Self-management education: history, definition, outcomes, and mechanisms

Bewältigung chronischer Erkrankung

Although chronic diseases build the main focus of health problems, the German health care system is not sufficiently prepared to deal with the new challenges. The reasons are diverse, but one of the most decisive is that the various consequences in dealing with chronic disease are scarcely noticed by the health service. These consequences are brought out by the following article by referring to the available literature and our own studies and are discussed in its implications for a needs-driven design of care. Special attention is paid to care, because it increasingly assumes a key role in the treatment of chronically ill, which still faces barriers in this country. These discussed are also.

Depression in adults with type 2 diabetes: the role of adherence, body mass index, and self-efficacy

Considerable evidence links depression with the development and worsening of diabetes, but the factors contributing to this link have not been established. The authors examined the role of adherence, body mass index (BMI), and self-efficacy. Adult patients with Type 2 diabetes (N = 56) completed self-report measures of diet and exercise adherence, diet and exercise self-efficacy, and depression. BMI was obtained from medical records. Path and mediation analyses indicated that both adherence and BMI independently contributed to self-efficacy. Self-efficacy mediated both the association between adherence and depression and the association between BMI and depression. These findings are consistent with the proposal that lower self-efficacy in reaction to adherence failure and higher BMI contributes to depression in adults with diabetes.

Is self-efficacy associated with diabetes self-management across race/ethnicity and health literacy?

OBJECTIVE

Although prior research demonstrated that improving diabetes self-efficacy can improve self-management behavior, little is known about the applicability of this research across race/ethnicity and health literacy levels. We examined the relationship between diabetes self-efficacy and self-management behavior in an urban, diverse, low-income population with a high prevalence of limited health literacy.

RESEARCH DESIGN AND METHODS

We administered an oral questionnaire in Spanish and English to patients with type 2 diabetes at two primary care clinics at a public hospital. We measured self-efficacy, health literacy, and self-management behaviors using established instruments. We performed multivariate regressions to explore the associations between self-efficacy and self-management, adjusting for clinical and demographic factors. We tested for interactions between self-efficacy, race/ethnicity, and health literacy on self-management.

RESULTS

The study participants were ethnically diverse (18% Asian/Pacific Islander, 25% African American, 42% Latino/a, and 15% white), and 52% had limited health literacy (short version of the Test of Functional Health Literacy in Adults score <23). Diabetes self-efficacy was associated with four of the five self-management domains (P < 0.01). After adjustment, with each 10% increase in self-efficacy score, patients were more likely to report optimal diet (0.14 day more per week), exercise (0.09 day more per week), self-monitoring of blood glucose (odds ratio 1.16), and foot care (1.22), but not medication adherence (1.10, P = 0.40). The associations between self-efficacy and self-management were consistent across race/ethnicity and health literacy levels.

CONCLUSIONS

Self-efficacy was associated with self-management behaviors in this vulnerable population, across both race/ethnicity and health literacy levels. However, the magnitude of the associations suggests that, among diverse populations, further study of the determinants of and barriers to self-management is warranted. Policy efforts should be focused on expanding the reach of self-management interventions to include ethnically diverse populations across the spectrum of health literacy.

Finding common ground: patient-centeredness and evidence-based chronic illness care

Health outcomes for patients with major chronic illnesses depend on the appropriate use of proven pharmaceuticals and other therapeutic technologies, and effective self-management by patients. Effective chronic illness care then bases clinical decisions on the best, rigorous scientific evidence, or evidence-based medicine. Effective support for patient self-management includes efforts to increase patient participation in care and collaborative goal-setting and planning of treatment. These interventions appear somewhat consistent with recent conceptualizations of patient-centered care. The consistent delivery of proven therapies and information and support for self-management requires practice systems organized for that purpose. The Chronic Care Model is a compilation of those practice system changes shown to improve chronic care. This paper explores the concept of patient-centeredness and its relationship to the Chronic Care Model. We conclude that the Model is both evidence-based and patient-centered and that these can be properties of health systems, and not just of individual practitioners.

