Evaluation of patient self-management outcomes in health care: a systematic review

Exploring the self-efficacy of patients with diabetes: its role as a predictor of diabetes management and well-being

Background

Self-efficacy is a popular psychological concept that refers to an individual's perception or belief in his ability to perform specific actions. This study aimed to assess the predictive value of self-efficacy, measured using the Self-Efficacy for Managing Chronic Disease 6-Item Scale (SEM6S) questionnaire, for diabetes management and overall well-being in patients with diabetes.

Subject and methods

An anonymous online cross-sectional study was conducted to evaluate the self-efficacy of diabetic patients in the Asser region of Saudi Arabia. The participants were requested to upload their most recent glycated hemoglobin A1C (HbA1C) measurements taken in the last three months, which helped in the accurate categorization of their diabetes as either controlled or uncontrolled. We used the valid Arabic version of the SEM6S and WHO-5 well-being questionnaires to assess patient self-efficacy and well-being.

Results

A cohort of 342 patients was enrolled in the study, 67.25% were married, their mean age was 43.17 ± 17.61 years, and 52.69% had university-level or higher education. Among the participants, 46.0% exhibited well-being, while 24.9% reported poor well-being, including 9.4% who were identified as experiencing depression. The mean scores of self-efficacy and well-being were significantly higher among those with controlled diabetes versus uncontrolled diabetes (40.86 ± 13.26 vs. 36.48 ± 13.26) and (67.35 ± 21.22 vs. 60.93 ± 25.05), respectively. The predictors of glycemic control were self-efficacy [Odds ratio (OR)=1.03 (95%CI, 1.01-1.06, P=0.002], having other chronic diseases [OR=3.25 (95%CI), P<0.001], having type 1 diabetes [OR=7.16, 95%CI, P=0.005], being Saudi [OR=7.67, (95%CI, P=0.027], working in a public sector [OR=0.15, (95%CI, 0.05-0.44), P=0.005], being unemployed [OR=0.19, (95%CI, 0.06-0.59), P=0.005], being a smoker [OR=0.44, 95%CI, 0.19-0.98, P=0.048], and duration of diabetes between 6-10 years [OR= 0.33, 95%CI, 0.11-0.95), P=0.043] or more than 10 years OR=0.32, 95%CI, 0.12-0.86), P=0.026]. The main determinants of well-being were having self-efficacy [OR=1.07 (95%CI, 1.04-1.09), P = 0.0001], having public health insurance [OR=4.36 (95%CI, P=0.015], and education level (read and write) [OR=0.13 (95%CI,.02-.70), P=0.021].

Conclusions

The study reveals that non-modifiable and modifiable factors, including self-efficacy, play a crucial role in diabetes control. The study recommends providing targeted educational interventions, using different social media platforms, psychosocial support programs, and inclusive healthcare policies to improve diabetes control and mental well-being among diabetic patients.

Differences in the Mediating Role of HL in Socioeconomic Inequalities in Health Across Age Groups: Results from the Dutch Doetinchem Cohort Study

BACKGROUND

Although it is known that health literacy (HL) plays an explanatory role in educational inequalities in health, it is unknown whether this role varies across age groups.

OBJECTIVE

The purpose of this study was to investigate whether the mediating role of HL in educational inequalities in four health outcomes varies across age groups: age 46 to 58 years, age 59 to 71 years, and age 72 to 84 years.

METHODS

We used data from the Dutch Doetinchem Cohort Study, which included 3,448 participants. We included years of education as predictor, chronic illness prevalence and incidence, mental and self-perceived health as outcomes, and HL, based on self-report, as mediator. We used multiple-group mediation models to compare indirect effects across age groups.

KEY RESULTS

In the complete sample without age stratification, HL partly mediated the effect of education on all health outcomes except for incidence of chronic diseases. These indirect effect estimates were larger for subjective (self-perceived health, proportion mediated [PM] = 37%, and mental health, PM = 37%) than for objective health outcomes (prevalence of chronic disease, PM = 17%). For the prevalence of chronic disease, the indirect effect estimate was significantly larger among individuals age 46 to 58 years compared to individuals age 59 to 71 years and for incidence of chronic disease also compared to individuals age 72 to 84 years. All other indirect effect estimates did not differ significantly between age groups. Using an alternative cut-off point for HL or adjusting for cognitive functioning did not meaningfully change the results.

CONCLUSIONS

Overall, we found that the explanatory role of HL in educational inequalities in mental and subjective health was stable but that it varied across age groups for chronic diseases, where it was largest among individuals age 46 to 58 years. Future studies may investigate the benefits of starting to intervene on HL from a younger age but means to improve HL may also benefit the subjective health of older adults with lower education. [HLRP: HL Research and Practice. 2023;7(1):e26-e38.] Plain Language Summary: This study examined age-group differences in the mediating role of HL in the relationship between education and health. Overall, we found that the explanatory role of HL in educational inequalities in mental and subjective health was stable but that it varied across age groups for chronic diseases, where it was largest among individuals age 46 to 58 years compared to individuals age 59 to 71 years and individuals age 72 to 84 years.

Association between Chronic Disease Self-Management, Health Status, and Quality of Life in Older Taiwanese Adults with Chronic Illnesses

Aging is accompanied by many chronic comorbidities and disabilities, and entails medical expenses, which affects the quality of life among older adults. The purpose of this study was to investigate whether the health status of older adults with chronic diseases mediates chronic disease self-management to predict quality of life. Methods: This research adopted a cross-sectional correlation study design. Convenient sampling was performed in outpatient departments commonly visited by older adults in a medical center in Southern Taiwan. The following measures were collected: (1) Physiological measurement: left handgrip, right handgrip, and lower extremities’ muscle strength. (2) Questionnaires: cognitive function was measured by the Alzheimer’s disease (AD)-8 scale, possible frailty with the Kihon Checklist (KCL), functional status with the Barthel Index (BI) and the Lawton and Brody Instrumental Activities of Daily Living (IADL) scales, and self-management for chronic disease and quality of life with the (WHOQOL)-BREF, Taiwan version. Results: Chronic disease self-management is correlated with health status and is directly related to quality of life. Chronic disease self-management also indirectly affects quality of life through health status (cognitive status and risk of frailty), showing that health status partly mediates the correlation between chronic disease self-management and quality of life. Conclusions: A health status feedback system should be introduced in related chronic disease self-management measures for older adults so that they can be aware of their own health status and so that their quality of life is improved. Custom-made nursing interventions are necessary for the reduction in or delay of disability or risk of frailty in older adults, thereby enhancing their quality of life.

Pain self‐management intervention supports successful attainment of self‐selected rehabilitation goals—secondary analysis of a randomized controlled trial

Objectives

(i) Describe patients' self‐selected activity‐related rehabilitation goals, and (ii) compare attainment of these rehabilitation goals among people with persistent tension‐type neck pain receiving a group‐based pain and stress self‐management intervention (PASS) or individual physiotherapy (IPT).

Methods

Before intervention and random allocation to PASS or IPT, 156 people (PASS n = 77, IPT n = 79), listed three self‐selected activity‐related rehabilitation goals by use of the Patient Goal Priority Questionnaire (PGPQ). For each activity goal, participants rated limitations in activity performance, self‐efficacy and fear of activity performance, readiness to change to improve performance, and expectations of future activity performance. At follow‐ups (10 weeks, 20 weeks, 1 year and 2 years after inclusion), participants also responded to a question on changes made to improve activity performance. Mann–Whitney U test was used to evaluate between‐group differences.

Results

There were between‐group differences in favour of PASS in the attainment of self‐selected rehabilitation goals with regard to activity limitations and satisfaction with activity performance at all follow‐ups.

Conclusions

PASS was more successful than IPT for the attainment of self‐selected rehabilitation goals, improvements in activity limitations and satisfaction with activity performance as measured by PGPQ. The PASS programme emphasized the importance of applying active pain‐ and stress‐coping techniques in personal ‘risk situations’ for pain flare‐ups, which appear to support people with persistent tension‐type neck pain to make changes in their lives to improve activity performance.

Patient or Public Contribution

Patient engagement in rehabilitation by self‐selected goals was investigated, but patients were not involved in the design or conduct of the study.

Does education of primary care professionals promote patient self-management and improve outcomes in chronic disease? An updated systematic review

BACKGROUND

Primary care has a vital role in supporting patient autonomy to enable people with long-term conditions to manage their own health and wellness. Evidence is needed on whether education and training of health professionals helps support patient self-management and improves outcomes. The authors' first systematic review included only two articles showing patient outcomes following health professional training for promoting patient self-management.

