Self-management education and support in chronic disease management

The feasibility and usability of a personal health record for patients with multiple sclerosis: a 2-year evaluation study

Background

Multiple sclerosis (MS) is a persistent inflammatory condition impacting the brain and spinal cord, affecting globally approximately 2.8 million individuals. Effective self-management plays a crucial role in the treatment of chronic diseases, including MS, significantly influencing health outcomes. A personal health record (PHR) is a promising tool to support self-management, potentially empowering patients and enhancing their engagement in treatment and health. Despite these promising aspects, challenges in implementation persist and PHRs are still a relatively new concept undergoing rapid development.

Objective

This study aimed to assess the feasibility and usability of the PHR. Secondary objectives included evaluating implementation determinants, and exploring preliminary effects on quality of care for both patients and healthcare professionals (HCPs), self-management, self-efficacy for patients, job satisfaction, efficiency, and demand for HCPs, and preliminary effects on costs and health-related quality of life.

Methods

This study had a mixed-methods design. Quantitative data of patients (n = 80) and HCPs (n = 12) were collected via self-reported questionnaires at baseline (T0), after one year (T1), and after two years (T2). One focus group interview was conducted at T2 with patients (n = 7), and another one with HCPs (n = 4), to get a more in-depth understanding of the feasibility and usability of the PHR via the Unified Theory of Acceptance and Use of Technology framework, and to further explore the secondary objectives in-depth.

Results

Most patients never logged in during the first year and logged in a couple of times per year during the second year, averaging around 15 min per log-in session. The HCPs mainly logged in a couple of times per year over the two years with an average use of six minutes per session. Patient usability and satisfaction scores were below average and moderate, respectively: with SUS-scores of 59.9 (SD = 14.2, n = 33) at T1 and 59.0 (SD = 16.3, n = 37) at T2, and CSQ-8 scores of 21.4 (SD = 5.0, n = 34) at T1, and 22.1 (SD = 5.0, n = 39) at T2. HCPs had similar usability and satisfaction scores. Multiple facilitators and barriers were identified by both patients and HCPs, such as (in)sufficient knowledge of how to use the PHR, lack of staff capacity and ICT obstacles. No significant differences were found in the preliminary effects. Qualitative data showed, among others, that both patients and HCPs saw the benefit of the PHR in terms of performance expectancy, by gaining more insight into health and health data, but challenges remained regarding effort expectancy, such as log-in issues and experiencing difficulties with information retrieval.

Conclusion

The feasibility and usability were considered moderate by patients and HCPs; however, potential regarding the performance of the PHR was observed. Implementation challenges, such as the complexity of usage, lowered the adoption of the PHR. The evolving nature of PHRs requires ongoing evaluation and adaptation to optimize their potential benefits. Utilizing a participatory design approach and a dedicated implementation team could help in achieving this optimization, ultimately enhancing their adoption.

Codesigning an E-Health Intervention for Surgery Preparation and Recovery

Surgery is a significant part of healthcare, but its demand is increasing, leading to challenges in managing patient care. Inefficient perioperative practices and traditional linear models contribute to adverse outcomes and patient anxiety. E-health interventions show promise in improving surgical care, but more research is needed. The purpose of this study was to involve patients and healthcare workers during the design phase of an e-health intervention that aims to support the perioperative care of elective surgery preparation and recovery. This study used an Information Systems Research Framework to guide collaborative codesign through semistructured interviews and cocreation workshops. Semistructured interviews collected insights on the perioperative journey and e-health needs from healthcare workers and consumers, resulting in the creation of a patient surgery journey map, experience map, and a stakeholder needs table. Collaborative work between consumers and healthcare workers in the cocreation workshops identified priority perioperative journey issues and proposed solutions, as well as prioritizing application software needs, guiding the development of the wireframe. The development of an e-health application aimed at supporting surgery preparation and recovery is a significant step toward improving patient engagement, satisfaction, and postsurgical health outcomes.

Knowledge, attitude, and practice toward postoperative self-management among patients after percutaneous coronary intervention: A structural equation modeling analysis

OBJECTIVE

The knowledge, attitude, and practice (KAP) toward post-percutaneous coronary intervention (PCI) self-management among Chinese patients remains unknown. This study investigated the KAP toward postoperative self-management among patients after PCI.

HYPOTHESIS

Patients exhibit poor knowledge, attitudes, and practices regarding post-PCI self-management, requiring enhanced education strategies.

METHODS

This cross-sectional study recruited patients after PCI at Jishuitan Hospital, Beijing, between November 2022 and May 2023. Inclusion criteria comprised patients 1-3 months post-PCI, those capable of self-care, and those willingly participating. The questionnaire (49 items) was designed with reference to current guidelines (the Cronbach α = .829). The final questionnaire included four dimensions with 49 items. The Pearson correlation analysis and structural equation modeling (SEM) were used to determine the relationship among knowledge, attitude, and practice.

RESULTS

A total of 476 valid questionnaires were included. The knowledge, attitude, and practice scores were 8.24 ± 2.78 (possible range: 0-12), 21.61 ± 3.15 (possible range: 9-45), and 32.62 ± 3.75 (possible range: 10-50). The Pearson correlation analysis showed only knowledge scores were correlated with the attitude scores (r = .446, p < .001). The SEM showed that knowledge directly affects attitude (β = .616, p < .001) but had no influence on practice (β = .119, p = .155); attitude had no influence on practice (β = .015, p = .809).

CONCLUSION

This study indicated that patients had poor knowledge, unfavorable attitudes, and unsatisfied practice toward post-PCI self-management. Strengthening patient health education through diverse approaches is imperative.

Recommendations for the future management of thrombocytopenia in patients with liver cirrhosis: A modified RAND/UCLA appropriateness method

OBJECTIVE

The lack of consensus and specific guidelines, and the introduction of new treatments in thrombocytopenia management in liver cirrhosis patients, required a series of recommendations by experts to improve knowledge on this disease. This study's aim was to improve the knowledge around thrombocytopenia in liver cirrhosis patients, in order to contribute to the generation of future evidence to improve the management of this disease.

PATIENTS AND METHODS

A modified version of the RAND/UCLA appropriateness method was used. The scientific committee, a multidisciplinary team of 7 experts in managing thrombocytopenia in liver cirrhosis patients, identified the expert panel, and participated in elaborating the questionnaire. Thirty experts from different Spanish institutions were invited to answer a 48-item questionnaire covering 6 areas on a nine-point Likert scale. Two rounds were voted. The consensus was obtained if >77.7% of panelists reached agreement or disagreement.

RESULTS

A total of 48 statements were developed by the scientific committee and then voted by the experts, resulting in 28 defined as appropriate and completely necessary, relating to evidence generation (10), care circuit, (8), hemorrhagic risk assessment, decision-making and diagnostic tests (14), professionals' role and multidisciplinary coordination (9) and patient education (7).

CONCLUSIONS

This is the first consensus in Spain on the management of thrombocytopenia in liver cirrhosis patients. Experts indicated several recommendations to be carried out in different areas that could help physicians make better decisions in their clinical practice.

The Pre-Adaptation of a Stroke-Specific Self-Management Program Among Older Adults

Objectives: Managing multimorbidity as aging stroke patients is complex; standard self-management programs necessitate adaptations. We used visual analytics to examine complex relationships among aging stroke survivors' comorbidities. These findings informed pre-adaptation of a component of the Chronic Disease Self-Management Program. Methods: Secondary analysis of 2013-2014 Medicare claims with stroke as an index condition, hospital readmission within 90 days (n = 42,938), and 72 comorbidities. Visual analytics identified patient subgroups and co-occurring comorbidities. Guided by the framework for reporting adaptations and modifications to evidence-based interventions, an interdisciplinary team developed vignettes that highlighted multimorbidity to customize the self-management program. Results: There were five significant subgroups (z = 6.19, p < .001) of comorbidities such as obesity and cancer. We constructed 6 vignettes based on the 5 subgroups. Discussion: Aging stroke patients often face substantial disease-management hurdles. We used visual analytics to inform pre-adaptation of a self-management program to fit the needs of older adult stroke survivors.

Design and development of an eHealth intervention to support self-management in people with musculoskeletal disorders - 'eHealth: It's TIME': a study protocol

Background: Musculoskeletal disorders (MSDs) are a leading cause of global morbidity, with the burden expected to increase in the near future. Self-management, with the support of healthcare professionals, is recommended for many MSDs. However, frequent clinical contact is not feasible. Previous research has highlighted the need for a co-designed eHealth-mediated self-management follow-up support intervention which integrates remote monitoring and behavioural change. Thus, the current study aims to develop and design a user-centred, eHealth-mediated self-management support prototype for people with MSDs. Methods: A three-step, iterative system development cycle will be utilised to develop and design the "eHealth: It's TIME prototype". The three-step process will include creating website features and content using two sequential focus groups with people with MSDs (n = 6 - 8); heuristic testing using the 10 heuristic principles of Nielsen (n = 5); and usability testing through in-person 60-minute interviews with people with MSDs (n = 3 - 5) and musculoskeletal physiotherapists (n = 3 - 5). Conclusion: The eHealth: It's TIME prototype will be a systematically developed, follow-up self-management support intervention guided by behavioural change theory and the preferences of end users.