Increasing self-management skills in heart failure patients: a pilot study

Nonadherence to medical treatment among heart failure patients is high and results in frequent exacerbations and premature death. This treatment-only pilot study examined whether a year-long group-based self-management intervention is feasible and improves self-management skills in patients with mild-to-moderate heart failure (ejection fraction < or =40% and New York Heart Association functional class I, II, or III). A total of 31 of 100 recruited patients (31%) agreed to participate. Twenty-six (84%) completed the year-long self-management program. Compared with baseline, the intervention was associated with an increase in overall self-efficacy in practicing self-management skills (p<0.001) and in four of five specific self-management skills. Patients and their group leaders also reported an increase in actual use of self-management skills (p<0.001) and in several psychosocial outcomes. The success of this pilot study suggests the need for a randomized clinical trial to test the efficacy of group-based self-management training on medical outcomes.

Antidepressants and cognitive-behavioral therapy for symptom syndromes

Somatic symptoms are common in primary care and clinicians often prescribe antidepressants as adjunctive therapy. There are many possible reasons why this may work, including treating comorbid depression or anxiety, inhibition of ascending pain pathways, inhibition of prefrontal cortical areas that are responsible for "attention" to noxious stimuli, and the direct effects of the medications on the syndrome. There are good theoretical reasons why antidepressants with balanced norepinephrine and serotonin effects may be more effective than those that act predominantly on one pathway, though head-to-head comparisons are lacking. For the 11 painful syndromes review in this article, cognitive-behavioral therapy is most consistently demonstrated to be effective, with various antidepressants having more or less randomized controlled data supporting or refuting effectiveness. This article reviews the randomized controlled trial data for the use of antidepressant and cognitive-behavior therapy for 11 somatic syndromes: irritable bowel syndrome, chronic back pain, headache, fibromyalgia, chronic fatigue syndrome, tinnitus, menopausal symptoms, chronic facial pain, noncardiac chest pain, interstitial cystitis, and chronic pelvic pain. For some syndromes, the data for or against treatment effectiveness is relatively robust, for many, however, the data, one way or the other is scanty.

Implementing a Multidisease Chronic Care Model in Primary Care Using People and Technology

Management of chronic disease is performed inadequately in the United States in spite of the availability of beneficial, effective therapies. Successful programs to manage patients with these diseases must overcome multiple challenges, including the recognized fragmentation and complexity of the healthcare system, misaligned incentives, a focus on acute problems, and a lack of team-based care. In many successful programs, care is provided in settings or episodes that focus on a single disease. While these programs may allow for streamlined, focused provision of care, comprehensive care for multiple diseases may be more difficult. At Intermountain Healthcare (Intermountain), a generalist model of chronic disease management was formulated to overcome the limitations associated with specialization. In the Intermountain approach, which reflects elements of the Chronic Care Model (CCM), care managers located within multipayer primary care clinics collaborate with physicians, patients, and other members of a primary care team to improve patient outcomes for a variety of conditions. An important part of the intervention is widespread use of an electronic health record (EHR). This EHR provides flexible access to clinical data, individualized decision support designed to encourage best practice for patients with a variety of diseases (including co-occurring ones), and convenient communication between providers. This generalized model is used to treat diverse patients with disparate and coexisting chronic conditions. Early results from the application of this model show improved patient outcomes and improved physician productivity. Success factors, challenges, and obstacles in implementing the model are discussed.