AIM

To present an updated review undertaken from September 2013 to August 2018.

DESIGN & SETTING

A systematic review was undertaken using the PRISMA guidelines, following the methodology of the first review and is outlined in the PROSPERO registered protocol.

METHOD

Six databases were searched - Cochrane Library, PubMed, ERIC, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and PsycINFO - in addition to web searches, hand searches, and bibliographies for articles published from 1 September 2013 to 31 August 2018.

RESULTS

The updated systematic review showed more evidence is now available with 18 articles in the 5-year period from the 4284 abstracts located. Twelve of these articles showed a difference between intervention and control groups. Of the 18 articles identified, 11 were assessed as having a low risk of bias and five overall were rated of weak quality. The educational interventions with health professionals spanned a range of techniques and modalities, and many incorporated multiple interventions including patient components. There may be a lack of adoption owing to several challenges, including that complex interventions may not be delivered as planned and are difficult to assess, and owing to patient engagement and the need for ongoing follow-up.

CONCLUSION

More high-quality research is needed on what methods work best, for which patients, and for what clinical conditions in the primary care setting. The practical implications of training healthcare professionals require specific attention.

Evaluation of a self-management intervention for adults with epilepsy in Taiwan: A longitudinal randomized controlled trial

PURPOSE

Epilepsy is a neurological disease that causes recurrent seizures and can have a significant impact on a person's quality of life (QOL). A self-management intervention (SMI) can allow adults with epilepsy to modify behaviors in order to manage their seizures and evaluate the impact of medication and treatments on their daily lives. The purpose of this study was to investigate the effects of a SMI for adults with epilepsy.

METHODS

This was a longitudinal randomized controlled trial. Adults with epilepsy between the age of 20 and 65 years were recruited from a medical center in northern Taiwan. Participants were assigned to an intervention group (IG) or control group (CG) through simple randomization. Data regarding demographic and clinical characteristics were collected at baseline (T0). In addition, participants answered nine validated self-report questionnaires, which were used as outcome measures. Following collection of baseline data, the CG received routine monthly counseling over the next 3 months. The IG received the routine monthly counseling, as well as individual face-to-face health counseling on self-management 1 h/month and remote counseling via the phone or computer network at least twice per month. After the first month (T1) and at the end of the third (T2) and sixth months (T3) participants answered the nine questionnaires again. Differences in outcomes between the IGs and CGs were analyzed by comparing scores for the nine outcome variables at T0 with scores at T1, T2, and T3 with generalized estimating equations.

RESULTS

A total of 210 adults agreed to participate in the study; however, only 155 participants completed the questionnaires for all three time points: 75 in the CG and 80 in the IG. The mean age of the 155 participants was 39.6 years (SD = 10.9). There was no significant difference between demographic or clinical variables between the two groups. The only difference in baseline scores (T0) among the nine self-report questionnaires was in epilepsy knowledge, measured with the Epilepsy Knowledge Profile questionnaire, which were significantly higher for the CG (mean = 32.28, SD = 3.92) than the IG (mean = 23.01, SD = 2.79) (p < 0.001). Generalized estimating equations (GEE) analysis showed scores decreased significantly at T3 from baseline for the CG for epilepsy knowledge and QOL (p < 0.001). Improvements in scores for sleep quality, anxiety, depression, self-efficacy, coping, and social support did not differ between groups. Classification of the IG by gender showed a significantly greater increase for males compared with females from baseline to T3 for epilepsy knowledge (p < 0.001). If we further classified the IGs by seizure frequency, participants with a seizure frequency of ≥1 per year had a more significant increase in epilepsy knowledge and increase in QOL compared with participants with a seizure frequency of <1 per year at T3 compared with T0.

CONCLUSION

The lack of improvement in health-related quality of life (HRQoL) following the SMI may indicate that additional time is required to change behaviors that impact this variable for patients with epilepsy. Additional research should focus on variables associated with medication compliance, epilepsy knowledge, medicine symptom distress, self-efficacy, anxiety, and HRQoL.

Psychometric testing of a set of patient-reported instruments to assess healthcare interventions for autistic adults

LAY ABSTRACT

Interventions to improve healthcare for autistic adults are greatly needed. To evaluate such interventions, researchers often use surveys to collect data from autistic adults (or sometimes, their supporters), but few survey measures have been tested for use with autistic adults. Our objective was to create and test a set of patient- or proxy-reported survey measures for use in studies that evaluate healthcare interventions. We used a community-based participatory research (CBPR) approach, in partnership with autistic adults, healthcare providers, and supporters. We worked together to create or adapt survey measures. Three survey measures focus on things that interventions may try to change directly: (1) how prepared patients are for visits; (2) how confident they feel in managing their health and healthcare; and (3) how well the healthcare system is making the accommodations patients feel they need. The other measures focus on the outcomes that interventions may hope to achieve: (4) improved patient-provider communication; (5) reduced barriers to care; and (6) reduced unmet healthcare needs. We then tested these measures in a survey of 244 autistic adults recruited from 12 primary care clinics in Oregon and California, USA (with 194 participating directly and 50 participating via a proxy reporter). Community partners made sure items were easy to understand and captured what was important about the underlying idea. We found the survey measures worked well in this sample. These measures may help researchers evaluate new healthcare interventions. Future research needs to assess whether interventions improve healthcare outcomes in autistic adults.

Self-management interventions in systemic sclerosis: A systematic review

Systemic sclerosis is a rare and incurable autoimmune disease in which patients are challenged with self-managing their disease. Systematic evaluation of the essential self-management intervention components and self-management outcomes is necessary to assess the state of the science of self-management for patients with systemic sclerosis. As such, the purpose of this systematic review was to identify and describe self-management interventions and their impact on self-management outcomes in adults with systemic sclerosis. Studies were included if they contained a self-management intervention, incorporated at least one self-management outcome identified as a common data element by the National Institute of Nursing Research (i.e., patient activation, self-efficacy, self-regulation, global health), and were conducted in adults with systemic sclerosis. Using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines, PubMed, Cumulative Index of Nursing and Allied Health Literature, and Embase were searched from the inception of each database to March 2020, yielding a total of 215 studies. Of these reports, 16 met the inclusion criteria for this review. There was notable variability in the types of self-management interventions and their effects on key self-management outcomes. Self-management interventions focused on improving physical function through rehabilitation programs were the most common interventions (n = 7). The poor methodological quality of the studies included in this systematic review, however, limited the synthesis of and recommendations for self-management interventions in adults with systemic sclerosis. Future research in systemic sclerosis should include key self-management outcomes in larger, more rigorously designed studies to allow for comparisons across studies and to advance the science of self-management.

Octopus Watch Fosters Family Resilience by Enhancing Occupational Engagement for Children with Spina Bifida and/or Hydrocephalus: Pilot Study

BACKGROUND

Children with spina bifida and/or hydrocephalus (SB&/H) often experience difficulties with activities of daily living (ADLs) due to impaired executive functioning, increasing sedentary behaviours. The HeyJoy Octopus watch, a child-friendly icon-based smartwatch could be used as an enabler to promote purposeful ADLs (i.e., goal-orientated ADLs).

OBJECTIVE

to investigate the effectiveness of the Octopus watch in promoting purposeful ADLs for children living with SB&/H (<8 years).

METHODS

Mixed-methods engaging parents and children in four phases: (1) Administered demographic questionnaire, semi-structured interview, childhood executive functioning inventory (CHEXI) and the Canadian occupational performance measure (COPM); focus group one introducing the study, information pack using smartwatch and photovoice data collection methods. (2) Measured baseline movement for four days with smartwatch without using functions. (3) Measured activity for 16-days while using the smartwatch. (4) Re-administered assessments and conducted a second focus group based on photovoice narratives.

RESULTS

movement data recorded for four participants, three of four showed mean activity increase (36%). N-of-1 analyses found one participant showed clear improvement (p = 0.021, r² = 0.28). Mean inhibition decreased by 16.4%, and mean change in COPM performance and satisfaction scores were 2.1 and 2.4, respectively. The photovoice narrative focus group supports findings evidenced with improved daily routines.

CONCLUSIONS

The Octopus watch is an innovative early intervention that can promote purposeful ADLs, fostering family resilience by enhancing occupational engagement. Further research is required.

