, Nephrology, Kidney e Renal Insufficiency, Chronic e seus correspondentes em português e espanhol e os operadores booleanos AND e OR. Não foi utilizado filtro de data para as buscas. Nove manuscritos compuseram a amostra final desta revisão. Resultados: A média do escore de ativação variou entre 51±10 e 65,02±16 pontos, com o predomínio de pessoas com alta ativação (níveis 3 e 4). A ativação do paciente foi associada a múltiplas variáveis, entre elas a idade, condição socioeconômica, escolaridade e carga de sintomas. Conclusões: Conhecer o nível de ativação dos pacientes e os fatores associados a ele direciona a atuação do profissional de saúde para obtenção e/ou manutenção da alta ativação.

Patients' and healthcare professionals' beliefs, perceptions and needs towards chronic kidney disease self-management in China: a qualitative study

OBJECTIVES

To support the adaptation and translation of an evidence-based chronic kidney disease (CKD) self-management intervention to the Chinese context, we examined the beliefs, perceptions and needs of Chinese patients with CKD and healthcare professionals (HCPs) towards CKD self-management.

DESIGN

A basic interpretive, cross-sectional qualitative study comprising semistructured interviews and observations.

SETTING

One major tertiary referral hospital in Henan province, China.

PARTICIPANTS

11 adults with a diagnosis of CKD with CKD stages G1-G5 and 10 HCPs who worked in the Department of Nephrology.

RESULTS

Four themes emerged: (1) CKD illness perceptions, (2) understanding of and motivation towards CKD self-management, (3) current CKD practice and (4) barriers, (anticipated) facilitators and needs towards CKD self-management. Most patients and HCPs solely mentioned medical management of CKD, and self-management was largely unknown or misinterpreted as adherence to medical treatment. Also, the majority of patients only mentioned performing disease-specific acts of control and not, for instance, behaviour for coping with emotional problems. A paternalistic patient-HCP relationship was often present. Finally, the barriers, facilitators and needs towards CKD self-management were frequently related to knowledge and environmental context and resources.

CONCLUSIONS

The limited understanding of CKD self-management, as observed, underlines the need for educational efforts on the use and benefits of self-management before intervention implementation. Also, specific characteristics and needs within the Chinese context need to guide the development or tailoring of CKD self-management interventions. Emphasis should be placed on role management and emotional coping skills, while self-management components should be tailored by addressing the existing paternalistic patient-HCP relationship. The use of electronic health innovations can be an essential facilitator for implementation.

Understanding the Turning Point of Patients with Diabetes

BACKGROUND

The patient's intention to engage in diabetes care is the hallmark of role acceptance as a health manager and implies one's readiness to change. The study aimed to understand the process of having the intention to engage in diabetes care.

METHODS

A qualitative study using narrative inquiry was conducted at a public primary care clinic. Ten participants with type 2 diabetes of more than a 1-year duration were selected through purposive sampling. In-depth interviews were conducted using a semi-structured protocol guide and were audio-taped. The interviews were transcribed and the texts were analyzed using a thematic approach with the Atlas.ti ver. 8.0 software (Scientific Software Development GmbH, Berlin, Germany).

RESULTS

Three themes emerged from the analysis. The first theme, "Initial reactions toward diabetes," described the early impression of diabetes encompassing negative emotions, feeling of acceptance, a lack of concern, and low level of perceived efficacy. "Process of discovery" was the second overarching theme marking the journey of participants in finding the exact truth about diabetes and learning the consequences of ignoring their responsibility in diabetes care. The third theme, "Making the right decision," highlighted that fear initiated a decision-making process and together with goal-setting paved the way for participants to reach a turning point, moving toward engagement in their care.

CONCLUSION

Our findings indicated that fear could be a motivator for change, but a correct cognitive appraisal of diabetes and perceived efficacy of the treatment as well as one's ability are essentially the pre-requisites for patients to reach the stage of having the intention to engage.