Implementation of efficacy enhancement nursing interventions with cardiac elders

Intervention strategies based on social cognitive theory and encompassing the bio-psycho-behavioral domains are proposed to enhance self-efficacy in men and women 65 years and older recovering from myocardial infarction and coronary artery bypass grafting. This paper describes a study in which the theory-based development of efficacy enhancement (EE) nursing interventions and their implementation and utilization with interventions from the Nursing Interventions Classification (NIC) were used with cardiac elders in the treatment group of the community-based randomized clinical, trial, "Improving Health Outcomes in Unpartnered Cardiac Elders." Advanced practice nurses (APNs) provided the nursing intervention to 110 participants (mean age = 76.2, SD = 6.0) for the first 12 weeks after discharge to home. After an initial introductory meeting in the acute-care setting, participant contacts by the APNs were made at a home visit and telephone calls at 2, 6, and 10 weeks. Results describe the number of participants receiving interventions at all contacts over 12 weeks, at specified contact points, and the intensity (nurse time) of the interventions. Verbal encouragement and mastery were EE interventions used with the greatest number of participants. Exercise promotion, energy management and active listening were NIC interventions used with the most participants. Variations in the use of interventions over 12 weeks and their intensities, suggest patterns of recovery in the elders. During rehabilitation EE interventions can be successfully implemented with men and women 65 years and older and individualized to the recovery trajectory. Nurses can integrate specific EE interventions with more general interventions from the bio-psycho-behavioral domains to enhance the recovery process for cardiac elders.

Using RE-AIM metrics to evaluate diabetes self-management support interventions

BACKGROUND

Current healthcare evidence relies on relatively narrow efficacy data to make decisions about program impact. This paper illustrates the application of impact indices derived from the RE-AIM (reach, effectiveness, adoption, implementation, and maintenance) framework that takes a broader perspective and includes issues important to decision makers, such as reach, adoption, and cost.

METHODS

Composite RE-AIM indices that summarize impact and cost efficiency at the individual participant and setting levels are used to compare two different diabetes self-management support approaches. One study, the Diabetes Priority (DP) program, involved 886 diabetes patients from 30 primary care offices, and relied on usual clinical staff for program implementation. The other study, Diabetes Health Connection (DHC), involved 335 diabetes patients in both HMO and fee-for-service settings, and used health education staff.

RESULTS

The DP performed better on the setting-level impact index, but the programs produced similar results on individual-level impact. The DP had a greater reach (50% vs 38%); was more effective at the initial follow-up (median effect size [ES]=0.23 vs 0.17); and had greater impact consistency across various populations. The DHC performed better on several indices, including higher physician office adoption (20% vs 6%) and staff adoption (79% vs 70%), and there was less variability among intervention staff on protocol implementation (median ES=0.0 vs 0.50).

CONCLUSIONS

Greater use of indices focused on public health and external validity criteria could help identify programs most likely to have a meaningful impact on population health and to fit local settings and priorities.

Building health promotion interventions for persons with chronic disabling conditions

There is a growing number of persons with chronic disabling conditions and a concurrent interest and need for health-promotion interventions to prevent disability and promote quality of life within the context of chronic conditions. Most often researchers/clinicians build their own intervention focusing on selected dimensions of health promotion for a specific population. This article recommends an alternative process of building health-promotion interventions for specific groups through the adaptation of content and processes of well-developed intervention frameworks with sound theoretical and empirical support. This efficient approach enhances the likelihood that new interventions will prove to be effective and enhance the quality of life for persons with chronic disabling conditions.

Patient-provider communication in chronic illness: a health promotion window of opportunity

As chronic illness takes its rightful place as an imperative for planners and policy makers globally, the obligation to provide appropriate self-care management support and promote optimal health among the chronically ill is attracting considerable attention. A generation of insider research into the chronic illness experience has yielded powerful evidence of the critical importance of communication between the chronically ill and those who provide their healthcare services. In this article, insights gained from the body of chronic illness research shape recommendations for attitudinal and structural adjustments that might steer our course toward promoting improved health for those affected by a chronic disease.

Use of the Patient Assessment of Chronic Illness Care (PACIC) with diabetic patients: relationship to patient characteristics, receipt of care, and self-management

OBJECTIVE

There is a dearth of information on the extent to which diabetic patients receive care congruent with the chronic care model (CCM) and evidence-based behavioral counseling. This study evaluates a new instrument to fill this gap.

RESEARCH DESIGN AND METHODS

A heterogeneous sample of 363 type 2 diabetic patients completed the original Patient Assessment of Chronic Illness Care (PACIC), along with additional items that allowed it to be scored according to the "5As" (ask, advise, agree, assist, and arrange) model of behavioral counseling. We evaluated relationships between survey scores and patient characteristics, quality of diabetes care, and self-management.