Implementing a self-management mobile app for spinal cord injury during inpatient rehabilitation and following community discharge: A feasibility study

Objective: To determine the feasibility of implementing and evaluating a self-management mobile app for spinal cord injury (SCI) during inpatient rehabilitation and following community discharge. Design: Pilot feasibility study. Setting: Rehabilitation hospital and community. Participants: Inpatients from rehabilitation hospital following admission for their first SCI. Intervention: A mobile app was developed to facilitate self-management following SCI. The app consisted of 18 tools focusing on goal setting, tracking various health aspects, and identifying confidence regarding components of self-management. In-person training and follow-up sessions were conducted during inpatient rehabilitation and follow-up calls were provided after participants were discharged into the community. Main outcome measures: Participants completed outcome measures at baseline, community discharge, and 3-months post discharge. This study focused on feasibility indicators including recruitment, retention, respondent characteristics, adherence, and app usage. Additionally, participants' self-management confidence relating to SCI (e.g. medication, skin, bladder, pain) was evaluated over time. Results: Twenty participants (median age 39, IQR: 31 years, 85% male) enrolled in the study. Participants' Spinal Cord Injury Independence Measure (SCIM-III) median score was 23 and IQR was 33 (range: 7-84), which did not correlate with app usage. Retention from admission to discharge was 85% and 70% from discharge to 3-months post discharge. Individuals in the study who used the app entered data an average of 1.7x/day in rehabilitation (n = 17), and 0.5x/day in the community (n = 7). Participants' bowel self-management confidence improved between admission and discharge (P < 0.01). Conclusions: Feasibility indicators support a larger clinical trial during inpatient rehabilitation; however, there were challenges with retention and adherence following community discharge.

Cross-Cultural Reliability of an Arabic Version of the Self-Efficacy for Managing Chronic Disease 6-Item Scale in Arab Patients with Diabetes mellitus

INTRODUCTION

Arab nations have the second highest diabetes mellitus (DM) prevalence in the world. There is a growing interest in self-management programs that emphasize patient's central role in managing type 2 DM.

AIM OF THE STUDY

To validate an Arabic version of the Self-Efficacy for Managing Chronic Disease 6-Item Scale (SEM6S) among Arab type 2 DM patients and to explore factors associated with self-efficacy measured with the SEM6S.

METHODS

Cross-sectional study on 302 Arab patients with T2DM of three different nationalities (Egyptian, Saudi, Kuwaiti).The SEM6S was translated using forward-backward method, and its reliability was determined by calculating Cronbach's alpha. A regression model was used to examine variables associated with self-efficacy in Arab patients with T2DM.

RESULTS

Questionnaire was successfully translated without language or content-related problem. The mean age of participants was 47.71±14.7 years with equally represented sexes. The mean total score of the SEM6S was 5.99±1.86. The scale psychometric properties was reproducible (ICC=0.61-0.71) with good reliability (Cronbach's alpha=0.79). Statistically significant increase in self-efficacy was observed in patients <30 years, uncomplicated DM, DM with hypertension, and in patients who had physical activity > 60min per day. Also, a bimodal increase in self-efficacy was detected in patients with DM<5 years and 10.1-15 years. After regression analysis, physical activity was significantly positively correlated with self-efficacy (β=0.8, P=0.01), and duration of diabetes was significantly negatively correlated with self-efficacy (β = -0.23, P=0.03).

CONCLUSION

Arabic SEM6S is acceptable, reliable and repeatable metric for self-efficacy.

[Differential impact and heterogeneous needs. A peer-led training program for improving chronic patients' health status and health behaviors]

OBJECTIVE

To measure the impact of the peer-led training for chronic patients on their health status and behaviors.

DESIGN

Descriptive, transversal pretest and posttest quantitative approach.

PLACEMENT

Andalusia.

PARTICIPANTS

Nine hundred sixty-four patients with Diabetes, fibromyalgia and heart failure, trained at the School of Patients between 2013 and 2015.

INTERVENTIONS

Peer-training intervention for self-efficacy for chronic patients.

MAIN MEASUREMENT

Self-reported health status, activity limitation, diet and physical activity. Statistical analysis included descriptive and bivariate statistics, correlation coefficient and net gains for paired variables.

RESULTS

Health status improved after the training, with less limitations and better diet and physical activity, with significant differences by sex, chronic illness, education level and marriage status. Improvement areas where identified for the training strategy, with special attention on the needs of more vulnerable groups (women, people with less education level).

CONCLUSIONS

The peer training had a positive impact, with differences depending on social profiles. 1-year and 2-years posttest measurements are needed and a qualitative study is required in order to better evaluate the peer-led strategy and to adapt it to participants' needs and expectations.

A systematic review examining whether community-based self-management programs for older adults with chronic conditions actively engage participants and teach them patient-oriented self-management strategies

OBJECTIVE

To identify whether community-based Self-Management Programs (SMPs) actively engaged, or taught, individuals patient-oriented strategies; and whether having these attributes led to significant differences in outcomes.

METHODS

This systematic review included randomized controlled trials (RCTs)and cluster RCTs reporting on community-based SMPs with a group component for older adults with chronic conditions. The ways SMPS actively engaged participants and whether they taught patient-oriented strategies were analyzed. All study outcomes were reported.

RESULTS

The 31 included studies demonstrated community-based SMP programs actively engaged participants and provided strategies to improve health behaviour or care of their condition. Few included strategies to help manage the impact of conditions on their everyday lives. Seventy-nine percent of studies reported significant differences; variations in sample sizes and outcomes made it difficult to conclude whether having these attributes led to significant differences.

CONCLUSION

SMPs are not supporting older adults to use strategies to address the impact of conditions on their everyday lives, addressing the needs of older adults with multiple conditions, nor assessing outcomes that align with the strategies taught.

PRACTICE IMPLICATIONS

Health-care providers delivering SMPs to older adults need to tailor programs to the needs of older adults and assess whether participants are using strategies being proposed.

Physiotherapy Based on a Biobehavioral Approach with or Without Orthopedic Manual Physical Therapy in the Treatment of Nonspecific Chronic Low Back Pain: A Randomized Controlled Trial

Objective

To compare the effectiveness of a biobehavioral approach with and without orthopedic manual physical therapy on the intensity and frequency of pain in patients diagnosed with nonspecific chronic low back pain.

Methods

A single-blind randomized controlled trial. Fifty patients were randomly allocated into two groups: one group received biobehavioral therapy with orthopedic manual physical therapy, and the other group received only biobehavioral therapy. Both groups completed a total of eight sessions, with a frequency of two sessions per week. The somatosensory, physical, and psychological variables were recorded at baseline and during the first and third month after initiation of treatment.

Results

In both groups, the treatment was effective, presenting significant differences for all the variables in the time factor. There were no significant differences between groups in intensity or frequency of pain, with a large effect size (&gt;0.80), but there were intragroup differences for both intervention groups at one- and three-month follow-up. There were also no significant differences between groups in the secondary variables during the same follow-up period.

Conclusions

The results of this study suggest that orthopedic manual physical therapy does not increase the effects of a treatment based on biobehavioral therapy in the short or medium term, but these results should be interpreted with caution.

Psychometric evaluation of the summary of diabetes self-care activities measure in Ghanaian adults living with type 2 diabetes

AIMS

We evaluated the content validity, factorial structure, internal consistency, construct validity, and floor and ceiling effects of the SDSCA among Ghanaian persons with type 2 diabetes.

METHODS

The summary of diabetes self-care activities measure (SDSCA) was administered to 187 adults living with type 2 diabetes from three diabetes clinics.

RESULTS

A confirmatory factor analysis maintained the four factor structure of the SDSCA. However, two items, 3 (fruit and vegetable servings) and 4 (red meat or full-fat dairy products) had factor loadings of 0.26 and 0.16 respectively. The model also had a statistical power of 0.72 (below acceptable criteria). Modification of the model by removing item 4 resulted in an improved revised model with a power of 0.82. Construct validity was found for the exercise and diet subscales of the SDSCA but not for the self-monitoring of blood glucose and foot care subscales. The internal consistency of the SDSCA measure was 0.68, below acceptable criteria for internal consistency. No floor effects were present but the exercise subscale had ceiling effects.

CONCLUSION

The SDSCA measure had content validity, maintained its multidimensionality and met the criteria for floor effects but not for construct validity, internal consistency and ceiling effects. The SDSCA measure may require improvements to evaluate self-care behaviours of adult type 2 diabetes patients in Ghana and probably in other sub-Saharan countries.

Gender Based Cognitive Determinants Of Medication Adherence In Older Adults With Chronic Conditions

BACKGROUND

Life course gender-role traits and social stereotypes could affect the pattern of medication adherence in old age.