Associations between underlying diseases with COVID-19 and its symptoms among adults: a cross-sectional study

Background

Specific underlying diseases were reported to be associated with severe COVID-19 outcomes, but little is known about their combined associations. The study was aimed to assess the relations of number of and specific underlying diseases to COVID-19, severe symptoms, loss of smell, and loss of taste.

Methods

A total of 28,204 adult participants in the National Health Interview Survey 2021 were included. Underlying diseases (including cardiovascular diseases, cancer, endocrine diseases, respiratory diseases, neuropsychiatric diseases, liver and kidney diseases, fatigue syndrome, and sensory impairments), the history of COVID-19, and its symptoms were self-reported by structured questionnaires. Multivariable logistic regression models were used to assess the combined relation of total number of underlying diseases to COVID-19 and its symptoms, while mutually adjusted logistic models were used to examine their independent associations.

Results

Among the 28,204 participants (mean ± standard deviation: 48.2 ± 18.5 years), each additional underlying disease was related to 33, 20, 37, and 39% higher odds of COVID-19 (odds ratio [OR]: 1.33, 95% confidence interval [CI]: 1.29-1.37), severe symptoms (OR: 1.20, 95% CI: 1.12-1.29), loss of smell (OR: 1.37, 95% CI: 1.29-1.46), and loss of taste (OR: 1.39, 95% CI: 1.31-1.49). In addition, independent associations of sensory impairments with COVID-19 (OR: 3.73, 95% CI: 3.44-4.05), severe symptoms (OR: 1.37, 95% CI: 1.13-1.67), loss of smell (OR: 8.17, 95% CI: 6.86-9.76), and loss of taste (OR: 6.13, 95% CI: 5.19-7.25), cardiovascular diseases with COVID-19 (OR: 1.13, 95% CI: 1.03-1.24), neuropsychiatric diseases with severe symptoms (OR: 1.41, 95% CI: 1.15-1.74), and endocrine diseases with loss of taste (OR: 1.28, 95% CI: 1.05-1.56) were observed.

Conclusion

A larger number of underlying diseases were related to higher odds of COVID-19, severe symptoms, loss of smell, and loss of taste in a dose-response manner. Specific underlying diseases might be individually associated with COVID-19 and its symptoms.

Telehealth interventions to support self-care of stroke survivors: An integrative review

Background

Self-care is essential for stroke survivors to recover from neurological disorders caused by stroke and to prevent recurrences. Self-care behaviors are activities that individuals undertake to prevent recurrence and complications, and have a positive effect on the quality of life of patients. Telehealth is an emerging technology through which self-care intervention can be provided from a distance. Review-based research is needed to determine the value and development of telehealth-based self-care interventions for stroke survivors.

Objective

Based on the middle range theory of self-care of chronic illness, to provide an effective guide when developing telehealth self-care interventions for stroke survivors by comprehensively understanding telehealth interventions to support self-care of stroke survivors.

Methods

An integrative review, this study was performed in accordance with Whittemore and Knafl's stages of an integrative review (problem identification, literature search, data evaluation, data analysis, and presentation of the results). The key search terms included combinations of concepts related to stroke survivors and self-care, and telehealth. The research year of searched publications was not limited, and five electronic databases (PubMed, Ovid-MEDLINE, Ovid-EMBASE, CINAHL and Cochrane Library) were searched.

Results

Four attributes were identified that represented telehealth's functions that appeared to be associated with a self-care intervention for stroke survivors. These included introducing the concept of interaction, monitoring, education, and store and forward. These self-care interventions were found to influence the behaviors of stroke survivors' self-care maintenance (physical activity and treatment adherence), self-care monitoring (blood pressure, healthy behaviors, health diet, psychological well-being, glucose control, and depression), and self-care management (sense of control, healthcare resource utilization, social integration, and support).

Conclusions

The results of this study can provide a guide for developing effective telehealth self-care intervention by identifying the attributes of telehealth self-care intervention for stroke survivors.

Effectiveness of online caries management platform in children's caries prevention: A randomized controlled trial

Purpose

To construct an online caries management platform and evaluate its efficacy in children's caries prevention based on caries risk.

Methods

The study participants were second-grade pupils. The caries risk assessment tool (CAT) was used to grade caries risk for all participants, who were randomly divided into the experimental (114 pupils) and control (111 pupils) groups. The experimental group used the Internet for caries management, while the control group was managed by traditional lecturing in classroom. The caries status of each surface of the first permanent molars was recorded. The basic information and oral health knowledge, attitude, and behaviors of participants were collected by questionnaire. One year later, outcome data were collected. Pearson's chi-squared test was used to analyze the caries risk assessment items and oral health behaviors. The Mann-Whitney U-test was used to analyze the decayed-missing-filled surfaces (DMFS) index, plaque index, and scores of oral health knowledge and attitude. P < 0.05 was considered statistically significant. This study was available on the website of Chinese Clinical Trials Register (No: MR-44-22-012947).

Results

After 1 year, the oral health knowledge score was improved by 20.58% (P < 0.001) in the experimental group and 6.02% in the control group. The plaque index was improved by 49.60% (P < 0.001) in the experimental group and 21.01% in the control group. The DMFS index increased in both groups but there were no significant differences (P = 0.608). The experimental group had a better improvement effect in caries risk assessment items than the control group, including "whether the frequency of eating sugary snacks or drinks between meals is more than 3 times/day" (P = 0.033) and the use of fluoridated toothpaste (P = 0.020). The experimental group was better than the control group in reported oral health behaviors, including frequency of eating sweets before sleep (P = 0.032), brushing time (P = 0.001), and the filled rate (proportion of FS in DMFS) of first permanent molars (P = 0.003).

Conclusions

The online caries management platform showed more advantages than traditional lecturing in improving oral health knowledge and behaviors (oral hygiene practice, sugar consumption behavior, and medical treatment behavior). This platform provides a reliable implementation path for the occurrence and continuous improvement of oral health-related behaviors.

Can digital health apps provide patients with support to promote structured diabetes education and ongoing self-management? A real-world evaluation of myDiabetes usage

Objective

Structured diabetes education has evidenced benefits yet reported uptake rates for those referred to traditional in-person programmes within 12 months of diagnosis were suboptimal. Digital health interventions provide a potential solution to improve diabetes education delivery at population scale, overcoming barriers identified with traditional approaches. myDiabetes is a cloud-based interactive digital health self-management app. This evaluation analysed usage data for people with type 2 diabetes focusing on digital structured diabetes education.

Methods

Descriptive quantitative analyses were conducted on existing anonymised user data over 12 months (November 2019-2020) to evaluate whether digital health can provide additional support to deliver diabetes education. Data was divided into two equal 6-month periods. As this overlapped the onset of COVID-19, analyses of its effect on usage were included as a secondary outcome. All data was reported via myDiabetes. Users were prescribed myDiabetes by National Health Service healthcare primary care teams. Those who registered for app use within the study period (n = 2783) were assessed for eligibility (n = 2512) and included if activated.

Results

Within the study period, n = 1245/2512 (49.6%) registered users activated myDiabetes. No statistically significant differences were observed between gender (p = 0.721), or age (p = 0.072) for those who activated (59.2 years, SD 12.93) and those who did not activate myDiabetes (57.6 years, SD 13.77). Activated users (n = 1119/1245 (89.8%)) viewed 11,572 education videos. No statistically significant differences were observed in education video views across age groups (p = 0.384), gender (p = 0.400), diabetes treatment type (p = 0.839) or smoking status (p = 0.655). Comparison of usage pre-COVID-19 and post-COVID-19 showed statistically significant increases in app activity (p ≤0.001).

Conclusion

Digital health is rapidly evolving in its role of supporting patients to self-manage. Since COVID-19 the benefits of digital technology have become increasingly recognised. There is potential for increasing diabetes education rates by offering patients a digital option in combination with traditional service delivery which should be substantiated through future research.

Primary Tooth Decay Prevention Program in Children: Application of Intervention Mapping Approach

Background. As the most common diseases globally, oral and dental diseases are closely related to people’s behavior. The present study is aimed at developing a program to prevent primary teeth decay in children using the intervention mapping approach. Methods. This study protocol is aimed at using the intervention mapping approach as the planning framework. The study consists of six steps of intervention mapping, including needs assessment based on the relevant literature review, development of an objectives matrix for changing people’s behaviors and environmental factors, program preparation, program implementation, and program evaluation to develop a family-centered program. Results. The use of the intervention mapping approach helped us identify the outcomes and functional objectives, develop an appropriate intervention program, and evaluate the program. Conclusions. The intervention mapping approach is an appropriate guide to developing a systematic and evidence-based program.