RESULTS

Findings replicated those of the initial PACIC validation study but with a much larger sample of diabetic patients and more Latinos. Areas of CCM activities reported least often were goal setting/intervention tailoring and follow-up/coordination. The 5As scoring revealed that patients were least likely to receive assistance with problem solving and arrangement of follow-up support. Few demographic or medical characteristics were related to PACIC or 5As scores, but survey scores were significantly related to quality of diabetes care received and level of physical activity.

CONCLUSIONS

The PACIC and the new 5As scoring method appear useful for diabetic patients. Its use is encouraged in future research and quality improvement studies.

Interactive Health Communication Applications for people with chronic disease

BACKGROUND

Interactive Health Communication Applications (IHCAs) are computer-based, usually web-based, information packages for patients that combine health information with at least one of social support, decision support, or behaviour change support. These are innovations in health care and their effects on health are uncertain.

OBJECTIVES

To assess the effects of IHCAs for people with chronic disease.

SEARCH STRATEGY

We designed a four-part search strategy. First, we searched electronic bibliographic databases for published work; second, we searched the grey literature; and third, we searched for ongoing and recently completed clinical trials in the appropriate databases. Finally, researchers of included studies were contacted, and reference lists from relevant primary and review articles were followed up. As IHCAs require relatively new technology, the search time period commenced at 1990, where possible, and ran until 31 December 2003.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of IHCAs for adults and children with chronic disease.

DATA COLLECTION AND ANALYSIS

One reviewer screened abstracts for relevance. Two reviewers screened all candidate studies to determine eligibility, apply quality criteria, and extract data from included studies. Authors of included RCTs were contacted for missing data. Results of RCTs were pooled using random-effects model with standardised mean differences (SMDs) for continuous outcomes and odds ratios for binary outcomes; heterogeneity was assessed using the I(2 )statistic.

MAIN RESULTS

We identified 24 RCTs involving 3739 participants which were included in the review.IHCAs had a significant positive effect on knowledge (SMD 0.46; 95% confidence interval (CI) 0.22 to 0.69), social support (SMD 0.35; 95% CI 0.18 to 0.52) and clinical outcomes (SMD 0.18; 95% CI 0.01 to 0.35). Results suggest it is more likely than not that IHCAs have a positive effect on self-efficacy (a person's belief in their capacity to carry out a specific action) (SMD 0.24; 95% CI 0.00 to 0.48). IHCAs had a significant positive effect on continuous behavioural outcomes (SMD 0.20; 95% CI 0.01 to 0.40). Binary behavioural outcomes also showed a positive effect for IHCAs, although this result was not statistically significant (OR 1.66; 95% CI 0.71 to 3.87). It was not possible to determine the effects of IHCAs on emotional or economic outcomes.

AUTHORS' CONCLUSIONS

IHCAs appear to have largely positive effects on users, in that users tend to become more knowledgeable, feel better socially supported, and may have improved behavioural and clinical outcomes compared to non-users. There is a need for more high quality studies with large sample sizes to confirm these preliminary findings, to determine the best type and best way to deliver IHCAs, and to establish how IHCAs have their effects for different groups of people with chronic illness.

Self-Management of Chronic Kidney Disease

Living with chronic kidney disease usually involves management of other chronic conditions, such as diabetes or hypertension, and often requires a change in the patient's way of life: medical and emotional aspects of the disease must be handled, symptoms interpreted and reported, partnerships with health care providers forged, and new resources used. Nurses can help patients maneuver this initially frightening and sometimes difficult terrain with strategies tailored to the stage of the disease.

Multiple sclerosis: diagnosis and the management of acute relapses

Multiple sclerosis is an inflammatory demyelinating disease of the central nervous system that may result in a wide range of neurological symptoms and accumulating disability. Its course is unpredictable resulting in a changing pattern of clinical need. Diagnostic criteria for multiple sclerosis require objective evidence for dissemination in space and time. The diagnostic and management process should follow good practice guidelines with the person at the centre of the process. Appropriate support and information should be available from the time of diagnosis. Continuing education is key in enabling the person to actively participate in their management. In the event of an acute relapse the person should have direct access to the most appropriate local service. Provided medical causes have been excluded, corticosteroid treatment to hasten the recovery from the relapse should be considered. Management of an acute relapse should be comprehensive addressing any medical, functional, or psychosocial sequelae.