OBJECTIVES

The main purpose of this study was to investigate gender based cognitive determinants of medication adherence in a sample of older adults who suffer from at least a chronic condition.

METHODS

In this cross-sectional design, 455 older adults participated from five health centers in Tabriz city, Iran from June to August 2017 using a random sampling method. Next, required data about medication adherence, knowledge and beliefs about prescribed medications, perceived self-efficacy in medication adherence, illness perception, and reasons for medication non-adherence were gathered using a structured written questionnaire through face-to-face interviews with the attendees.

RESULTS

Low medication adherence was reported by 54.5% of the study participants. Perceived self-efficacy for medication adherence (OR = 1.04; 95% CI: 1.00, 1.08) and medication adherence reason (OR = 0.96; 95% CI: 0.92, 0.99) were two identified strong predictors of medication adherence among the studied older men. Illness perception (OR = 1.02; 95% CI: 1.00, 1.02) and beliefs toward prescribed medication (OR = 0.95; 95% CI: 0.93, 0.98) were both recognized as the significant predictors of medication adherence in the older women subgroup.

CONCLUSION

Gender based variations were noted regarding the medication adherence in the studied sample and attributes of cognitive function were the main pinpointed elucidating parameters for the non-conformity. The explicit cognitive processes must be considered in care provision or interventional programs that target medication adherence in older adults.

Twelve-month effect of chronic pain self-management intervention delivered in an easily accessible primary healthcare service - a randomised controlled trial

Background

To investigate the effects after twelve months related to patient activation and a range of secondary outcomes on persons with chronic pain of a chronic pain self-management course compared to a low-impact outdoor physical activity, delivered in an easily accessible healthcare service in public primary care.

Methods

An open, pragmatic, parallel group randomised controlled trial was conducted. The intervention group was offered a group-based chronic pain self-management course with 2.5-h weekly sessions for a period of six weeks comprising education that included cognitive and behavioural strategies for pain management, movement exercises, group discussions and sharing of experiences among participants. The control group was offered a drop-in, low-impact, outdoor physical activity in groups in one-hour weekly sessions that included walking and simple strength exercises for a period of six weeks. The primary outcome was patient activation assessed using the Patient Activation Measure (PAM-13). Secondary outcomes included assessments of pain, anxiety and depression, pain self-efficacy, sense of coherence, health-related quality of life, well-being and the 30-s Chair to Stand Test. Analyses were performed using a linear mixed model.

Results

After twelve months, there were no statistically significant differences between the intervention group (n = 60) and the control group (n = 61) for the primary or the secondary outcomes. The estimated mean difference between the groups for the primary outcome PAM was 4.0 (CI 95% -0.6 to 8.6, p = 0.085). Within both of the groups, there were statistically significant improvements in pain experienced during the previous week, the global self-rated health measure and the 30-s Chair to Stand Test.

Conclusions

No long-term effect of the chronic pain self-management course was found in comparison with a low-impact physical activity intervention for the primary outcome patient activation or for any secondary outcome.

Trial registration

ClinicalTrials.gov: NCT02531282. Registered on August 212,015

Does patient self-management education of primary care professionals improve patient outcomes: a systematic review

BACKGROUND

Patient self-management support is recognised as a key component of chronic care. Education and training for health professionals has been shown in the literature to be associated with better uptake, implementation and effectiveness of self-management programs, however, there is no clear evidence regarding whether this training results in improved health outcomes for patients with chronic conditions.

METHODS

A systematic review was undertaken using the PRISMA guidelines using the Cochrane Library, PubMEd, ERIC, EMBASE, CINAHL, PsycINFO, Web searches, Hand searches and Bibliographies. Articles published from inception to September 1st, 2013 were included. Systematic reviews, Meta-analysis, Randomized controlled trials (RCTs), Controlled clinical trials, Interrupted time series and Controlled before and after studies, which reported on primary care health professionals' continuing education or evidence-based medicine/education on patient self-management for any chronic condition, were included. A minimum of two reviewers participated independently at each stage of review.

RESULTS

From 7533 abstracts found, only two papers provided evidence on the effectiveness of self-management education for primary healthcare professionals in terms of measured outcomes in patients. These two articles show improvement in patient outcomes for chronic back pain and diabetes based on RCTs. The educational interventions with health professionals spanned a range of techniques and modalities but both RCTs included a motivational interviewing component.

CONCLUSIONS

Before and up to 2 years after the incorporation of patient empowerment for self-management into the WONCA Europe definition of general practice, there was a scarcity of high quality evidence showing improved outcomes for patients as a result of educating health professionals in patient self-management of chronic conditions.

Self-Management and Yoga for Older Adults with Chronic Stroke: A Mixed-Methods Study of Physical Fitness and Physical Activity

OBJECTIVE

This study investigated changes in physical fitness and physical activity among older patients with chronic stroke (stroke ≥ 6 months previous) after participation in a yoga infused self-management intervention.

METHODS

A mixed-methods secondary data analysis examined quantitative measures of endurance, strength, and gait speed and qualitative perspectives of intervention participants.

RESULTS

Based on Wilcoxon analysis, physical fitness outcome measures including endurance and lower and upper body strength significantly (p < .02) improved. Based on qualitative results of 2 focus groups and 14 individual interviews, participants expressed positive changes in endurance, strength, gait speed, flexibility, and balance. They also reported improvements in walking ability and duration, and expressed a desire to continue yoga and increase levels of exercise.

CONCLUSIONS

With the objective of improving physical fitness and exercise for older adults with chronic stroke, it is important for self-management interventions to provide specific safe and feasible physical activity components, such as yoga.

CLINICAL IMPLICATIONS

Health professionals may improve offered chronic stroke self-management interventions by incorporating yoga.

Patient-Reported Measures for Person-Centered Coordinated Care: A Comparative Domain Map and Web-Based Compendium for Supporting Policy Development and Implementation

Background

Patient-reported measure (PRM) questionnaires were originally used in research to measure outcomes of intervention studies. They have now evolved into a diverse family of tools measuring a range of constructs including quality of life and experiences of care. Current health and social care policy increasingly advocates their use for embedding the patient voice into service redesign through new models of care such as person-centered coordinated care (P3C). If chosen carefully and used efficiently, these tools can help improve care delivery through a variety of novel ways, including system-level feedback for health care management and commissioning. Support and guidance on how to use these tools would be critical to achieve these goals.

Objective

The objective of this study was to develop evidence-based guidance and support for the use of P3C-PRMs in health and social care policy through identification of PRMs that can be used to enhance the development of P3C, mapping P3C-PRMs against an existing model of domains of P3C, and integration and organization of the information in a user-friendly Web-based database.

Methods

A pragmatic approach was used for the systematic identification of candidate P3C-PRMs, which aimed at balancing comprehensiveness and feasibility. This utilized a number of resources, including existing compendiums, peer-reviewed and gray literature (using a flexible search strategy), and stakeholder engagement (which included guidance for relevant clinical areas). A subset of those candidate measures (meeting prespecified eligibility criteria) was then mapped against a theoretical model of P3C, facilitating classification of the construct being measured and the subsequent generation of shortlists for generic P3C measures, specific aspects of P3C (eg, communication or decision making), and condition-specific measures (eg, diabetes, cancer) in priority areas, as highlighted by stakeholders.

Results

In total, 328 P3C-PRMs were identified, which were used to populate a freely available Web-based database. Of these, 63 P3C-PRMs met the eligibility criteria for shortlisting and were classified according to their measurement constructs and mapped against the theoretical P3C model. We identified tools with the best coverage of P3C, thereby providing evidence of their content validity as outcome measures for new models of care. Transitions and medications were 2 areas currently poorly covered by existing measures. All the information is currently available at a user-friendly web-based portal (p3c.org.uk), which includes all relevant information on each measure, such as the constructs targeted and links to relevant literature, in addition to shortlists according to relevant constructs.

Conclusions

A detailed compendium of P3C-PRMs has been developed using a pragmatic systematic approach supported by stakeholder engagement. Our user-friendly suite of tools is designed to act as a portal to the world of PRMs for P3C, and have utility for a broad audience, including (but not limited to) health care commissioners, managers, and researchers.

The Influence of Self-Efficacy, Fear-Avoidance Belief, and Coping Styles on Quality of Life for Chinese Patients with Chronic Nonspecific Low Back Pain: A Multisite Cross-Sectional Study

BACKGROUND

As a bio-psycho-social issue, chronic low back pain (CLBP) has been a significant topic in health management, and patients' quality of life (QOL) is gaining extensive attention. Self-efficacy, pain fear-avoidance belief (FAB), and coping styles play important roles in the QOL of CLBP patients. However, it remains unclear how self-efficacy and FAB influence QOL through specific coping styles. This study aimed to explore the influencing paths of self-efficacy, FAB, and coping styles on the QOL of patients with CLBP.