Factors that facilitate patient activation in the self-management of diabetes and depression among participants enrolled in an integrated chronic care model in India

BACKGROUND

The aim of this study was to identify factors that influence patients' motivation and ability to self-manage their diabetes and depressive symptoms.

METHODS

From 2016 to 17, in-depth interviews were conducted with 62 patients receiving the INDEPENDENT care model across two clinics in India. Using a realist evaluation approach, a hypothesized program theory for patient activation was tested and refined.

FINDINGS

The refined theory demonstrates that motivation, education, and engagement cumulatively contribute to patient activation.

CONCLUSION

The results indicate that positive and sustained patient-provider relationships drive patient motivation and enhance implementation of the care model.

Quality of life in patients with comorbid serious mental illness and chronic diseases: A structural equation model

AIMS

To investigate the factors affecting the quality of life among adults with comorbid serious mental illness and chronic diseases.

DESIGN

Descriptive, cross-sectional study design.

METHODS

In total, 204 patients with serious mental illness were recruited from two hospitals. Self-reported data were collected using the Brief Psychiatric Rating Scale, Internalised Stigma of Mental Illness, Patient Activation Measure and brief version of the World Health Organization Quality of Life Instrument. Data were collected between July 2018 - January 2019. The structural equation model was applied to examine the associations among the study variables.

RESULTS

Internalized stigma (β = -0.479, p = .002) had the greatest direct effect on quality of life, followed by patient activation (β = 0.238, p = .002), severity of comorbidities (β = -0.207, p = .002) and psychiatric symptoms (β = -0.186, p = .006). In addition, psychiatric symptoms directly influenced the severity of comorbidities, which in turn directly influenced internalized stigma and then in turn directly influenced patient activation and ultimately influenced quality of life.

CONCLUSION

The relationship between internalized stigma and quality of life is significantly mediated by patient activation. This finding provides a theoretical basis for developing patient activation interventions for patients with comorbid mental and chronic diseases, which potentially improve the quality of life of this population.

IMPACT

Multiple comorbidities cause impaired quality of life in patients with serious mental illnesses. We found that patient activation plays an important role in the management of chronic diseases for achieving more favourable quality of life, but this is negatively affected by internalized stigma. These findings can help mental health professionals develop tailored intervention strategies to enhance quality of life by promoting patient activation and reducing internalized stigma, psychiatric symptoms, and comorbidity severity in patients with comorbid serious mental illnesses and chronic diseases.

Psychometric Properties of the Altarum Consumer Engagement (ACE) Measure of Activation in Patients with Prediabetes

BACKGROUND

Patient activation is associated with better outcomes in chronic conditions.

OBJECTIVE

We evaluated the psychometric properties of the 12-item Altarum Consumer Engagement™ Measure (ACE-12) in patients with prediabetes.

PARTICIPANTS

ACE-12 was administered to patients in the Prediabetes Informed Decisions and Education Study.

MAIN MEASURES

We conducted an exploratory factor analysis followed by confirmatory factor analytic models. We evaluated item response categories using item characteristic curves. Construct validity was assessed by examining correlations of the ACE-12 scales with education, depressive symptoms, self-rated health, hemoglobin A1c, body mass index, and weight loss.

KEY RESULTS

Participants (n = 515) had a median age of 58; 56% were female; 17% Hispanic; 54% were non-White. The scree plot and Tucker and Lewis reliability coefficient (0.95) suggested three factors similar to the original scales. One item loaded on the navigation rather than the informed choice scale. Ordinal alpha coefficients for the original scales were commitment (0.75); informed choice (0.71); and navigation (0.54). ICCs indicated that one or more of the response categories for 5 of the 12 items were never most likely to be selected. Patients with lower education were less activated on the commitment (r = - 0.124, p = 0.004), choice (r = - 0.085, p = 0.009), and overall score (r = - 0.042, p = 0.011). Patients with depressive symptoms had lower commitment (r = - 0.313, p ≤ 0.001) and overall scores (r = - 0.172, p = 0.012). Patients with poorer health scored lower on the Commitment (r = - 0.308, p ≤ 0.001), Navigation (r = - 0.137, p ≤ 0.001), and overall score (r = - 0.279, p ≤ 0.001).