Role and modalities of information and education in the management of patients with rheumatoid arthritis: development of recommendations for clinical practice based on published evidence and expert opinion

OBJECTIVES

To develop recommendations for the information and education of patients with rheumatoid arthritis (RA) seen in everyday practice, using evidence from the literature, supplemented with expert opinion when needed.

METHODS

A scientific committee developed eight questions using the Delphi consensus procedure. A task force reviewed the literature for answers to these questions, using the PubMed Medline database (1980-2004) and the 2002-2004 databases of the annual meetings held by the French Society for Rheumatology (SFR), the European League Against Rheumatism (EULAR), and the American College of Rheumatology (ACR); the indexing terms for the search were rheumatoid, arthritis, patient, education, information, knowledge, general practitioner, family doctor, and continuing medical education. Only articles in French or English were included. A panel of rheumatologists used the evidence thus compiled to develop recommendations for each question; gaps in evidence were filled by calling on the panelists' expert opinion. For each recommendation, the level of evidence and extent of agreement among panelists were specified.

RESULTS

There were four general questions about the objectives, supports, and mode of delivery (group or one-on-one) of patient information and education, as well as on evaluating knowledge, and four specific questions on program content. The search identified 1235 articles; 144 were selected on the title and 118 of those on the abstract. Three abstracts presented at meetings were also kept. The evidence from the literature was presented to the panelists during interactive workshops. The panelists then developed eight recommendations, all of which were grade D because no published studies specifically addressed everyday clinical practice. Agreement among panelists ranged across recommendations from 85.7% to 100%.

CONCLUSION

Recommendations about educating and informing patients with RA in everyday practice were developed. They should increase practice uniformity and ultimately optimize the management of patients with RA.

Ecological approaches to self-management: the case of diabetes

In the Diabetes Initiative of The Robert Wood Johnson Foundation, an ecological perspective helped identify the following key resources and supports for self-management (RSSM): individualized assessment, collaborative goal setting, skills enhancement, follow-up and support, access to resources, and continuity of quality clinical care. These RSSM reflect the grounding of diabetes self-management in the context of social and environmental influences. Research supports the value of each of these key resources and supports. Differences among self-management interventions may be seen as complementary, rather than conflicting, ways of providing RSSM. This way of understanding differences among interventions may aid development of varied programs to reach diverse audiences. In contrast to the "5 A's" model of key provider services (Assess, Advise, Agree, Assist, and Arrange), RSSM articulate self-management from the perspective of individuals' needs. Both approaches emphasize identification of goals, teaching of skills, and facilitation and reinforcement of the use of those skills.

The frequency and behavioral outcomes of goal choices in the self-management of diabetes

PURPOSE

The purpose of this study was to determine the frequency and effectiveness of behavioral goal choices in the self-management of diabetes and to test goal-setting theory hypotheses that self-selection and behavioral specificity of goals are key to enhancing persistence.

METHODS

Participants with type 2 diabetes in a randomized controlled trial (n = 422) completed baseline behavioral assessments using a clinic-based, interactive, self-management CD-ROM that allowed them to select a behavioral goal and receive mail and telephone support for the initial 6 months of the trial followed by additional behavioral assessments. Frequency of behavioral goal selection and 6-month behavioral data were collected.

RESULTS

Approximately 49%, 27%, and 24% of the participants, respectively, set goals to increase physical activity (PA), reduce fat intake, or increase fruits and vegetables (F&V) consumed. At baseline, participants who selected PA, reduced fat consumption, or F&V were significantly, and respectively, less active, consumed more dietary fat, and ate fewer F&V regardless of demographic characteristics. Participants who selected a reduced-fat goal showed a significantly larger decrease than did those that selected PA or F&V goals. Participants who selected an F&V goal showed significant changes in F&V consumption. Participants who selected a PA goal demonstrated significant changes in days of moderate and vigorous physical activity.