Telehealth interventions for mobility after lower limb loss: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Mobility is a crucial component for healthy aging after lower limb loss (LLL). Telehealth technologies, for example, smart devices, are novel approaches for health programs delivery regardless of geographical boundaries.

OBJECTIVES

To assess the effect of telehealth interventions on mobility, quality of life, and antecedents of health behavior compared with a control condition (usual care or simpler telehealth interventions with fewer number of behavior change techniques [BCTs]) for community-dwelling adults (>50 years) with an LLL and the effect of mode of delivery and BCTs used in telehealth interventions on health outcomes.

STUDY DESIGN

Systematic review and meta-analysis.

METHODS

We systematically searched MEDLINE, PubMed, Embase, Cumulative Index to Nursing and Allied Health Literature, Cochrane, PsycINFO, and SPORTDiscus on January 28, 2021, to identify relevant randomized controlled trials. Two authors independently screened records and assessed risk of bias. We conducted a narrative synthesis of evidence and, when appropriate, used the standardized mean difference (SMD) and mean difference for meta-analyses and the Grading Recommendations Assessment, Development, and Evaluation approach for practice recommendations.

RESULTS

We identified six randomized controlled trials. Telephone was the most common delivery mode (n = 3), and "instructions for performing behaviors" was the most common BCT (n = 5). Very low certainty evidence showed no changes in mobility (six studies: SMD = 0.33 [95% confidence interval [CI] = -0.08, 0.75]), quality of life (two studies: mean difference = -0.08 [95% CI = -0.30, 0.15]), and antecedents of behavior (five studies: SMD = 0.04 [95% CI = -0.28, 0.36]).

CONCLUSIONS

Our review highlights a knowledge gap for the effect of telehealth interventions for people with LLL. Although no promising effect was shown for telehealth interventions, very low certainty evidence precludes making a definitive clinical recommendation.

Educational Resources and Self-Management Support to Engage Patients in Advance Care Planning: An Interpretation of Current Practice in the US

BACKGROUND

Educational resources and decision aids help patients, their care partners and health care providers prepare for and confidently engage in Advance Care Planning (ACP). Incorporating ACP resources as part of a self-management approach may lead to fuller engagement with ACP beyond identifying a surrogate decision-maker, towards supporting a person to identify their values and goals and to communicate them with their care partners and health care providers.

OBJECTIVE

To examine the use of educational resources and decision aids to support self-management of ACP in 11 health systems across the US.

METHODS

This study was a qualitative interview study examining barriers and facilitators to ACP. Guided by interpretative description and the chronic care model, we sought to describe how health care stakeholders (clinicians and administrators) and patients use ACP resources to support engagement with ACP.

RESULTS

274 health care stakeholders were interviewed, and 7 patient focus groups were conducted across 11 health systems. The majority of participants reported using resources to support completion of preference documentation, with fewer participants using resources that promote more engagement in ACP. ACP resources were reported as valuable in preparing for and complementing a complex, interpersonal, and interprofessional process. Barriers to using resources included a lack of a defined workflow and time.

CONCLUSION

Our data suggest that ACP resources that promote engagement are valued but under-utilized in practice. The use of ACP resources with an inter-professional team and a self-management approach is a promising strategy to mitigate the barriers of ACP implementation while improving engagement in ACP.

eHealth Interventions to Support Self-Management in People With Musculoskeletal Disorders, "eHealth: It's TIME"-A Scoping Review

OBJECTIVE

eHealth-mediated interventions have been proposed as one option to support self-management in those with musculoskeletal disorders (MSDs). This scoping review aimed to chart the evidence regarding eHealth modalities, musculoskeletal diagnosis, and outcomes of eHealth-mediated self-management support interventions in persons with MSDs and identify any gaps within the literature.

METHODS

Six electronic databases (MEDLINE, CINAHL, PsycINFO, Embase, Scopus, and the Cochrane Database of Systematic Reviews), 7 grey literature sources (eg, OpenGrey), and reference and citation lists of included studies were searched from database inception to July 2020. Published studies of adult participants with a MSD utilizing an eHealth intervention to support self-management were included. Studies were limited to those published in English. Two reviewers independently screened all studies. Data were extracted by 1 reviewer and reviewed by another reviewer.

RESULTS

After screening 3377 titles and abstracts followed by 176 full texts, 87 studies fulfilled the eligibility criteria. The majority were published in the last 5 years (n = 48; 55%), with almost one-third originating in the United States (n = 28; 32%). The most common eHealth modality type was internet based (n = 22; 35%), with almost one-half (n = 41; 47%) of the included studies involving participants with widespread musculoskeletal symptoms. The most commonly reported outcomes were related to body functions (ie, pain intensity) (n = 67; 45%), closely followed by activities and participation (ie, function) (n = 65; 44%), with environmental factors (ie, health care utilization) the least commonly reported (n = 17; 20%).

CONCLUSIONS

There is considerable variation within the eHealth-mediated self-management support intervention literature. Research is needed on the role of eHealth-mediated self-management support interventions across a broad range of MSDs to guide clinical practice.

IMPACT

This scoping review has identified gaps in the literature relating to specific eHealth modalities, musculoskeletal diagnoses, and health care utilization data, which should guide future research.

Common reported barriers and facilitators for self-management in adults with chronic musculoskeletal pain: A systematic review of qualitative studies

BACKGROUND

Self-management strategies are considered a necessary component of chronic musculoskeletal pain management to address ongoing symptoms and challenges. However uptake of self-management can be impeded by a number of factors.

OBJECTIVES

The aim of this study was to explore common impeding and facilitating factors of self-management strategies from the patient perspective.

METHODS

An electronic search was performed between 2009 to May 2020 for the following databases: MEDLINE, AMED, PsychINFO, Cochrane Library, PubMed, CINAHL, PEDro, and Google Scholar. The search terms included peer-reviewed qualitative or mixed-method studies investigating the perspective of chronic musculoskeletal pain patients in regards to the use of self-management strategies. Study rigor and bias was assessed using the CASP (Critical Appraisal Skills Programme) questionnaire specific to qualitative studies. Qualitative data was coded using a three-stage thematic synthesis process. Confidence in findings was assessed using CERQual (The Confidence in the Evidence from Review of Qualitative Research).

RESULTS

Twenty-seven studies were included with 487 participants. Six major themes were identified and divided into external and internal influencing factors. The external influencing factors were made up of the following three themes: health care practitioner role, supportive environment, accessibility. While the three internal influencing themes were: physical factors, knowledge and understanding, and psychological factors.

CONCLUSION

Learning to self-manage for patients in chronic pain required ongoing support either from healthcare practitioners or from social circles. To further assist the self-management process practitioners can improve self-efficacy through increasing patient knowledge of chronic pain, utilising goal setting and finding ways an individual can access ongoing support, either from the practitioner or through group programs.

Changes in the level of knowledge of diabetes among elderly with diabetes in Slovenia in the period 2011-2020

AIMS

To achieve better treatment decisions, type 2 diabetes patients need to be empowered also through knowledge increase. The aim of this study was to evaluate and compare the level of knowledge and overall perceptions of type 2 diabetes within the elderly diabetic patients before and after the National Diabetes Prevention and Care Development Programme 2010-2020.

METHODS

Diabetes knowledge test was used in two cross-sectional studies in 2011 and 2020 where the samples of type 2 diabetes patients 65+ were surveyed. Besides descriptive statistics, non-parametric tests and general linear model were used to compare the level of knowledge.

RESULTS

The comparison reveals that in the last decade the general knowledge about diabetes has not significantly changed (U = 16942, p = 0.809). The average scores in 2011 and 2020 were 7.98 ± 2.41 and 7.96 ± 2.36 respectively. The average level of knowledge has slightly worsened for patients in the age group 80+, while it remained approximately the same in the other three age groups (65-69, 70-74, 75-79).

CONCLUSIONS

Our study has shown that despite the National Diabetes Prevention and Care Development Programme the knowledge of elderly diabetic patients in Slovenia remained at the same level or worsened.

Technology Acceptance Among Patients With Hemophilia in Hong Kong and Their Expectations of a Mobile Health App to Promote Self-management: Survey Study

Background

The lifelong management of hemophilia is demanding and complex. In July 2019, we published a review in the Journal of Medical Internet Research, summarizing telehealth interventions that facilitate monitoring of bleeding events and promoting the appropriate use of clotting factors among patients with hemophilia. This work has led to the development of a community program that aims to harness technology to promote self-management among patients with hemophilia in Hong Kong.

Objective

Before the inception of this program, we conducted a cross-sectional survey to evaluate the patients’ level of technology acceptance and identify their expectations of the use of mobile technology for self-management of hemophilia.