CONCLUSION

The analyses provide some support for the psychometric properties of the ACE-12 in prediabetic patients. Future research evaluating this tool among patients with other chronic conditions are needed to determine whether Q1 (I spend a lot of time learning about health) should remain in the informed choice or be included in the navigation scale. Additional items may be needed to yield acceptable reliability for the navigation scale.

Can nurses help improve self-care of patients living with atrial fibrillation? A focus group study exploring patients' disease knowledge gaps

Aims

To identify knowledge gaps and preferences for educational material to improve nurse-patient communication and self-care.

Design

Using a mixed-methods design, we conducted focus groups and quantitative surveys.

Methods

We conducted three focus groups with atrial fibrillation (AF) patients and support persons (N = 17 participants; 66 ± 16 years) at critical treatment junctures (recent diagnosis or medication switch). Patients and support persons were also surveyed on patient activation (self-management skills and knowledge), medication adherence, AF knowledge and health literacy. Iterative thematic analysis was performed using focus group transcripts.

Results

Although most participants had adequate health literacy, most reported gaps in AF knowledge. Participants lacked disease-related knowledge and were unsure how to manage health behaviours (e.g. diet and exercise). Few felt they received adequate education from their healthcare provider. Results emphasize the need for consistent information from nursing staff, in lay language, via both electronic and printed means.

Enhancing Patient Activation and Self-Management Activities in Patients With Type 2 Diabetes Using the US Department of Defense Mobile Health Care Environment: Feasibility Study

Background

Past mobile health (mHealth) efforts to empower type 2 diabetes (T2D) self-management include portals, text messaging, collection of biometric data, electronic coaching, email, and collection of lifestyle information.

Objective

The primary objective was to enhance patient activation and self-management of T2D using the US Department of Defense’s Mobile Health Care Environment (MHCE) in a patient-centered medical home setting.

Methods

A multisite study, including a user-centered design and a controlled trial, was conducted within the US Military Health System. Phase I assessed preferences regarding the enhancement of the enabling technology. Phase II was a single-blinded 12-month feasibility study that randomly assigned 240 patients to either the intervention (n=123, received mHealth technology and behavioral messages tailored to Patient Activation Measure [PAM] level at baseline) or the control group (n=117, received equipment but not messaging. The primary outcome measure was PAM scores. Secondary outcome measures included Summary of Diabetes Self-Care Activities (SDSCA) scores and cardiometabolic outcomes. We used generalized estimating equations to estimate changes in outcomes.

Results

The final sample consisted of 229 patients. Participants were 61.6% (141/229) male, had a mean age of 62.9 years, mean glycated hemoglobin (HbA_1c) of 7.5%, mean BMI of 32.7, and a mean duration of T2D diagnosis of 9.8 years. At month 12, the control group showed significantly greater improvements compared with the intervention group in PAM scores (control mean 7.49, intervention mean 1.77; P=.007), HbA_1c (control mean −0.53, intervention mean −0.11; P=.006), and low-density lipoprotein cholesterol (control mean −7.14, intervention mean 4.38; P=.01). Both groups showed significant improvement in SDSCA, BMI, waist size, and diastolic blood pressure; between-group differences were not statistically significant. Except for patients with the highest level of activation (PAM level 4), intervention group patients exhibited significant improvements in PAM scores. For patients with the lowest level of activation (PAM level 1), the intervention group showed significantly greater improvement compared with the control group in HbA_1c (control mean −0.09, intervention mean −0.52; P=.04), BMI (control mean 0.58, intervention mean −1.22; P=.01), and high-density lipoprotein cholesterol levels (control mean −4.86, intervention mean 3.56; P<.001). Significant improvements were seen in AM scores, SDSCA, and waist size for both groups and in diastolic and systolic blood pressure for the control group; the between-group differences were not statistically significant. The percentage of participants who were engaged with MHCE for ≥50% of days period was 60.7% (68/112; months 0-3), 57.4% (62/108; months 3-6), 49.5% (51/103; months 6-9), and 43% (42/98; months 9-12).