METHODS

This study relies on a multisite, cross-sectional design involving 221 CLBP patients. Stepwise multiple regression and structural equation modeling were employed.

RESULTS

CLBP patients lived with a poor global QOL. Self-efficacy played a direct, positive role in predicting QOL for patients with CLBP (β = 0.35), and it also played an indirect, positive role in predicting QOL (β = 0.19) through active coping styles (β = 0.31). FAB played a direct, negative role in predicting QOL (β = -0.33), and it also played an indirect, negative role in predicting QOL (β = -0.32) through passive coping styles (β = 0.32).

CONCLUSIONS

Self-efficacy and FAB are both directly and indirectly related to global QOL, and coping styles are important mediating variables. Self-efficacy and active coping are protective factors for the QOL of CLBP patients, while FAB and passive coping are risk factors. Health education strategies are recommended by medical personnel to enhance CLBP patients' pain self-efficacy, decrease pain FAB, and modify pain coping styles, so that their global QOL can be improved.

Chronicity and use of health services: peer education of the School of Patients

OBJECTIVE

To evaluate the impact of the training strategy of the Escuela de Pacientes (School of Patients) on the use of health services among people with chronic diseases.

METHOD

Quantitative design study of pretest and posttest evaluation with a population of 3,350 chronic patients of the Escuela de Pacientes (Andalusia, 2013-2015). A questionnaire adapted from the Stanford University was used. It measured the self-perceived health, number of health visits, and level of trust and communication with health personnel. A descriptive and bivariate study, a correlation study and a pretest/posttest net gain analysis were performed.

RESULTS

Participation of 964 patients (28.8% of the population), of which 18.8% were men, mean age 56 years. Training increased trust in Primary Care (PC) and Hospital Care (HC) professionals (0.44 and 0.65 points), medical visits decreased by 25%, and hospital admissions fell by 51% with statistically significant differences by sex and disease. The correlation index between trust in professionals and use of health services was -0.215.

CONCLUSION

The training strategy had a positive impact on the use of health services and trust in health professionals, and were identified areas of improvement from which recommendations are established.

Patient-Centred Innovations for Persons with Multimorbidity: funded evaluation protocol

BACKGROUND

The high prevalence of multimorbidity necessitates rethinking of the health care system. The overarching goal of the Patient-Centred Innovations for Persons with Multimorbidity program is to build on existing structures and find and evaluate patient-centred innovations relevant to multimorbidity.

METHODS

We describe the protocol for a proposed multijurisdictional (Quebec and Ontario) concurrent triangulation mixed-methods study. In both provinces, a qualitative descriptive study will be used to explore innovations in patient-centred multimorbidity care. Two randomized controlled trials, 1 in either province, will evaluate the innovations in a wait-list-controlled design using patient-reported outcomes. An additional control group, matched on age, sex, enrolment/index date (± 3 mo) and propensity score, will be created with the use of health administrative data. Patients will be 18-80 years of age and will have 3 or more chronic conditions. The innovations will have elements of relevance to multimorbidity care, patient-centred partnerships and integration of care. The primary outcome measures will be 2 patient-reported outcomes: patient education and self-efficacy. Secondary outcomes will include patient-reported health status, quality of life, psychological distress and health behaviours, and costs of care.

INTERPRETATION

This protocol describes a mixed-method study in 2 jurisdictions. The studies will answer the questions of what innovations work and how they work for patients, health care professionals and policy-makers. Trial registration: ClinicalTrials.gov, no NCT02789800 (Quebec Trial), NCT02742597 (Ontario Trial).

Nursing clinical practice changes to improve self-management in chronic obstructive pulmonary disease

AIM

To propose nursing clinical practice changes to improve the development of patient self-management.

BACKGROUND

Chronic obstructive pulmonary disease is one of the main causes of chronic morbidity, loss of quality of life and high mortality rates.

INTRODUCTION

Control of the disease's progression, the preservation of autonomy in self-care and maintenance of quality of life are extremely challenging for patients to execute in their daily living. However, there is still little evidence to support nursing clinical practice changes to improve the development of self-management.

METHODS

A participatory action research study was performed in a medicine inpatient department and the outpatient unit of a Portuguese hospital. The sample comprised 52 nurses and 99 patients. For data collection, we used interviews, participant observation and content analysis.

RESULTS

The main elements of nursing clinical practice that were identified as a focus for improvement measures were the healthcare model, the organization of healthcare and the documentation of a support decision-making process. The specific guidelines, the provision of material to support decision-making and the optimization of information sharing between professionals positively influenced the change process. This change improved the development of self-management skills related to the awareness of the need for 'change', hope, involvement, knowledge and abilities.

DISCUSSION

The implemented changes have improved health-related behaviours and clinical outcomes.

CONCLUSION

To support self-management development skills, an effective nursing clinical practice change is needed. This study has demonstrated the relevance of a portfolio of techniques and tools to help patients adopt healthy behaviours.

IMPLICATIONS FOR NURSING AND/OR HEALTH POLICY

The involvement and participation of nurses and patients in the conceptualization, implementation and evaluation of policy change are fundamental issues to improve the quality of nursing care and clinical outcomes.

A review of web-based chronic disease self-management for older adults

Objective

To examine the current evidence related to the efficacy of web-based chronic disease self-management interventions (web-based SM) for older populations.

Methods

A search of experimental and quasi-experimental publications related to older adults and web-based SM was conducted. The search identified 12 articles representing 10 distinct studies that were used for review and critique.

Results

Articles most frequently investigated web-based SM targeting diabetes and heart disease. Interventions incorporated a variety of technologies including visual-charting, instant messenger, among others. Overall the web-based SM for older adults resulted in positive effects for most outcomes, including: healthcare utilization, depression, loneliness, social support, quality of life, self-efficacy, anxiety, disease specific outcomes, functioning levels, diet, exercise, and health status.

Discussion

While these studies suggest that web-based SM may be effective in producing positive health outcomes for older adults, more research is needed to focus on the efficacy and appropriateness of such interventions for older adults.

Self-management in patients with diabetes and chronic kidney disease is associated with incremental benefit in HRQOL

AIMS

There is insufficient and inconsistent data regarding the association between diabetes self-management, the process of facilitating the knowledge, skill, and ability necessary for diabetes self-care, and health-related quality of life (HRQOL) in people with diabetes and moderate to severe chronic kidney disease (CKD).

METHODS

In a cross sectional study, participation in diabetes self-management assessed by the Summary of Diabetes Self-Care Activities (SDSCA) questionnaire and HRQOL was examined in 308 patients with diabetes and CKD (stages 3 to 5) recruited from outpatient diabetes and renal clinics of 4 public tertiary hospitals. Associations were examined by Pearson correlation coefficients and hierarchical multiple regression after controlling for potential confounders. An examination of trend across the levels of patient participation in self-management was assessed using a non-parametric test for trend.

RESULTS

The median age and interquartile range (IQR) of patients were 68 and 14.8years, respectively with 59% of the population being over 65years old and 69.5% male. The median durations of diabetes and CKD were 18years (IQR-17) and 5years (IQR-8) respectively. General diet, exercise and medication taking were positively associated with at least one HRQOL subscale (all p<0.05) but diabetes specific diet, blood sugar testing and foot checking were not. As levels of participation in self-management activities increased there was a graded increase in mean HRQOL scores across all subscales (p for trend <0.05).

CONCLUSIONS

In people with diabetes and moderate to severe CKD, participation in diabetes self-management activities, particularly those focused on general diet, exercise and medication taking, was associated with higher HRQOL.

A Nursing Approach to Self-Management Education for Individuals With Mental Illness and Diabetes

Patients with serious mental illness (SMI) and diabetes often seek care in primary care settings and have worse health outcomes than patients who have either illness alone. Individual, provider, and system-level barriers present challenges to addressing both psychiatric and medical comorbidities. This article describes the feasibility, acceptability, and implementation of Targeted Training and Illness Management (TTIM), a self-management intervention delivered by trained nurse educators and peer educators to groups of individuals with SMI and diabetes to improve self-management of both diseases. TTIM is intended to be delivered in a primary care setting. Findings are intended to support the future development of nurse-led programs within the primary care setting that teach self-management to individuals with concurrent SMI and diabetes. This approach supports both adaptability and flexibility in delivering the intervention. Interventions such as TTIM can provide self-management skills, accommodate people with both SMI and diabetes in primary care settings such as patient-centered medical homes, and address known barriers to access.