CONCLUSIONS

When participants are provided with information on health behavior status and an option of behavioral goals for managing type 2 diabetes, they will select personally appropriate goals, resulting in significant behavioral changes over a 6-month period.

Harnessing the potential of the internet to promote chronic illness self-management: diabetes as an example of how well we are doing

OBJECTIVES

Given the potential for the Internet to be used as a dynamic, interactive medium for providing information, changing attitudes and behaviour and enhancing social support, it is important to consider whether what is currently available online for chronic illness self-management adequately harnesses this potential. The objective of this paper was to review the content of diabetes self-management websites and to identify strengths and limitations of online diabetes self-management.

METHODS

We reviewed and coded features of 87 publicly available diabetes websites hosted by governmental, health plan, commercial, pharmaceutical, and not-for-profit organizations. We assessed whether each website was using online opportunities in the areas of interactivity, theory-based interventions, social support, and evidence-based care.

RESULTS

The majority of sites provided information, essentially using an electronic newspaper or pamphlet format. Few sites offered interactive assessments, social support or problem-solving assistance, although there were some significant differences in these characteristics across the types of site.

DISCUSSION

Current diabetes websites fall short of their potential to help consumers. Suggestions are made for ways to improve the helpfulness and interactivity of these resources.

Patients' perceived barriers to active self-management of chronic conditions

Few studies have elicited barriers to patient self-management of chronic conditions, and only one concerned people with two or more conditions. To inform development of Homing in on Health (HioH), a home delivery variant of the Chronic Disease Self-Management Program (CDSMP), we conducted 10 focus groups involving 54 chronically ill people, 46 (85%) of whom had multiple conditions. The goals were to elicit perceived barriers to active self-management and to accessing self-management support resources. Depression, weight problems, difficulty exercising, fatigue, poor physician communication, low family support, pain, and financial problems were the most frequently noted barriers to active self-management. The most common barriers to accessing self-management support resources were lack of awareness, physical symptoms, transportation problems, and cost/lack of insurance coverage. Our findings provided initial support for the Homing in on Health approach, since many of the barriers identified may be more amenable to home-based intervention than to centralized, facility-based programs.

Development and Validation of the Patient Assessment of Chronic Illness Care (PACIC)

RATIONALE

There is a need for a brief, validated patient self-report instrument to assess the extent to which patients with chronic illness receive care that aligns with the Chronic Care Model-measuring care that is patient-centered, proactive, planned and includes collaborative goal setting; problem-solving and follow-up support.

SAMPLE

A total of 283 adults reporting one or more chronic illness from a large integrated health care delivery system were studied.

METHODS

Participants completed the 20-item Patient Assessment of Chronic Illness Care (PACIC) as well as measures of demographic factors, a patient activation scale, and subscales from a primary care assessment instrument so that we could evaluate measurement performance, construct, and concurrent validity of the PACIC.

RESULTS

The PACIC consists of 5 scales and an overall summary score, each having good internal consistency for brief scales. As predicted, the PACIC was only slightly correlated with age and gender, and unrelated to education. Contrary to prediction, it was only slightly correlated (r = 0.13) with number of chronic conditions. The PACIC demonstrated moderate test-retest reliability (r = 0.58 during the course of 3 months) and was correlated moderately, as predicted (r = 0.32-0.60, median = 0.50, P < 0.001) to measures of primary care and patient activation.

DISCUSSION

The PACIC appears to be a practical instrument that is reliable and has face, construct, and concurrent validity. The resulting questionnaire is in the public domain, and recommendations for its use in research and quality improvement are outlined.