Conclusions

Our study produced mixed results with improvement in PAM scores and outcomes in both the intervention and control groups. Structural design issues may have hampered the influence of tailored behavioral messaging within the intervention group.

Trial Registration

ClinicalTrials.gov NCT02949037; https://clinicaltrials.gov/ct2/show/NCT02949037

International Registered Report Identifier (IRRID)

RR2-10.2196/resprot.6993

The effectiveness of patient activation intervention on type 2 diabetes mellitus glycemic control and self-management behaviors: A systematic review of RCTs

BACKGROUND

Type 2 diabetes mellitus T2DM is a major health challenge and associated with several complications and mortality. Self-management behaviors SMBs such as healthy diet, physical activity, blood glucose self-monitoring, foot care and medication adherence are critical part of diabetic care. Empowered or activated patients, are more likely to practice better SMBs. However, the effectiveness of patient activation intervention on T2DM glycemic control and SMBs is not totally well understood.

AIM

To assess the effectiveness of patient activation intervention on T2DM glycemic control and SMBs.

METHOD

A systematic search was undertaken through five databases to find relevant studies published between 2004 and 2018. We included randomized controlled trials with sample size ≥120 and follow up period of ≥12 months and assess the effectiveness of patient activation intervention on T2DM glycemic control and SMBs.

RESULTS

10 RCTs were identified for analysis. The total sample size is 3728 and the combined mean age is 57.3 years. The combined mean BMI is 31.2kg/m² (obese). Seven intervention demonstrated a significant reduction in HbA1c, ranged from 0.36 to 0.80%. All interventions presented an improvement in at least one self-management behavior.

DISCUSSION AND CONCLUSION

Patient activation intervention showed a significant positive effect on T2DM glycemic control and SMBs, particularly physical activity, healthy diet, foot care and blood glucose self-monitoring. The effectiveness on SMBs was seen across different intervention strategies, modes of delivery, length of intervention, and number of providers. Better effectiveness on HbA1c was associated with poorly controlled participants, culturally tailored-intervention, and in-person sessions intervention combined with telephone calls follow up.

Patient activation and Type 2 diabetes mellitus self-management: a systematic review and meta-analysis

Patient activation has been recognised as a reliable driver of self-management decision-making. This systematic review and meta-analysis examines existing evidence on whether embedding patient activation within Type 2 diabetes mellitus (T2DM) self-management programs can improve patient outcomes. This review has included 10 randomised controlled trials (RCTs) conducted between 2004 and 2019 retrieved from well-known databases such as MEDLINE, PubMed, CINAHL Plus, Scopus, ProQuest and ScienceDirect. The eligible RCTs were excluded if they scored low according to Cochrane Collaboration’s ‘risk of bias’ criteria. Random-effects meta-analyses showed that there were no significance changes in haemoglobin A1C (HbA1c), body mass index (BMI) and patient activation measure (PAM) between intervention and control groups after the intervention; however, the systematic review findings indicated that an improved patient activation level led to significant improvements in T2DM self-management and clinical outcomes including HbA1c level. Studies with a longer follow-up period conducted in community settings and delivered by peer coaches were more likely to lead to significant improvement in both patient activation levels and T2DM self-management and clinical outcomes. This review concludes that patient activation can be used as a reliable tool for improving T2DM self-management and clinical outcomes.

Increased Patient Activation Is Associated with Fewer Emergency Room Visits and Hospitalizations for Pain in Adults with Sickle Cell Disease

OBJECTIVE

Recurrent vaso-occlusive pain episodes, the most common complication of sickle cell disease (SCD), cause frequent health care utilization. Studies exploring associations between patient activation and acute health care utilization for pain are lacking. We tested the hypothesis that increased activation and self-efficacy are associated with decreased health care utilization for pain in SCD.