Types of vicarious learning experienced by pre-dialysis patients

Objective:

Haemodialysis and peritoneal dialysis renal replacement treatment options are in clinical equipoise, although the cost of haemodialysis to the National Health Service is £16,411/patient/year greater than peritoneal dialysis. Treatment decision-making takes place during the pre-dialysis year when estimated glomerular filtration rate drops to between 15 and 30 mL/min/1.73 m². Renal disease can be familial, and the majority of patients have considerable health service experience when they approach these treatment decisions. Factors affecting patient treatment decisions are currently unknown. The objective of this article is to explore data from a wider study in specific relation to the types of vicarious learning experiences reported by pre-dialysis patients.

Methods:

A qualitative study utilised unstructured interviews and grounded theory analysis during the participant’s pre-dialysis year. The interview cohort comprised 20 pre-dialysis participants between 24 and 80 years of age. Grounded theory design entailed thematic sampling and analysis, scrutinised by secondary coding and checked with participants. Participants were recruited from routine renal clinics at two local hospitals when their estimated glomerular filtration rate was between 15 and 30 mL/min/1.73 m².

Results:

Vicarious learning that contributed to treatment decision-making fell into three main categories: planned vicarious leaning, unplanned vicarious learning and historical vicarious experiences.

Conclusion:

Exploration and acknowledgement of service users’ prior vicarious learning, by healthcare professionals, is important in understanding its potential influences on individuals’ treatment decision-making. This will enable healthcare professionals to challenge heuristic decisions based on limited information and to encourage analytic thought processes.

A family-focused intervention for heart failure self-care: conceptual underpinnings of a culturally appropriate intervention

AIM

A discussion of the conceptual elements of an intervention tailored to the needs of Lebanese families.

BACKGROUND

The role of informal caregiving is strongly recommended for individuals with chronic conditions including heart failure. Although this importance is recognized, conceptual and theoretical underpinnings are not well elucidated nor are methods of intervention implementation.

DESIGN

Discussion paper on the conceptual underpinning of the FAMILY model.

METHODS AND DATA SOURCES

This intervention was undertaken using linked methods: (1) Appraisal of theoretical model; (2) review of systematic reviews on educational interventions promoting self-management in chronic conditions in four databases with no year limit; (3) socio-cultural context identification from selected papers; (4) expert consultation using consensus methods; and (5) model development.

RESULTS

Theories on self-care and behavioural change, eighteen systematic reviews on educational interventions and selected papers identifying sociocultural elements along with expert opinion were used to guide the development of The FAMILY Intervention Heart Failure Model. Theory and practice driven concepts identified include: behavioural change, linkage, partnership and self-regulation.

IMPLICATIONS FOR NURSING

Heart failure is a common condition often requiring in-hospital and home-based care. Educational interventions targeting the socio-cultural influences of the patients and their family caregivers through a structured and well-designed program can improve outcomes.

CONCLUSION

As the burden of chronic diseases increases globally, particularly in emerging economies, developing models of intervention that are appropriate to both the individual and the socio-cultural context are necessary.

Structure and content components of self-management interventions that improve health-related quality of life in people with inflammatory bowel disease: a systematic review, meta-analysis and meta-regression

AIMS AND OBJECTIVES

The purpose of this review was to identify and categorise the components of the content and structure of effective self-management interventions for patients with inflammatory bowel disease.

BACKGROUND

Inflammatory bowel diseases are chronic gastrointestinal disorders impacting health-related quality of life. Although the efficacy of self-management interventions has been demonstrated in previous studies, the most effective components of the content and structure of these interventions remain unknown.

DESIGN

A systematic review, meta-analysis and meta-regression of randomised controlled trials was used.

METHODS

A systematic search of six electronic databases, including Pubmed, Embase, Cochrane central register of controlled trials, Web of Science, Cumulative Index of Nursing and Allied Health Literature and Chinese Biomedical Literature Database, was conducted. Content analysis was used to categorise the components of the content and structure of effective self-management interventions for inflammatory bowel disease. Clinically important and statistically significant beneficial effects on health-related quality of life were explored, by comparing the association between effect sizes and various components of self-management interventions such as the presence or absence of specific content and different delivery methods.

RESULTS

Fifteen randomised controlled trials were included in this review. Distance or remote self-management interventions demonstrated a larger effect size. However, there is no evidence for a positive effect associated with specific content component of self-management interventions in adult patients with inflammatory bowel disease in general.

CONCLUSIONS

The results showed that self-management interventions have positive effects on health-related quality of life in patients with inflammatory bowel disease, and distance or remote self-management programmes had better outcomes than other types of interventions.

RELEVANCE TO CLINICAL PRACTICE

This review provides useful information to clinician and researchers when determining components of effective self-management programmes for patients with inflammatory bowel disease. More high-quality randomised controlled trials are needed to test the results.

Assessing self-management in patients with diabetes mellitus type 2 in Germany: validation of a German version of the Summary of Diabetes Self-Care Activities measure (SDSCA-G)

Background

One of the most widely used self-reporting tools assessing diabetes self-management in English is the Summary of Diabetes Self-Care Activities (SDSCA) measure. To date there is no psychometric validated instrument in German to assess self-management in patients with diabetes mellitus. Therefore, this study aimed to translate the SDSCA into German and examine its psychometric properties.

Methods

The English version of the SDSCA was translated into German following the guidelines for cultural adaptation. The German version of the SDSCA (SDSCA-G) was administered to a random sample of 315 patients with diabetes mellitus type 2. Reliability was analyzed using Cronbach’s alpha coefficient and item characteristics were assessed. Exploratory and confirmatory factor analysis (EFA and CFA) were carried out to explore the construct validity. A multivariable linear regression model was used to identify the influence of predictor variables on the SDSCA-G sum score.

Results

The Cronbach’s alpha for the SDSCA-G (all items) was α = 0.618 and an acceptable correlation between the SDSCA-G and Self-management Diabetes Mellitus-Questionnaire (SDQ) (ρ = 0.664) was identified. The EFA suggested a four factor construct as did the postulated model. The CFA showed the goodness of fit of the SDSCA-G. However, item 4 was found to be problematic regarding the analysis of psychometric properties. The omission of item 4 yielded an increase in Cronbach’s alpha (α = 0.631) and improvements of the factor structure and model fit. No statistically significant influences of predictor variables on the SDSCA-G sum score were observed.

Conclusion

The revised German version of the SDSCA (SDSCA-G) is a reliable and valid tool assessing self-management in adults with type 2 diabetes in Germany.

Electronic supplementary material

The online version of this article (doi:10.1186/s12955-014-0185-1) contains supplementary material, which is available to authorized users.

The multiple sclerosis self-management scale: clinicometric testing

BACKGROUND

The Multiple Sclerosis Self-Management Scale (MSSM) is currently the only measure that was developed specifically to address self-management among individuals with multiple sclerosis (MS). While good internal consistency (α = 0.85) and construct validity have been demonstrated, other psychometric properties have not been established. This study was undertaken to evaluate the criterion validity, test-retest reliability, and face validity of the MSSM.

METHODS

Thirty-one individuals with MS who met the inclusion criteria were recruited to complete a series of questionnaires at two time points. At Time 1, participants completed the MSSM and two generic self-management tools-the Partners in Health (PIH-12) and the Health Education Impact Questionnaire (heiQ)-as well as a short questionnaire to capture participants' opinions about the MSSM. At Time 2, approximately 2 weeks after Time 1, participants completed the MSSM again.

RESULTS

The available MSSM factors showed moderate to high correlations with both PIH-12 and heiQ and were deemed to have satisfactory test-retest reliability. Face validity pointed to areas of the MSSM that need to be revised in future work. As indicated by the participants, some dimensions of MS self-management are missing in the MSSM and some items such as medication are redundant.

CONCLUSIONS

This study provides evidence for the reliability and validity of the MSSM; however, further changes are required for both researchers and clinicians to use the tool meaningfully in practice.