Methods

In total, 56 participants (75% adult patients and 25% parents of pediatric patients; 87.5% with moderate to severe disease) were recruited from a local nongovernmental organization that serves patients with hemophilia. They rated their perceived confidence and acceptance in using the new mobile technology (score 1 to 5 for each item, with a higher score indicating better acceptance) using a structured questionnaire (adapted from the Technology Acceptance Model). They also identified the top features that they perceived to be the most important components of a mobile app for the self-management of hemophilia. The Mann–Whitney U test was used to compare technology acceptance scores across subgroups of different clinical and socioeconomic characteristics.

Results

In general, the participants considered themselves skilled in using mobile apps (mean 4.3, 95% CI 4.1-4.5). They were willing to learn to use the new mobile app to organize their bleeding records (mean 4.0, 95% CI 3.7-4.3) and to manage their health (mean 4.2, 95% CI 4.1-4.5). Participants who lived in public housing (a surrogate marker for lower socioeconomic status in Hong Kong) reported lower technology acceptance than those who lived in private housing (P=.04). The most important features identified by the participants concerned documenting of infusion logs (n=49, 87.5%), bleeding events (n=48, 85.7%), and the secure delivery of the bleeding information to health care professionals (n=40, 71.4%).

Conclusions

It is encouraging to infer that patients with hemophilia in Hong Kong are receptive to the use of mobile health technology. The findings of this survey are applicable in designing the key features of a patient-centered, multimodal program harnessing mobile technology to promote self-management among patients with hemophilia. Future studies should evaluate participants’ acceptability and perceived usability of the mobile app via user metrics and assess clinical and humanistic outcomes of this program.

"Pain Special Issue" "Stakeholders' perspectives and requirements on pain self-management for adolescents living with HIV/AIDS in Malawi: a cross-sectional qualitative study"

Malawi has one of the highest HIV prevalence rates (8.9%), and data suggest 27% pain prevalence among adolescents living with HIV (ALHIV) in Malawi. Pain among ALHIV is often under-reported and pain management is suboptimal. We aimed to explore stakeholders' perspectives and experiences on pain self-management for ALHIV and chronic pain in Malawi. We conducted cross-sectional in-depth qualitative interviews with adolescents/caregiver dyads and healthcare professionals working in HIV clinics. Data were audio-recorded, transcribed verbatim and translated (where applicable) then imported into NVivo version 12 software for framework analysis. We identified three main themes: (1) Experiencing "total pain": adolescents experienced physical, psychosocial, and spiritual pain which impacted their daily life activities. (2) Current self-management approaches: participants prefer group-based self-management approaches facilitated by healthcare professionals or peers at the clinic focussing on self-management of physical, psychosocial, and spiritual pain. (3) Current pain strategies: participants used prescribed drugs, traditional medicine, and non-pharmacological interventions, such as exercises to manage pain. A person-centred care approach to self-management of chronic pain among ALHIV is needed to mitigate the impact of pain on their daily activities. There is a need to integrate self-management approaches within the existing structures such as teen clubs in primary care.

Self-Management of Dementia by Family Carers: A Scoping Review

Family carers increasingly take on the responsibility of self-management of dementia as the condition progresses. However, research on this topic is scarce. This scoping review aimed to identify the key characteristics related to self-management of dementia by carers including its components, theoretical/conceptual frameworks that underpinned these components and measurements. A scoping review was conducted in 8 databases and 16 publications met the inclusion criteria. Twenty-two components were identified and grouped into two categories: activities and carer characteristics and skills. The identified theoretical/conceptual frameworks were numerous and varied as were the measures. There was a little consistency of the key characteristics of self-management of dementia by carers. The findings assist carers and healthcare providers to understand the components involved in self-managing dementia which will guide the development and delivery of self-management support interventions for carers. Further research is required to validate these findings and to develop specialized conceptual frameworks and measures.

eHealth interventions to support self-management in people with musculoskeletal disorders: a scoping review protocol

OBJECTIVE

The objective of this scoping review is to explore existing literature related to the role of eHealth interventions in supporting self-management in those with musculoskeletal disorders in order to investigate and chart the evidence, and identify any gaps within the literature.

INTRODUCTION

Musculoskeletal disorders are one of the leading causes of disability worldwide. Self-management interventions are consistently recommended as a core component of treatment for people with musculoskeletal disorders. Given limited health care resources, there is increasing interest in the potential role of eHealth interventions to support self-management in this population.

INCLUSION CRITERIA

Studies that include adult participants (older than 18 years) with a musculoskeletal disorder will be considered. Studies that include participants with pain of specific pathological origin (eg, infection, malignancy, osteoporosis, inflammatory disease, fracture), those who are pregnant, or individuals following surgery will be excluded. The concept is eHealth interventions that support self-management conducted in any setting and geographical location. All settings and locations will be included.

METHODS

The following electronic databases will be searched with no limit on publication date: MEDLINE, CINAHL, PsycINFO, Embase, Scopus and the Cochrane Database of Systematic Reviews. A structured search of the gray literature will also be conducted. Studies will be limited to those published in English. Two reviewers will undertake title and abstract screening, followed by full-text screening. Data extraction will be conducted utilizing a standardized form for included studies, and a narrative summary will accompany the charted results and will describe how the results relate to the review's objective.

SYSTEMATIC REVIEW REGISTRATION

Open Science Framework (https://osf.io/29rd6).

Falls After Dysvascular Transtibial Amputation: A Secondary Analysis of Falling Characteristics and Reduced Physical Performance

INTRODUCTION

Over half of all people with lower limb amputation (LLA) experience at least one fall annually. Furthermore, the majority of LLAs result from dysvascular health complications, contributing to balance deficits. However, fall-related research specific to dysvascular LLA remains limited.

OBJECTIVE

To characterize falls among adults with dysvascular LLA, using an existing Fall-Type Classification Framework and to describe the functional characteristics of participants across the framework categories.

DESIGN

Secondary data analysis from two randomized controlled trials.

SETTING

Outpatient setting.

PARTICIPANTS

People (n = 69) 6 months to 5 years from dysvascular lower extremity amputation, who were ≥50 years of age and independently ambulatory using a prosthesis.

INTERVENTION

None.

OUTCOME

Descriptions of self-reported falls were collected on a weekly basis for 12 weeks, and analyzed using an existing Fall-Type Classification Framework. Fall frequencies, estimated count, and estimated proportions were compared across all framework categories, with 95% confidence intervals. Functional measures (Timed Up and Go, Two Minute Walk, Five Meter Walk, and average step count) were collected, and averages for each participant who experienced a fall were calculated.

RESULTS

Thirty participants (43.5%) reported 42 falls within 12 weeks. A variety of fall types were described. Incidence of falls was highest for intrinsic destabilization sources, from incorrect weight shift patterns during transfer activities.

CONCLUSION

Patients with dysvascular LLAs experience a variety of fall types. The high frequency of intrinsically sourced, incorrect weight-shift falls during transfer activities emphasizes the need to focus rehabilitation efforts on improving postural control in patients with dysvascular LLAs during activities such as reaching, turning, and transferring.

Digital telemedicine interventions for patients with multimorbidity: a systematic review and meta-analysis

OBJECTIVE

To determine the effectiveness of digital telemedicine interventions designed to improve outcomes in patients with multimorbidity.

DESIGN

Systematic review and meta-analysis of available literature.

DATA SOURCES

MEDLINE, EMBASE, The Cochrane Central Register of Controlled Trials, ClinicalTrials.gov, and the Database of Abstracts of Reviews of Effectiveness and hand searching. The search included articles from inception to 19 April 2019 without language restrictions. The search was updated on 7 June 2020 without additional findings.

ELIGIBILITY CRITERIA

Prospective interventional studies reporting multimorbid participants employing interventions with at least one digital telemedicine component were included. Primary outcomes were patient physical or mental health outcomes, health-related quality of life scores and the utilisation of health services.

RESULTS

Out of 5865 studies initially identified, 7 articles, reporting on 6 studies were retained (total of 699 participants). Four of these studies reported interventions including integration with usual care, two studies had interventions with no links to usual patient care. Follow-up periods lasted between 2 and 6 months. Among the studies with links to usual care, the primary outcomes were systolic blood pressure (SBP) (three studies), haemoglobin A1c (HbA1c) (three studies), total cholesterol (two studies) and self-perceived health status (one study). The evidence ranged from very low to moderate certainty. Meta-analysis showed a moderate decrease in SBP (8 mm Hg (95% CI 4.6 to 11.4)), a small to moderate decrease in HbA1c (0.46 mg/dL (95% CI 0.25 to 0.67)) and moderate decrease in total cholesterol (cholesterol 16.5 mg/dL (95% CI 8.1 to 25.0)) in the intervention groups. There was an absence of evidence for self-perceived health status. Among the studies with no links to usual care, time to hospitalisation (median time to hospitalisation 113.4 days intervention and 104.7 days control group, absolute difference 12.7 days) and the Minnesota Living with Heart Failure Questionnaire (intervention group 35.2 score points, control group 23.9 points, absolute difference 11.3, 95% CI 5.5 to 17.1) showed small reductions. The Personal Health Questionnaire (PHQ-8) showed no evidence of improvement (intervention 7.6 points, control 8.6 points, difference 1.0 points, 95% CI -22.9% to 11.9%).