METHODS

In this cross-sectional study of adults with SCD at a tertiary medical center, we collected demographics, SCD phenotype, Patient Activation Measure levels, and self-efficacy scores using structured questionnaires. We reviewed charts to obtain disease-modifying therapy and acute health care utilization, defined as emergency room visits and hospitalizations, for vaso-occlusive pain episodes. Negative binomial regression analyses were used to test the hypothesis.

RESULTS

We surveyed 67 adults with SCD. The median age was 27.0 years, 53.7% were female, and 95.5% were African American. Median health care utilization for pain over one year (range) was 2.0 (0-24). Only one-third of participants (38.8%) were at the highest activation level (median [range] = 3 [1-4]). Two-thirds (65.7%) of participants had high self-efficacy (median [range] = 32.0 [13-45]). Regressions showed significant association between health care utilization and activation (incidence rate ratio [IRR] = 0.663, P = 0.045), self-efficacy (IRR = 0.947, P = 0.038), and male sex (IRR = 0.390, P = 0.003). Two outliers with high activation, self-efficacy, and health care utilization also had addictive behavior.

CONCLUSIONS

Many individuals with SCD have suboptimal activation and reduced self-efficacy. Higher activation and self-efficacy were associated with lower health care utilization for pain. Additional studies are needed to evaluate interventions to improve activation and self-efficacy and reduce acute health care utilization for pain.

Popular Diabetes Apps and the Impact of Diabetes App Use on Self-Care Behaviour: A Survey Among the Digital Community of Persons With Diabetes on Social Media

Introduction: This study aimed to identify popular diabetes applications (apps) and to investigate the association of diabetes app use and other factors with cumulative self-care behaviour. Methods: From November 2017 to March 2018, we conducted a web-based survey with persons 18 years of age and above. We recruited respondents via diabetes Facebook groups, online patient-forums and targeted Facebook advertisements (ads). Data on participants' demographic, clinical, and self-management characteristics, as well as on self-care behaviour and characteristics of the diabetes apps use were collected. Self-care behaviour was measured using a licensed version of the Summary of Diabetes Self-care Activities (SDSCA) questionnaire. The cumulative self-care score was calculated by summing up scores for "general diet," "specific diet," "exercise," "blood glucose testing," "foot care" and "smoking." To identify popular diabetes apps, users were requested to list all apps they use for diabetes self-management. Two sample t-test and multiple linear regression stratified by type of diabetes were performed to examine associations between app use and self-care behaviour, by controlling for key confounders. Results: One thousand fifty two respondents with type 1 and 630 respondents with type 2 diabetes mellitus (DM) entered the survey. More than half, 549 (52.2%), and one third, 210 (33.3%), of respondents with type 1 and 2 DM, respectively, reported using diabetes apps for self-management. "mySugr" and continuous glucose monitoring apps, such as "Dexcom," "Freestyle Libre," and "Xdrip+" were some of the most popular diabetes apps. In both respondent groups, the cumulative self-care behaviour score was significantly higher among diabetes app users (compared to non-users) and scores for three individual self-care components, namely "blood glucose monitoring," "general diet," and "physical activity" were significantly higher among diabetes app users than among non-users. After adjusting for confounding factors, diabetes app use increased the cumulative self-care score by 1.08 (95%CI: 0.46-1.7) units among persons with type 1 DM and by 1.18 (95%CI: 0.26-2.09) units among persons with type 2 DM, respectively. Conclusion: For both, persons with type 1 and type 2 diabetes, using diabetes apps for self-management was positively associated with self-care behaviour. Our findings suggest that apps can support changes in lifestyle and glucose monitoring in these populations.

Patient participation in patient safety-An exploration of promoting factors

AIMS

To study how internal medicine patients experienced patient safety during their recent periods of care and to identify explanatory factors for patient participation.

BACKGROUND

Patient participation is recognized as one of the main factors promoting quality and safety and the identification of effective interventions that encourage safe care.