Psychological approaches to understanding and treating disease-related pain

Psychologists are increasingly involved in the assessment and treatment of disease-related pain such as pain secondary to arthritis or cancer. This review is divided into four sections. In the first section, we provide a conceptual background on this area that discusses the limitations of the biomedical model of disease-related pain and traces the evolution of psychosocial theories of pain. In the second section, we discuss special issues and challenges involved in working with persons having disease-related pain, including the reluctance of some persons to report pain and to become involved in psychological treatments for pain. Section three provides an overview of psychosocial research conducted on arthritis pain and cancer pain that addresses both psychosocial factors related to pain and psychosocial interventions for pain management. In the final section, we describe important future directions, including strategies for disseminating psychosocial treatments and disparities in pain management.

The relationship between knowledge of recent HbA1c values and diabetes care understanding and self-management

OBJECTIVE

Knowledge of one's actual and target health outcomes (such as HbA(1c) values) is hypothesized to be a prerequisite for effective patient involvement in managing chronic diseases such as diabetes. We examined 1) the frequency and correlates of knowing one's most recent HbA(1c) test result and 2) whether knowing one's HbA(1c) value is associated with a more accurate assessment of diabetes control and better diabetes self-care understanding, self-efficacy, and behaviors related to glycemic control.

RESEARCH DESIGN AND METHODS

We conducted a cross-sectional survey of a sample of 686 U.S. adults with type 2 diabetes in five health systems who had HbA(1c) checked in the previous 6 months. Independent variables included patient characteristics, health care provider communication, and health system type. We examined bivariate and multivariate associations between each variable and the respondents' knowledge of their last HbA(1c) values and assessed whether knowledge of HbA(1c) was associated with key diabetes care attitudes and behaviors.

RESULTS

Of the respondents, 66% reported that they did not know their last HbA(1c) value and only 25% accurately reported that value. In multivariate analyses, more years of formal education and high evaluations of provider thoroughness of communication were independently associated with HbA(1c) knowledge. Respondents who knew their last HbA(1c) value had higher odds of accurately assessing their diabetes control (adjusted odds ratio 1.59, 95% CI 1.05-2.42) and better reported understanding of their diabetes care (P < 0.001). HbA(1c) knowledge was not associated with respondents' diabetes care self-efficacy or reported self-management behaviors.

CONCLUSIONS

Respondents who knew their HbA(1c) values reported better diabetes care understanding and assessment of their glycemic control than those who did not. Knowledge of one's HbA(1c) level alone, however, was not sufficient to translate increased understanding of diabetes care into the increased confidence and motivation necessary to improve patients' diabetes self-management. Strategies to provide information to patients must be combined with other behavioral strategies to motivate and help patients effectively manage their diabetes.

Chronically ill rural women: self-identified management problems and solutions

OBJECTIVE

To add to the knowledge base of illness management of chronically ill, rural women by describing the self-identified problems and solutions reported by women participants in the online health-education segment of the Women to Women (WTW) computer outreach project.

METHODS

WTW is a research-based computer intervention providing health education and online peer support for rural women with chronic diseases. Messages posted to the online chat room were examined to determine the women's self-management problems and solutions.

RESULTS

The self-identified problems were: (1) difficulties in carrying through on self-management programmes; (2) negative fears and feelings; (3) poor communication with care providers; and (4) disturbed relationships with family and friends. The self-identified solutions to these problems included problem-solving techniques that were tailored to the rural lifestyle. Although not all problems were 'solvable', they could be 'lived with' if the women's prescriptions for self-management were used.

DISCUSSION

Glimpses into the women's day-to-day experiences of living with chronic illness gleaned from the interactive health-education discussions will give health professionals insights into the women's efforts to manage their illnesses. The data provide health professionals with information to heighten their sensitivity to their clients' day-to-day care and educational needs.

Justifying patient self-management--evidence based medicine or the primacy of the first person perspective

Patient self-management programs have become increasingly popular and are now also receiving official endorsements. This paper analyses two possible types of positive justifications for promoting patient self-management: evidence-based and patient-centred justifications. It is argued that evidence-based justifications, although important politically are deficient and that the primary justification for patient self-management must be a patient-centred justification focusing on the patient's privileged access to his or her own lived body.