CONCLUSION

Digital telemedicine interventions provided moderate evidence of improvements in measures of disease control but little evidence and no demonstrated benefits on health status. Further research is needed with clear descriptions of conditions, interventions and outcomes based on patients' and healthcare providers' preferences.

PROSPERO REGISTRATION NUMBER

CRD42019134872.

Evaluating a Theoretically Informed and Cocreated Mobile Health Educational Intervention for First-Time Hearing Aid Users: Qualitative Interview Study

BACKGROUND

Adults living with hearing loss have highly variable knowledge of hearing aids, resulting in suboptimal use or nonuse. This issue can be addressed by the provision of high-quality educational resources.

OBJECTIVE

This study aims to assess the everyday experiences of first-time hearing aid users when using a newly developed, theoretically informed cocreated mobile health (mHealth) educational intervention called m2Hear. This intervention aims to deliver greater opportunities for individualization and interactivity compared with our previously developed multimedia intervention, C2Hear.

METHODS

A total of 16 first-time hearing aid users trialed m2Hear for a period of 10-weeks in their everyday lives, after which individual semistructured interviews were completed. The data were analyzed using an established deductive thematic analysis procedure underpinned by the Capability, Opportunity, Motivation-Behavior model. The model stipulates that to engage in a target behavior, an individual must have physical and psychological capability, physical and social opportunity, and automatic and reflective motivation.

RESULTS

Capability-m2Hear was viewed as a concise and comprehensive resource, suitable for a range of digital literacy skills. It was stated that m2Hear could be conveniently reused to provide useful reminders that facilitate knowledge of hearing aids and communication. Opportunity-m2Hear was simple and straightforward to use, enabling greater individualization and independence. The availability of m2Hear via mobile technologies also improved accessibility. Motivation-m2Hear provided greater support and reassurance, improving confidence and empowering users to self-manage their hearing loss.

CONCLUSIONS

Overall, this qualitative study suggests that m2Hear supports first-time hearing aid users to successfully self-manage their hearing loss postfitting. Furthermore, this study demonstrates the utility of employing a combined theoretical and ecologically valid approach in the development of mHealth educational resources to meet the individual self-management needs of adults living with hearing loss.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03136718; https://clinicaltrials.gov/ct2/show/NCT03136718.

A self-management support intervention for patients with atrial fibrillation: a randomized controlled pilot trial

BACKGROUND

Atrial fibrillation (AF) is the most common arrhythmia worldwide. Despite effective treatment, it is characterized by frequent recurrences. Optimal therapeutic management of AF requires active participation and self-management from patients. Two major components of self-management are self-monitoring and sign-and-symptom management. Pulse self-palpation (PSP) is a method of self-monitoring; however, not all AF patients are capable of successfully performing PSP. Due to a lack of interventions on this topic, a nurse-led intervention for patients with AF (PSPAF intervention) was developed to foster self-monitoring and to enhance self-management through PSP. The purpose of this pilot study was to test the acceptability, feasibility, and potential effects of this intervention on the capability of patients' PSP and sign-and-symptom management. Moreover, we aimed at gathering data on the feasibility of applied research methods to aid in the design of future studies.

METHODS

The pilot trial involved 20 adult patients with AF, randomized to an intervention or usual care group. At baseline and during a home visit 3-5 weeks later, we collected data using questionnaires, checklists, field notes, a mobile ECG device, and a diary. Acceptability and feasibility measures were validated through predefined cut-off points. Effect size estimates were expressed as relative risks (RR) and the number needed to treat (NNT).

RESULTS

The PSPAF intervention seemed feasible, but only partly acceptable. There were limitations in terms of potential effectiveness, suitability, addressing participants' willingness to implement its content in daily life, and adherence. Estimations of effect sizes suggest a large effect of the intervention on patients' PSP capability (RR = 6.0; 95% CI = [0.83, 43.3]; NNT = 2.4), but almost no effect on sign-and-symptom management (RR = 1.5; 95% CI = [0.7, 3.1]; NNT = 4.0). The feasibility of applied research methods showed minor limitations on recruitment and participant burden.

CONCLUSIONS

Despite some limitations, the intervention seemed to be applicable and promising. Taking into account the suggestions and amendments we have made, we recommend conducting a full-scale trial to examine the efficacy of the PSPAF intervention.

TRIAL REGISTRATION

This pilot study was registered in the German Clinical Trials Register at September 4, 2017 (Main ID: DRKS00012808).

Beyond Oncology: Question Prompt Lists in Healthcare-A Scoping Review Protocol

Question prompt lists (QPL) are an instrument to promote patient participation in medical encounters by providing a set of questions patients can use during consultations. QPL have predominantly been examined in oncology. Less is known about their use in other contexts. Therefore, we plan to conduct a scoping review to provide an overview of the fields of healthcare in which QPL have been developed and evaluated. MEDLINE/PUBMED, PSYCINFO, PSYNDEX, WEB OF SCIENCE, and CINAHL will be systematically searched. Primary studies from different healthcare contexts that address the following participants/target groups will be included: persons with an acute, chronic, or recurring health condition other than cancer; healthy persons in non-oncological primary preventive measures. There will be no restrictions in terms of study design, sample size, or outcomes. However, only published studies will be included. Studies that were published in English and German between 1990 and 2019 will be examined. Two independent reviewers will apply defined inclusion/exclusion criteria and determine study eligibility in the review process guided by the PRISMA statement.

Enhancing migraine self-efficacy and reducing disability through a self-management program

BACKGROUND

Chronic migraine is a primary headache disorder affecting approximately 3-7 million individuals in the United States. This condition is associated with significant individual and societal consequences, causing impaired function and high levels of health care utilization.

PURPOSE

The aim of this quasi-experimental single cohort study was to determine if an 8-week outpatient self-management program for chronic migraine would decrease migraine disability and enhance self-efficacy.

METHODS

This was a prospective, single cohort, pre- and postintervention pilot study. Fifteen adults aged 18-65 years who met the criteria for diagnosis of chronic migraine were enrolled in the study through convenience sampling. Participants participated in an evidence-based self-management program with multimodal formats including verbal, written, video, and online materials. Outcome measures included migraine disability (using Migraine Disability Assessment tool [MIDAS]), headache self-efficacy (using Headache Management Self-Efficacy Scale [HMSE]), acute medication use, and migraine frequency. Participants also completed a postintervention survey to assess satisfaction.

RESULTS

Findings showed a reduction in MIDAS scores, acute medication use, and frequency of migraine. Outcomes also included an increase in HMSE scores and a trend of improved health behaviors. Acute medication use decreased by more than 50%, and frequency of migraine and headache days reduced by close to 40%.

IMPLICATIONS FOR PRACTICE

Despite high rates of disability, patient education and self-management programs for chronic migraine are not readily available. The findings of this study encourage use of a hybrid clinic and web-based self-management model to improve migraine disability and self-efficacy.

Telehealth Interventions for Improving Self-Management in Patients With Hemophilia: Scoping Review of Clinical Studies

Background

The introduction of home therapy for hemophilia has empowered patients and their families to manage the disease more independently. However, self-management of hemophilia is demanding and complex. The uses of innovative interventions delivered by telehealth routes such as social media and Web-based and mobile apps, may help monitor bleeding events and promote the appropriate use of clotting factors among patients with hemophilia.

Objective

This scoping review aims to summarize the literature evaluating the effectiveness of telehealth interventions for improving health outcomes in patients with hemophilia and provides direction for future research.

Methods

A search was conducted in Ovid MEDLINE, EMBASE, and PubMed databases for studies that (1) focused on patients with hemophilia A or B; (2) tested the use of remote telehealth interventions via the internet, wireless, satellite, telephone, and mobile phone media on patients and caregivers; and (3) reported on at least one of the following patient-/caregiver-focused outcomes related to empowering patients/caregivers to be active decision makers in the emotional, social, and medical management of the illness: quality of life, monitoring of bleeding episodes, joint damage or other measures of functional status, medication adherence, and patients’ knowledge. Implementation outcomes (user metrics, cost saving, and accuracy of electronic records) were also evaluated. Reviews, commentaries, and case reports comprising ≤10 cases were excluded.