The association of family social support, depression, anxiety and self-efficacy with specific hypertension self-care behaviours in Chinese local community

This study aimed to test the role of family social support, depression, anxiety and self-efficacy on specific self-care behaviours. In a local community health center, 318 patients with hypertension completed a questionnaire assessing self-care, family social support, depression, anxiety and self-efficacy in 2012. Each self-care behaviour was separately analyzed with logistic regression models. The mean score of perceived family social support for hypertension treatment was 20.91 (maximum=60). Adult children were identified as the primary support source. Approximately 22.3% and 15.4% of participants reported symptoms of anxiety and depression, respectively. Participants had moderately positive levels of confidence performing self-care (42.1±13.3 out of 60). After adjusting for demographic and health variables, a 10-unit increase in family social support increased the odds ratio (OR) of taking medication by 1.39 (95% confidence interval (CI) 1.03-1.87) and increased the OR for measuring blood pressure (BP) regularly by 1.33 (95% CI 1.02-1.74). Depression and anxiety were not associated with any self-care behaviours. A10-unit increase in self-efficacy increased the adjusted OR for performing physical exercise to 1.25 (95% CI 1.04-1.49). In conclusion, family social support was positively associated with medication adherence and regular BP measurement. Strategies to improve family social support should be developed for hypertension control, yet further prospective studies are needed to understand the effects of family social support, depression, anxiety and self-efficacy on self-care behaviours.

Practice network-based care management for patients with type 2 diabetes and multiple comorbidities (GEDIMAplus): study protocol for a randomized controlled trial

BACKGROUND

Care management interventions in the German health-care system have been evaluated with promising results, but further research is necessary to explore their full potential in the context of multi-morbidity. Our aim in this trial is to assess the efficacy of a primary care practice network-based care management intervention in improving self-care behaviour among patients with type 2 diabetes mellitus and multiple co-occurring chronic conditions.

METHODS/DESIGN

The study is designed as a prospective, 18-month, multicentre, investigator-blinded, two-arm, open-label, individual-level, randomized parallel-group superiority trial. We will enrol 582 patients with type 2 diabetes mellitus and at least two severe chronic conditions and one informal caregiver per patient. Data will be collected at baseline (T0), at the primary endpoint after 9 months (T1) and at follow-up after 18 months (T2). The primary outcome will be the differences between the intervention and control groups in changes of diabetes-related self-care behaviours from baseline to T1 using a German version of the revised Summary of Diabetes Self-Care Activities (SDSCA-G). The secondary outcomes will be the differences between the intervention and control groups in: changes in scores on the SDSCA-G subscales, glycosylated haemoglobin A level, health-related quality of life, self-efficacy, differences in (severe) symptomatic hypoglycaemia, cost-effectiveness and financial family burden. The intervention will be delivered by trained health-care assistants as an add-on to usual care and will consist of three main elements: (1) three home visits, including structured assessment of medical and social needs; (2) 24 structured telephone monitoring contacts; and (3) self-monitoring of blood glucose levels after T1 in 3-month intervals. The control group will receive usual care. The confirmatory primary analysis will be performed following the intention-to-treat (ITT) principle. The efficacy of the intervention will be quantified using two-level linear regression stratified by type of medical treatment adjusted for baseline values on the SDSCA-G. Secondary analyses will be performed according to the ITT principle. In health economic evaluations, we will estimate the incremental cost-effectiveness ratios.

DISCUSSION

We hope that the results of this study will provide insights into the efficacy of practice network-based care management among patients with complex health-care needs.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN 83908315 (ISRCTN assigned 25 February 2014).

Manage at work: a randomized, controlled trial of a self-management group intervention to overcome workplace challenges associated with chronic physical health conditions

BACKGROUND

The percentage of older and chronically ill workers is increasing rapidly in the US and in many other countries, but few interventions are available to help employees overcome the workplace challenges of chronic pain and other physical health conditions. While most workers are eligible for job accommodation and disability compensation benefits, other workplace strategies might improve individual-level coping and problem solving to prevent work disability. In this study, we hypothesize that an employer-sponsored group intervention program employing self-management principles may improve worker engagement and reduce functional limitation associated with chronic disorders.

METHODS

In a randomized controlled trial (RCT), workers participating in an employer-sponsored self-management group intervention will be compared with a no-treatment (wait list) control condition. Volunteer employees (n = 300) will be recruited from five participating employers and randomly assigned to intervention or control. Participants in the intervention arm will attend facilitated group workshop sessions at work (10 hours total) to explore methods for improving comfort, adjusting work habits, communicating needs effectively, applying systematic problem solving, and dealing with negative thoughts and emotions about work. Work engagement and work limitation are the principal outcomes. Secondary outcomes include fatigue, job satisfaction, self-efficacy, turnover intention, sickness absence, and health care utilization. Measurements will be taken at baseline, 6-, and 12-month follow-up. A process evaluation will be performed alongside the randomized trial.

DISCUSSION

This study will be most relevant for organizations and occupational settings where some degree of job flexibility, leeway, and decision-making autonomy can be afforded to affected workers. The study design will provide initial assessment of a novel workplace approach and to understand factors affecting its feasibility and effectiveness.

TRIAL REGISTRATION

Clinicaltrials.gov: NCT01978392 (Issued November 6, 2013).

Limited evidence of the effects of patient education and self-management interventions in psoriasis patients: a systematic review

OBJECTIVE

To describe the contents of educational and self-management programmes for patients with psoriasis, and to evaluate their effects.

METHODS

A systematic review of randomized controlled trials (RCTs), quasi-randomized trials and controlled clinical trials identified by a systematic literature search. Risk of bias was assessed by two independent reviewers and interventional effects were summarized descriptively and by meta-analysis.

RESULTS

Nine studies were included, which ranged from single brief interventions to long complex multidisciplinary programmes. Four RCTs with adequate sequence allocation were included to analyze interventional effects. One RCT compared two different educational programmes and found no differences between groups. The results of three trials that focused on combinations of education and self-management were heterogeneous. One RCT based on a 12-week comprehensive programme reported statistically significant effects (p<0.05) on disease severity and health-related quality of life. Two RCTs with less comprehensive programmes reported no effects on HRQoL.

CONCLUSION

This review showed that little evidence is available to support the effects of educational and self-management interventions in patients with psoriasis that are studied in RCTs. There is a significant lack of focused self-management and, compared with other chronic conditions, there appear to be few effective disease-specific tailored educational programmes for psoriasis.

Factors Associated with Women's Chronic Disease Management: Associations of Healthcare Frustrations, Physician Support, and Self-Care Needs

Previous research emphasizes the importance of reducing healthcare frustrations and enhancing physician supports to help patients engage in recommended healthcare regimens. However, less is known about how these factors are associated with aging women's knowledge about self-care behavior. This study examined the sociodemographics, health indicators, healthcare-related frustrations, and perceptions of physician support associated with middle-aged and older adult females' self-reported need for help to learn how to take better care of their health. Data were analyzed from 287 females with one or more chronic conditions who completed The National Council on Aging (NCOA) Chronic Care Survey. A logistic regression model was developed. Women who were non-White (OR = 2.26, P = 0.049) were more likely to need help learning how to better manage their health. Those who had some college education or more (OR = 0.55, P = 0.044) and lower healthcare-related frustrations (OR = 0.44, P = 0.017) and perceived to have more physician support (OR = 0.49, P = 0.033) were less likely to need help learning how to better manage their health. Findings can inform the planning, implementation, assessment, and dissemination of evidence-based self-management programs for middle-aged and older women within and outside of clinical settings.

Depression self-management support: a systematic review

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

PRACTICE IMPLICATIONS

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

Validation of a Chinese Version of the Self-Efficacy for Managing Chronic Disease 6-Item Scale in Patients with Hypertension in Primary Care

The aim of this study was to validate a Chinese version of the Self-Efficacy for Managing Chronic Disease 6-Item Scale (SES6C). In 2012, a cross-sectional study was conducted in a community clinic, in Beijing, China. A total of 262 hypertension patients participated in this study. Concurrent validity was validated by Pearson’s correlations between the SES6C and Hospital Anxiety and Depression Scale (HADS). Intraclass correlation coefficients (ICC) were performed to evaluate test-retest reliability of the scale. Related factors of self-efficacy were explored in linear regression models. The results of our study display acceptable psychometric properties: the scale was two-dimensional, reproducible (ICC = 0.78; 95% CI, 0.70–0.84), and the reliability was good (Cronbach’s alpha = 0.88). Significant (r=-0.30; P<0.001) correlation was found between the level of self-efficacy and the level of psychological distress. In multivariable analysis, the factors significantly associated with self-efficacy were regular exercise (β=0.659, P<0.01), HADS total score (β=-0.076, P<0.001) and health status (β=-0.530, P<0.001). The study provides evidence that the SES6C is acceptable, valid and repeatable for hypertension patients.