METHODS

A cross-sectional survey of patients (n = 462) in the internal medicine wards (n = 18) of all five Finnish university hospitals. Data were analysed using principal component analysis and multiple linear regression.

RESULTS

Most patients (78%) assessed the level of patient safety on their ward as "very good" or "excellent," 20% of patients assessed it as acceptable or worse. The following were considered to be the most important factors explaining higher patient participation: informing patients about the research and encouraging them to participate (β = 0.378, p < 0.001), providing necessary information promptly and comprehensibly (β = 0.393, p < 0.001), and enhancing patients' ability to identify patient safety incident(s) (β = 0.186, p < 0.001).

CONCLUSIONS

Healthcare workers must improve by encouraging patient participation and providing relevant information to patients.

IMPLICATION FOR NURSING MANAGEMENT

Nursing leaders must be competent to support, lead, and allocate resources for the creation of an environment where patient participation can occur and is valued by health care workers.

Younger people with Type 2 diabetes have poorer self-care practices compared with older people: results from the Australian National Diabetes Audit

AIM

This cross-sectional study compares the self-care practices of younger and older people with Type 2 diabetes.

METHODS

Data were analysed from the Australian National Diabetes Audit (ANDA) including 2552 adults with Type 2 diabetes from Australian Diabetes Centres. Pre-specified demographic and clinical variables were obtained. Self-care variables (physical activity, following dietary recommendations, medication adherence and monitoring blood glucose levels) were compared in people ≤ 64 and > 64 years of age.

RESULTS

Mean age (± sd) of participants was 63 ± 13 years overall, 53 ± 9 years for the younger group and 73 ± 6 years for the older group. A greater proportion of younger people had HbA_1c levels > 53 mmol/mol (> 7.0%) (76% vs. 68%), reported difficulty following dietary recommendations (50% vs. 32%) and forgetting medications (37% vs. 22%) compared with older people (all P-values <0.001). A smaller proportion of younger compared with older people reported monitoring their blood glucose levels as often as recommended (60% vs. 70%, P < 0.001). Similar proportions of people aged ≤ 64 and > 64 years required insulin therapy (59% vs. 57%, P = 0.200). Younger age was associated with a twofold increase in the odds of not following the recommended self-care practices after adjustment for gender, smoking, insulin therapy, depression and allied health attendance (all P < 0.001).

CONCLUSIONS

Despite shorter diabetes duration, younger age was associated with worse glycaemic control and poorer diabetes self-care practices among people with Type 2 diabetes. Targeted strategies are required to optimize diabetes self-care practices and thereby glycaemic control.

The association between patient activation and self-care practices: A cross-sectional study of an Australian population with comorbid diabetes and chronic kidney disease

Objective

This study aimed to examine the association between performance of self‐care activities and patient or disease factors as well as patient activation levels in patients with diabetes and chronic kidney disease (CKD) in Australia.

Methods

A cross‐sectional study was conducted among adults with diabetes and CKD (eGFR <60 mL/min/1.73m²) who were recruited from renal and diabetes clinics of four tertiary hospitals in Australia. Demographic and clinical data were collected, as well as responses to the Patient Activation Measure (PAM) and the Summary of Diabetes Self‐Care Activities (SDSCA) scale. Regression analyses were performed to determine the relationship between activation and performance of self‐care activities.

Results

A total of 317 patients (70% men) with a mean age of 66.9 (SD=11.0) years participated. The mean (SD) PAM and composite SDSCA scores were 57.6 (15.5) % (range 0‐100) and 37.3 (11.2) (range 0‐70), respectively. Younger age, being male, advanced stages of CKD and shorter duration of diabetes were associated with lower scores in one or more self‐care components. Patient activation was positively associated with the composite SDSCA score, and in particular the domains of general diet and blood sugar checking (P<.05), but not specific diet, exercising and foot checking.

Conclusion

In people with diabetes and CKD, a high level of patient activation was positively associated with a higher overall level of self‐care. Our results identify subgroups of people who may benefit from tailored interventions to further improve their health outcomes. Further prospective studies are warranted to confirm present findings.