Results

Sixteen articles fulfilled the inclusion criteria. The majority of the interventions (10/16, 62%) evaluated both implementation outcomes and patient-/caregiver-focused outcomes. User performance and accuracy and comprehensiveness of electronic records were also measured in most studies (4/16, 87%). The components of the interventions were rather homogenous and typically involved electronic logging and reminders for prophylactic infusions, reporting of spontaneous and traumatic bleeding events, monitoring of infusion product usage and home inventory, and real-time communication with health care professionals and hemophilia clinics. Telemedicine-supported education and information interventions seemed to be particularly effective among adolescent and young adult patients. Although the patients reported improvements in their health-related quality of life and perception of illness, telemonitoring devices did not appear to have a significant effect on quantifiable health outcomes such as joint health. Longitudinal studies seemed to suggest that the response and adherence rates to recording decreased over time.

Conclusions

Preliminary evidence from this review suggests that telehealth-delivered interventions could feasibly improve patients’ adherence to medication use and promote independence in disease management. Given the complexity and resources involved in developing a mature and established system, support from a dedicated network of hemophilia specialists and data managers will be required to maintain the technology, improve adherence to prophylactic treatment and recording, and validate the electronic data locally.

Patient assessment of chronic kidney disease self-care using the chronic kidney disease self-care scale in Taiwan

AIM

Self-care represents the 'action' element of self-management. This study aimed to use the chronic kidney disease self-care (CKDSC) scale to examine factors associated with self-care and aspects of self-care deficits among CKD patients in Taiwan.

METHODS

A cross-sectional investigation was conducted using the CKDSC scale with 449 CKD patients in Taiwan. The CKDSC is a 16-item questionnaire with five subscales, including medication adherence, diet control, exercise, smoking behaviours and blood pressure monitoring. Patient demographic and clinical factors taht may affect CKD self-care were analyzed in the multivariable regression models.

RESULTS

Overall CKDSC scores were significantly higher for women (P = 0.020), older patients (P < 0.001), higher education (P = 0.033), BMI <24 kg/m² (P = 0.005), later CKD stage or participants in the CKD care programme. Early-stage CKD patients had significantly lower for medication adherence, diet control, and blood pressure monitoring. Patients who participated in the CKD care programme had higher for medication adherence, diet control and regular exercise habits.

CONCLUSION

The CKDSC scale is a tool to assess patient self-care. However, given the CKDSC tool is in Chinese, future studies should validate it in CKD patients in other languages or countries before it can be considered for general use.

Managing with Learning Disability and Diabetes: OK-Diabetes - a case-finding study and feasibility randomised controlled trial

BACKGROUND

Obesity and type 2 diabetes are common in adults with a learning disability. It is not known if the principles of self-management can be applied in this population.

OBJECTIVES

To develop and evaluate a case-finding method and undertake an observational study of adults with a learning disability and type 2 diabetes, to develop a standardised supported self-management (SSM) intervention and measure of adherence and to undertake a feasibility randomised controlled trial (RCT) of SSM versus treatment as usual (TAU).

DESIGN

Observational study and an individually randomised feasibility RCT.

SETTING

Three cities in West Yorkshire, UK.

PARTICIPANTS

In the observational study: adults aged > 18 years with a mild or moderate learning disability, who have type 2 diabetes that is not being treated with insulin and who are living in the community. Participants had mental capacity to consent to research and to the intervention. In the RCT participants had glycated haemoglobin (HbA_1c) levels of > 6.5% (48 mmol/mol), a body mass index (BMI) of > 25 kg/m² or self-reported physical activity below national guideline levels.

INTERVENTIONS

Standardised SSM. TAU supported by an easy-read booklet.

MAIN OUTCOME MEASURES

(1) The number of eligible participants identified and sources of referral; (2) current living and support arrangements; (3) current health state, including level of HbA_1c, BMI and waist circumference, blood pressure and lipids; (4) mood, preferences for change; (5) recruitment and retention in RCT; (6) implementation and adherence to the intervention; (7) completeness of data collection and values for candidate primary outcomes; and (8) qualitative data on participant experience of the research process and intervention.

RESULTS

In the observational study we identified 147 eligible consenting participants. The mean age was 54.4 years. In total, 130 out of 147 (88%) named a key supporter, with 113 supporters (77%) being involved in diabetes management. The mean HbA_1c level was 54.5 mmol/mol [standard deviation (SD) 14.8 mmol/mol; 7.1%, SD 1.4%]. The BMI of 65% of participants was > 30 kg/m² and of 21% was > 40 kg/m². Many participants reported low mood, dissatisfaction with lifestyle and diabetes management and an interest in change. Non-response rates were high (45/147, 31%) for medical data requested from the primary care team. In the RCT, 82 participants were randomised. The mean baseline HbA_1c level was 56 mmol/mol (SD 16.5 mmol/mol; 7.3%, SD 1.5%) and the mean BMI was 34 kg/m² (SD 7.6 kg/m²). All SSM sessions were completed by 35 out of 41 participants. The adherence measure was obtained in 37 out of 41 participants. The follow-up HbA_1c level and BMI was obtained for 75 out of 82 (91%) and 77 out of 82 (94%) participants, respectively. Most participants reported a positive experience of the intervention. A low response rate and difficulty understanding the EuroQol-5 Dimensions were challenges in obtaining data for an economic analysis.

LIMITATIONS

We recruited from only 60% of eligible general practices, and 90% of participants were on a general practice learning disability register, which meant that we did not recruit many participants from the wider population with milder learning disability.

CONCLUSIONS

A definitive RCT is feasible and would need to recruit 194 participants per arm. The main barrier is the resource-intensive nature of recruitment. Future research is needed into the effectiveness of obesity treatments in this population, particularly estimating the longer-term outcomes that are important for health benefit. Research is also needed into improving ways of assessing quality of life in adults with a learning disability.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN41897033.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 22, No. 26. See the NIHR Journals Library website for further project information.

Promoting the Use of Self-management Strategies for People With Persistent Musculoskeletal Disorders: The Role of Physical Therapists

Persistent musculoskeletal pain is a worldwide health problem resulting in negative effects on individuals' wellbeing and substantial costs to society. Recently, there has been discussion about effective treatment approaches to persistent musculoskeletal disorders, including low back pain. In this Viewpoint, the authors argue that self-management strategies are essential to the management of persistent musculoskeletal disorders and outline the physical therapist's role in supporting effective self-management. J Orthop Sports Phys Ther 2019;49(4):212-215. doi:10.2519/jospt.2019.0605.

[Testing a Middle-Range Theory of Self-Care of Chronic Illness: A Validation for Korean Adult Patients with Severe Hypertension]

PURPOSE

The aims of this study are to provide a theoretical framework for improving the self-care of adults with severe hypertension and to examine the practical suitability of a middle-range theory of self-care for chronic illness by validating the structural model.

METHODS

Data were collected at a university hospital in D metropolitan city from July 1 to August 14, 2015. A total of 224 Korean adult patients with severe hypertension were recruited. Data were analyzed using SPSS 22.0 and AMOS 22.0.

RESULTS

The results show that the fit index of the hypothetical model meets the recommended level; 7 out of 8 hypothetical model paths were statistically significant. Motivation, self-efficacy, support from others, and accessibility to care showed statistical significance and explained 67.3% of the self-care process. The self-care process explained 45.3%, 63.6%, and 26.5% of quality of life, health, and illness stability, respectively.

CONCLUSION

This model can be used as a theoretical framework for improving self-care among adult Korean patients with severe hypertension. Moreover, the practical suitability and validity of the middle-range theory of self-care for chronic illness is secured.

Behavior-Change Intervention Targeting Physical Function, Walking, and Disability After Dysvascular Amputation: A Randomized Controlled Pilot Trial

OBJECTIVE

To determine preliminary efficacy of a home-based behavior-change intervention designed to promote exercise, walking activity, and disease self-management.

DESIGN

A single-blind, randomized controlled pilot trial.

SETTING

One Veterans Administration and 2 regional medical centers.

PARTICIPANTS

A total of 38 participants randomized to behavior-change intervention (n=19) or attention control (CTL; n=19) group.

INTERVENTIONS

Weekly 30-minute telephone sessions for 12 weeks with intervention group sessions focused on health behavior change and CTL group sessions focused on health status monitoring.

MAIN OUTCOME MEASURES

Physical function, walking activity (steps/d averaged over 10d), and disability were measured at baseline, 12 weeks (intervention end), and 24 weeks after baseline with the Timed Up and Go (TUG) test as the primary outcome measure.

RESULTS

The TUG test was not changed from baseline in either group and was not different between groups after 12 or 24 weeks. Several exploratory outcomes were assessed, including daily step count, which increased 1135 steps per day in the intervention group compared to 144 steps per day in the CTL group after 12 weeks (P=.03). Only the intervention group had within-group increase in steps per day from baseline to 12 (P<.001) and 24 (P=.03) weeks and spent significantly less time in sedentary activity (4.8% decrease) than the CTL group (0.2% decrease) at 24 weeks (P=.04). There were no other between-group differences in physical function or disability change over time.