Using insights from behavioral economics and social psychology to help patients manage chronic diseases

Despite a revolution in therapeutics, the ability to control chronic diseases remains elusive. We present here a conceptual model of the potential role of behavioral tools in chronic disease control. Clinicians implicitly accept the assumption that patients will act rationally to maximize their self-interest. However, patients may not always be the rational actors that we imagine. Major behavioral barriers to optimal health behavior include patients' fear of threats to health, unwillingness to think about problems when risks are known or data are ambiguous, the discounting of risks that are far in the future, failure to act due to lack of motivation, insufficient confidence in the ability to overcome a health problem, and inattention due to pressures of everyday life. Financial incentives can stimulate initiation of health-promoting behaviors by reducing or eliminating financial barriers, but may not produce long-term behavior change without additional interventions. Strategies have been developed by behavioral economists and social psychologists to address each of these barriers to better decision-making. These include: labeling positive behaviors in ways consistent with patient life goals and priorities; greater focus on more immediate risks of chronic diseases; intermediate subgoals as steps to a large health goal; and implementation of specific plans as to when, where, and how an action will be taken. Such strategies hold promise for improving health behaviors and disease control, but most have not been studied in medical settings. The effectiveness of these approaches should be evaluated for their potential as tools for the clinician.

A systematic review of self-management interventions for children and youth with physical disabilities

PURPOSE

Evidence shows that effective self-management behaviors have the potential to improve health outcomes, quality of life, self-efficacy and reduce morbidity, emergency visits and costs of care. A better understanding of self-management interventions (i.e. programs that help with managing symptoms, treatment, physical and psychological consequences) is needed to achieve a positive impact on health because most children with a disability now live well into adulthood.

METHOD

A systematic review of self-management interventions for school age youth with physical disabilities was undertaken to assess their effectiveness. Comprehensive electronic searches using international web-based reference libraries were conducted for peer-reviewed and gray literature published between 1980 and January 2012. Eligible studies examined the effectiveness of self-management interventions for children and youth between 6 and 18 years of age with congenital or acquired physical disabilities. Studies needed to include a comparison group (e.g. single group pre/post-test design) and at least one quantifiable health-related outcome.

RESULTS

Of the 2184 studies identified, six met the inclusion criteria; two involved youth with spina bifida and four with juvenile arthritis. The majority of the interventions ran several sessions for at least 3 months by a trained interventionist or clinician, had one-to-one sessions and meetings, homework activities and parental involvement. Although outcomes varied between the studies, all of the interventions reported at least one significant improvement in either overall self-management skills or a specific health behavior.

CONCLUSIONS

While self-management interventions have the potential to improve health behaviors, there were relatively few rigorously designed studies identified. More studies are needed to document the outcomes of self-management interventions, especially their most effective characteristics for children and youth with physical disabilities. Implications for Rehabilitation There is some evidence to suggest that self-management interventions for children and youth with spina bifida and arthritis can improve self-management behaviors and health outcomes. Parents' involvement should be considered in encouraging self-management behaviors at different stages of their child's development. Much work is needed to explore the longer term implications of self-management interventions for youth with physical disabilities as well as the impact on health care utilization.

Self-management programme for cancer patients: a literature review

BACKGROUND

With increased cancer survivorship, cancer, in its chronic form, self-management among cancer patients has become an international research focus. Self-management programmes are used to guide the self-care process. Over the past 10 years, six self-management programmes for cancer patients (Taking CHARGE, Expert Patients Programme, Living with Cancer Education Program, Focus Program, PRO-SELF Program and Oncologist-referred exercise self-management programme) were used in a variety of self-management studies for cancer patients.

AIM

The aims of this paper are to describe, compare and critique these six self-management programmes that are commonly used to guide self-management for cancer patients, and propose directions for new self-management programme development among cancer patients.

METHODS

Medline, Pubmed and Embase, Springer, Elsevier, EBSCO and ProQuest were searched for literatures on self-management programmes for cancer patients from 2000 to November 2010. Search terms such as 'self-management' or 'self-care' or 'patient education' or 'self-management' or 'self-care' or 'self-efficacy', 'intervention' or 'program*' 'cancer' or 'carcinoma' or 'neoplasms' were used.

RESULTS

Comparison and critique of these programmes revealed important limitations of cancer self-management programmes including lack of the facilitators' training process, failure to assess the cultural differences and failure to cover all of the outcome measures.

CONCLUSION

Researchers and clinicians need to build more individualized and dynamic self-management programmes that parallel advances in clinical research and practice for cancer patients.

Self-management: a systematic review of outcome measures adopted in self-management interventions for stroke

Purpose

To systematically review the psychometric properties of outcome measures used in stroke self-management interventions (SMIs) to (1) inform researchers, clinicians and commissioners about the properties of the measures in use and (2) make recommendations for the future development of self-management measurement in stroke.

Methods

Electronic databases, government websites, generic internet search engines and hand searches of reference lists. Abstracts were selected against inclusion criteria and retrieved for appraisal and systematically scored, using the COSMIN checklist.

Results

Thirteen studies of stroke self-management originating from six countries were identified. Forty-three different measures (mean 5.08/study, SD 2.19) were adopted to evaluate self-SMIs. No studies measured self-management as a discreet concept. Six (46%) studies included untested measures. Eleven (85%) studies included at least one measure without reported reliability and validity in stroke populations.

Conclusions

The use of outcome measures which are related, indirect or proxy indicators of self-management and that have questionable reliability and validity, contributes to an inability to sensitively evaluate the effectiveness of stroke self-SMIs. Further enquiry into how the concept of self-management in stroke operates, would help to clarify the nature and range of specific self-management activities to be targeted and aid the selection of existing appropriate measures or the development of new measures.

Assessment of proximal outcomes of self-management programs: translation and psychometric evaluation of a German version of the Health Education Impact Questionnaire (heiQ™)

PURPOSE

This paper describes the translation, cultural adaption, and psychometric evaluation of a German version of the Health Education Impact Questionnaire (heiQ™), a widely used generic instrument assessing a wide range of proximal outcomes of self-management programs.

METHODS

The translation was carried out according to international standards and included forward and backward translations. Comprehensibility and content validity were tested using cognitive interviews with 10 rehabilitation inpatients. Psychometric properties were examined in rehabilitation inpatients (n = 1,202) with a range of chronic conditions. Factorial validity was assessed using confirmatory factor analysis; concurrent validity was explored by correlations with comparator scales.

RESULTS

The items of the German heiQ™ were well understood by rehabilitation inpatients. The structure of the eight heiQ™ scales was replicated after minor adjustment. heiQ™ scales had higher correlations with comparator scales with similar constructs, particularly mental health concepts than with physical health. Moreover, all heiQ™ scales differentiated between individuals across different levels of depression.

CONCLUSION

The German heiQ™ is comprehensible for German-speaking patients suffering from different types of chronic conditions; it assesses relevant outcomes of self-management programs in a reliable and valid manner. Further studies involving its practical application are warranted.

The association between self-efficacy and hypertension self-care activities among African American adults

Chronic disease management requires the individual to perform varying forms of self-care behaviors. Self-efficacy, a widely used psychosocial concept, is associated with the ability to manage chronic disease. In this study, we examine the association between self-efficacy to manage hypertension and six clinically prescribed hypertension self-care behaviors. We interviewed 190 African Americans with hypertension who resided in the greater metropolitan Charlotte area about their self-efficacy and their hypertension self-care activities. Logistic regression for correlated observations was used to model the relationship between self-efficacy and adherence to hypertension self-care behaviors. Since the hypertension self-care behavior outcomes were not rare occurrences, an odds ratio correction method was used to provide a more reliable measure of the prevalence ratio (PR). Over half (59%) of participants reported having good self-efficacy to manage their hypertension. Good self-efficacy was statistically significantly associated with increased prevalence of adherence to medication (PR = 1.23, 95% CI: 1.08, 1.32), eating a low-salt diet (PR = 1.64, 95% CI: 1.07-2.20), engaging in physical activity (PR = 1.27, 95% CI: 1.08-1.39), not smoking (PR = 1.10, 95% CI: 1.01-1.15), and practicing weight management techniques (PR = 1.63, 95% CI: 1.30-1.87). Hypertension self-efficacy is strongly associated with adherence to five of six prescribed self-care activities among African Americans with hypertension. Ensuring that African Americans feel confident that hypertension is a manageable condition and that they are knowledgeable about appropriate self-care behaviors are important factors in improving hypertension self-care and blood pressure control. Health practitioners should assess individuals' self-care activities and direct them toward practical techniques to help boost their confidence in managing their blood pressure.