Psychometric testing of the self-care of heart failure index

BACKGROUND

Self-care is believed to improve outcomes in heart failure (HF) patients. However, research testing this assumption is hampered by difficulties in measuring self-care. The purpose of this study was to evaluate the psychometric properties of a revised instrument measuring self-care in persons with HF, the Self-Care of Heart Failure Index (SCHFI). The SCHFI is a self-report measure comprised of 15 items rated on a 4-point response scale and divided into 3 subscales.

METHODS AND RESULTS

Psychometric testing was done using data from 760 HF patients (age 70.36 +/- 12.3 years, 51% male) from 7 sites in the United States. Reliability of the SCHFI (alpha.76) was adequate. Reliability of the Self-Care Maintenance subscale was lower than desired (alpha.56) but the reliability of the other subscales was adequate: Self-Care Management (alpha.70) and Self-Care Self-Confidence (alpha.82). Construct validity was supported with satisfactory model fit on confirmatory factor analysis (NFI=.69, CFI.73). Construct validity was supported further with significant total and subscale (all P <.05) differences between patients experienced with HF and those newly diagnosed, consistent with the underlying theory.

CONCLUSION

Low reliability of the Self-Care Maintenance subscale was expected because the items reflect behaviors known to vary in individuals. The reliability and validity of the SCHFI are sufficient to support its use in clinical research.

Multiple behavioral risk factor interventions in primary care. Summary of research evidence

BACKGROUND

An important barrier to the delivery of health behavior change interventions in primary care settings is the lack of an integrated screening and intervention approach that can cut across multiple risk factors and help clinicians and patients to address these risks in an efficient and productive manner.

METHODS

We review the evidence for interventions that separately address lack of physical activity, an unhealthy diet, obesity, cigarette smoking, and risky/harmful alcohol use, and evidence for interventions that address multiple behavioral risks drawn primarily from the cardiovascular and diabetes literature.

RESULTS

There is evidence for the efficacy of interventions to reduce smoking and risky/harmful alcohol use in unselected patients, and evidence for the efficacy of medium- to high-intensity dietary counseling by specially trained clinicians in high-risk patients. There is fair to good evidence for moderate, sustained weight loss in obese patients receiving high-intensity counseling, but insufficient evidence regarding weight loss interventions in nonobese adults. Evidence for the efficacy of physical activity interventions is limited. Large gaps remain in our knowledge about the efficacy of interventions to address multiple behavioral risk factors in primary care.

CONCLUSIONS

We derive several principles and strategies for delivering behavioral risk factor interventions in primary care from the research literature. These principles can be linked to the "5A's" construct (assess, advise, agree, assist, and arrange-follow up) to provide a unifying conceptual framework for describing, delivering, and evaluating health behavioral counseling interventions in primary healthcare settings. We also provide recommendations for future research.

Is client-centred care planning for chronic disease sustainable? Experience from rural South Australia

This qualitative evaluation of a chronic disease self-management project in rural South Australia considers the sustainability of client-centred care planning under current organisational and funding arrangements. The study involved consultation with a range of five stakeholder types over two stages (40 in the beginning stage and 39 in the middle stage) about their satisfaction with the care planning and self-management approach used in the project. All stakeholder types valued the client-centred approach because they perceived that clients were better able to accept and deal with the long-term management of their condition. However, this required that care planning should deal with a wider range of issues than just medical management, and so it took longer, which raised its sustainability in general practice under the current funding through the national health insurance programme (Medicare). The study concludes that sustainability may be addressed through further research into the role of and funding for peer-led self-management groups and the employment of care planners in organisational settings that are conducive to a client-centred approach.

Osteoporosis Self-management:Choices For Better Bone Health

Despite recent pharmacologic advances in the prevention and treatment of osteoporosis, the disease remains incurable. Effective disease management ultimately lies in the hands of the individual patient, who must take responsibility for key health behaviors related to bone health. One behavior modification strategy that has proven effective, but which has not previously been applied to osteoporosis, is "self-management." This article describes the principals, evolution, and initial outcomes of a new self-management program, Choices For Better Bone Health. Choices is a group education course directed to postmenopausal women who are at risk or already affected by osteoporosis, and has shown positive results in early evaluations.