CONCLUSION

The behavior-change intervention demonstrates promise for increasing walking activity for people with dysvascular transtibial amputation (TTA). The efficacy of implementing such intervention in the scope of conventional TTA rehabilitation should be further studied.

Development of a supported self-management intervention for adults with type 2 diabetes and a learning disability

BACKGROUND

Although supported self-management is a well-recognised part of chronic disease management, it has not been routinely used as part of healthcare for adults with a learning disability. We developed an intervention for adults with a mild or moderate learning disability and type 2 diabetes, building on the principles of supported self-management with reasonable adjustments made for the target population.

METHODS

In five steps, we:Clarified the principles of supported self-management as reported in the published literatureIdentified the barriers to effective self-management of type 2 diabetes in adults with a learning disabilityReviewed existing materials that aim to support self-management of diabetes for people with a learning disabilitySynthesised the outputs from the first three phases and identified elements of supported self-management that were (a) most relevant to the needs of our target population and (b) most likely to be acceptable and useful to themImplemented and field tested the intervention.

RESULTS

The final intervention had four standardised components: (1) establishing the participant's daily routines and lifestyle, (2) identifying supporters and their roles, (3) using this information to inform setting realistic goals and providing materials to the patient and supporter to help them be achieved and (4) monitoring progress against goals.Of 41 people randomised in a feasibility RCT, thirty five (85%) completed the intervention sessions, with over three quarters of all participants (78%) attending at least three sessions.Twenty-three out of 40 (58%) participants were deemed to be very engaged with the sessions and 12/40 (30%) with the materials; 30 (73%) participants had another person present with them during at least one of their sessions; 15/41 (37%) were reported to have a very engaged main supporter, and 18/41 (44%) had a different person who was not their main supporter but who was engaged in the intervention implementation.

CONCLUSIONS

The intervention was feasible to deliver and, as judged by participation and engagement, acceptable to participants and those who supported them.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN41897033 (registered 21/01/2013).

Characteristics of Adults Seeking Health Care Provider Support Facilitated by Mobile Technology: Secondary Data Analysis

Background

Mobile health technology is rapidly evolving with the potential to transform health care. Self-management of health facilitated by mobile technology can maximize long-term health trajectories of adults. Little is known about the characteristics of adults seeking Web-based support from health care providers facilitated by mobile technology.

Objective

This study aimed to examine the following: (1) the characteristics of adults who seek human support from health care providers for health concerns using mobile technology rather than from family members and friends or others with similar health conditions and (2) the use of mobile health technology among adults with chronic health conditions. Findings of this study were interpreted in the context of the Efficiency Model of Support.

Methods

We first described characteristics of adults seeking Web-based support from health care providers. Using chi-square tests for categorical variables and t test for the continuous variable of age, we compared adults seeking Web-based and conventional support by demographics. The primary aim was analyzed using multivariate logistic regression to examine whether chronic health conditions and demographic factors (eg, sex, income, employment status, race, ethnicity, education, and age) were associated with seeking Web-based support from health care providers.

Results

The sample included adults (N=1453), the majority of whom were female 57.60% (837/1453), white 75.02% (1090/1453), and non-Hispanic 89.13% (1295/1453). The age of the participants ranged from 18 to 92 years (mean 48.6, standard deviation [SD] 16.8). The majority 76.05% (1105/1453) of participants reported college or higher level of education. A disparity was found in access to health care providers via mobile technology based on socioeconomic status. Adults with annual income of US $30,000 to US $100,000 were 1.72 times more likely to use Web-based methods to contact a health care provider, and adults with an annual income above US $100,000 were 2.41 to 2.46 times more likely to access health care provider support on the Web, compared with those with an annual income below US $30,000. After adjusting for other demographic covariates and chronic conditions, age was not a significant factor in Web-based support seeking.

Conclusions

In this study, the likelihood of seeking Web-based support increased when adults had any or multiple chronic health conditions. A higher level of income and education than the general population was found to be related to the use of mobile health technology among adults in this survey. Future study is needed to better understand the disparity in Web-based support seeking for health issues and the clinicians’ role in promoting access to and use of mobile health technology.

The experience of facilitators and participants of long term condition self-management group programmes: A qualitative synthesis

OBJECTIVE

Our aim was to systematically review the qualitative literature about the experiences of both facilitators and participants in a range of group-based programmes to support the self-management of long-term conditions.

METHODS

We searched 7 databases using the terms 'self-management', 'group' and 'qualitative'. Full text articles meeting the inclusion criteria were retrieved for review. A thematic synthesis approach was used to analyse the studies.

RESULTS

2126 articles were identified and 24 were included for review. Group participants valued being with similar others and perceived peer support benefits. Facilitators (HCP and lay) had limited group specific training, were uncertain of purpose and prioritised education and medical conformity over supportive group processes and the promotion of self-management agency and engagement. Overall, studies prioritised positive descriptions.

CONCLUSION

Group programmes' medical self-management focus may reduce their ability to contribute to patient-valued outcomes. Further research is needed to explore this disconnect.

PRACTICE IMPLICATIONS

This review supports broadening the scope of group-based programmes to foreground shared learning, social support and development of agency. It is of relevance to developers and facilitators of group self-management programmes and their ability to address the burden of long-term conditions.

Developing dimensions for a multicomponent multidisciplinary approach to obesity management: a qualitative study

BACKGROUND

There have been consistent recommendations for multicomponent and multidisciplinary approaches for obesity management. However, there is no clear agreement on the components, disciplines or processes to be considered within such an approach. In this study, we explored multicomponent and multidisciplinary approaches through an examination of knowledge, skills, beliefs, and recommendations of stakeholders involved in obesity management. These stakeholders included researchers, practitioners, educators, and patients.

METHODS

We used qualitative action research methods, including convergent interviewing and observation, to assist the process of inquiry.

RESULTS

The consensus was that a multicomponent and multidisciplinary approach should be based on four central meta-components (patient, practitioner, process, and environmental factors), and specific components of these factors were identified. Psychologists, dieticians, exercise physiologists and general practitioners were nominated as key practitioners to be included.

CONCLUSIONS

A complex condition like obesity requires that multiple components be addressed, and that both patients and multiple disciplines are involved in developing solutions. Implementing cycles of continuous improvement to deal with complexity, instead of trying to control for it, offers an effective way to deal with complex, changing multisystem problems like obesity.

Stakeholder engagement in diabetes self-management: patient preference for peer support and other insights

BACKGROUND

Self-management support (SMS) for patients with diabetes can improve adherence to treatment, mitigate disease-related distress, and improve health outcomes. Translating this evidence into real-world practice is needed, as it is not clear which SMS models are acceptable to patients, and feasible and sustainable for primary care practices.

OBJECTIVE

To use the Boot Camp Translation (BCT) method to engage patient, practice, community resource and research stakeholders in translation of evidence about SMS and diabetes distress into mutually acceptable care models and to inform patient-centred outcomes research (PCOR).

PARTICIPANTS

Twenty-seven diabetes care stakeholders, including patients and providers from a local network of federally qualified health centres participated.

METHODS

Stakeholders met in-person and by conference call over the course of 8 months. Subject matter experts provided education on the diabetes SMS evidence. Facilitators engaged the group in discussions about barriers to self-management and opportunities for improving delivery of SMS.

KEY RESULTS

BCT participants identified lack of social support, personal resources, trust, knowledge and confidence as barriers to diabetes self-management. Intervention opportunities emphasized peer support, use of multidisciplinary care teams and centralized systems for sharing information about community and practice resources. BCT informed new services and a PCOR study proposal.

CONCLUSIONS

Patients and family engaged in diabetes care research value peer support, group visits, and multidisciplinary care teams as key features of SMS models. SMS should be tailored to an individual patient's health literacy. BCT can be used to engage multiple stakeholders in translation of evidence into practice and to inform PCOR.

Telehealth Interventions to Support Self-Management of Long-Term Conditions: A Systematic Metareview of Diabetes, Heart Failure, Asthma, Chronic Obstructive Pulmonary Disease, and Cancer

Background

Self-management support is one mechanism by which telehealth interventions have been proposed to facilitate management of long-term conditions.

Objective

The objectives of this metareview were to (1) assess the impact of telehealth interventions to support self-management on disease control and health care utilization, and (2) identify components of telehealth support and their impact on disease control and the process of self-management. Our goal was to synthesise evidence for telehealth-supported self-management of diabetes (types 1 and 2), heart failure, asthma, chronic obstructive pulmonary disease (COPD) and cancer to identify components of effective self-management support.

Methods

We performed a metareview (a systematic review of systematic reviews) of randomized controlled trials (RCTs) of telehealth interventions to support self-management in 6 exemplar long-term conditions. We searched 7 databases for reviews published from January 2000 to May 2016 and screened identified studies against eligibility criteria. We weighted reviews by quality (revised A Measurement Tool to Assess Systematic Reviews), size, and relevance. We then combined our results in a narrative synthesis and using harvest plots.

Results

We included 53 systematic reviews, comprising 232 unique RCTs. Reviews concerned diabetes (type 1: n=6; type 2, n=11; mixed, n=19), heart failure (n=9), asthma (n=8), COPD (n=8), and cancer (n=3). Findings varied between and within disease areas. The highest-weighted reviews showed that blood glucose telemonitoring with feedback and some educational and lifestyle interventions improved glycemic control in type 2, but not type 1, diabetes, and that telemonitoring and telephone interventions reduced mortality and hospital admissions in heart failure, but these findings were not consistent in all reviews. Results for the other conditions were mixed, although no reviews showed evidence of harm. Analysis of the mediating role of self-management, and of components of successful interventions, was limited and inconclusive. More intensive and multifaceted interventions were associated with greater improvements in diabetes, heart failure, and asthma.

Conclusions

While telehealth-mediated self-management was not consistently superior to usual care, none of the reviews reported any negative effects, suggesting that telehealth is a safe option for delivery of self-management support, particularly in conditions such as heart failure and type 2 diabetes, where the evidence base is more developed. Larger-scale trials of telehealth-supported self-management, based on explicit self-management theory, are needed before the extent to which telehealth technologies may be harnessed to support self-management can be established.

Do self-management interventions in COPD patients work and which patients benefit most? An individual patient data meta-analysis

Background

Self-management interventions are considered effective in patients with COPD, but trials have shown inconsistent results and it is unknown which patients benefit most. This study aimed to summarize the evidence on effectiveness of self-management interventions and identify subgroups of COPD patients who benefit most.

Methods

Randomized trials of self-management interventions between 1985 and 2013 were identified through a systematic literature search. Individual patient data of selected studies were requested from principal investigators and analyzed in an individual patient data meta-analysis using generalized mixed effects models.

Results

Fourteen trials representing 3,282 patients were included. Self-management interventions improved health-related quality of life at 12 months (standardized mean difference 0.08, 95% confidence interval [CI] 0.00–0.16) and time to first respiratory-related hospitalization (hazard ratio 0.79, 95% CI 0.66–0.94) and all-cause hospitalization (hazard ratio 0.80, 95% CI 0.69–0.90), but had no effect on mortality. Prespecified subgroup analyses showed that interventions were more effective in males (6-month COPD-related hospitalization: interaction P=0.006), patients with severe lung function (6-month all-cause hospitalization: interaction P=0.016), moderate self-efficacy (12-month COPD-related hospitalization: interaction P=0.036), and high body mass index (6-month COPD-related hospitalization: interaction P=0.028 and 6-month mortality: interaction P=0.026). In none of these subgroups, a consistent effect was shown on all relevant outcomes.

Conclusion

Self-management interventions exert positive effects in patients with COPD on respiratory-related and all-cause hospitalizations and modest effects on 12-month health-related quality of life, supporting the implementation of self-management strategies in clinical practice. Benefits seem similar across the subgroups studied and limiting self-management interventions to specific patient subgroups cannot be recommended.

Self-management interventions: Proposal and validation of a new operational definition

OBJECTIVES

Systematic reviews on complex interventions like self-management interventions often do not explicitly state an operational definition of the intervention studied, which may impact the review's conclusions. This study aimed to propose an operational definition of self-management interventions and determine its discriminative performance compared with other operational definitions.

STUDY DESIGN AND SETTING

Systematic review of definitions of self-management interventions and consensus meetings with self-management research experts and practitioners.

RESULTS

Self-management interventions were defined as interventions that aim to equip patients with skills to actively participate and take responsibility in the management of their chronic condition in order to function optimally through at least knowledge acquisition and a combination of at least two of the following: stimulation of independent sign/symptom monitoring, medication management, enhancing problem-solving and decision-making skills for medical treatment management, and changing their physical activity, dietary, and/or smoking behavior. This definition substantially reduced the number of selected studies (255 of 750). In two preliminary expert meetings (n = 6), the proposed definition was identifiable for self-management research experts and practitioners (80% and 60% agreement, respectively).

CONCLUSION

Future systematic reviews must carefully consider the operational definition of the intervention studied because the definition influences the selection of studies on which conclusions and recommendations for clinical practice are based.

Primer for nutritionists: Managing the side effects of antidepressants

Depression is a chronic disease affecting a significant portion of the U.S.

POPULATION

Due to the popularity of ADs most nutrition professionals working in the outpatient setting will encounter patients taking one of these medications. Nutritionist can assist patients in managing the short and long term side effects of ADs and, taking into account other nutritional issues, improve overall wellbeing of the patient. The objective of this paper is to identify what side effects nutritionists can help manage, provide the information necessary to help nutritionists feel comfortable assisting with that management, and, as a result, play a valuable role in the team that is vested in the health and wellbeing of the patient.

Characteristics of effective self-management interventions in patients with COPD: individual patient data meta-analysis

It is unknown whether heterogeneity in effects of self-management interventions in patients with chronic obstructive pulmonary disease (COPD) can be explained by differences in programme characteristics. This study aimed to identify which characteristics of COPD self-management interventions are most effective.

Systematic search in electronic databases identified randomised trials on self-management interventions conducted between 1985 and 2013. Individual patient data were requested for meta-analysis by generalised mixed effects models.

14 randomised trials were included (67% of eligible), representing 3282 patients (75% of eligible). Univariable analyses showed favourable effects on some outcomes for more planned contacts and longer duration of interventions, interventions with peer contact, without log keeping, without problem solving, and without support allocation. After adjusting for other programme characteristics in multivariable analyses, only the effects of duration on all-cause hospitalisation remained. Each month increase in intervention duration reduced risk of all-cause hospitalisation (time to event hazard ratios 0.98, 95% CI 0.97–0.99; risk ratio (RR) after 6 months follow-up 0.96, 95% CI 0.92–0.99; RR after 12 months follow-up 0.98, 95% CI 0.96–1.00).

Our results showed that longer duration of self-management interventions conferred a reduction in all-cause hospitalisations in COPD patients. Other characteristics are not consistently associated with differential effects of self-management interventions across clinically relevant outcomes.

Electronic health records to support obesity-related patient care: Results from a survey of United States physicians

OBJECTIVE

Obesity-related electronic health record functions increase the rates of measuring Body Mass Index, diagnosing obesity, and providing obesity services. This study describes the prevalence of obesity-related electronic health record functions in clinical practice and analyzes characteristics associated with increased obesity-related electronic health record sophistication.

METHODS

Data were analyzed from DocStyles, a web-based panel survey administered to 1507 primary care providers practicing in the United States in June, 2013. Physicians were asked if their electronic health record has specific obesity-related functions. Logistical regression analyses identified characteristics associated with improved obesity-related electronic health record sophistication.

RESULTS

Of the 88% of providers with an electronic health record, 83% of electronic health records calculate Body Mass Index, 52% calculate pediatric Body Mass Index percentile, and 32% flag patients with abnormal Body Mass Index values. Only 36% provide obesity-related decision support and 17% suggest additional resources for obesity-related care. Characteristics associated with having a more sophisticated electronic health record include age ≤45years old, being a pediatrician or family practitioner, and practicing in a larger, outpatient practice.

CONCLUSIONS

Few electronic health records optimally supported physician's obesity-related clinical care. The low rates of obesity-related electronic health record functions currently in practice highlight areas to improve the clinical health information technology in primary care practice. More work can be done to develop, implement, and promote the effective utilization of obesity-related electronic health record functions to improve obesity treatment and prevention efforts.

Development and preliminary evaluation of a rehabilitation consult for survivors of head and neck cancer: an intervention mapping protocol

BACKGROUND

Evidence suggests that rehabilitation interventions can improve function and quality of life in survivors of head and neck cancer (HNC), but there is a lack of coordinated, integrated services, and those offered are inconsistent. To address these gaps, we will develop and conduct preliminary evaluation of a rehabilitation consult, built on the theoretical foundations of goal setting and self-management, and composed of a brief functional evaluation, a resource compendium, and collaborative goal-setting and action planning processes.

METHODS/DESIGN

The development of the rehabilitation consult will be guided by intervention mapping, which consists of six steps: 1. Needs assessment; 2. Definition of program objectives; 3. Selection of theory-based intervention methods; 4. Production and pretesting; 5. Adoption, implementation and sustainability planning; 6. Process and effect evaluation. Within the intervention mapping framework, an iterative process of constructing drafts and mini-evaluations with consumers and experts will be used, modifying the rehabilitation consult intervention until a version suitable for formal evaluation is established. The rehabilitation consult will then be evaluated using a prospective, mixed method, single group design with 30 survivors of head and neck cancer. Outcomes will be assessed pre- and post-intervention and at 6-month follow-up.

DISCUSSION

Survivors of head and neck cancer have among the most complex rehabilitation needs of all cancer patients. The rehabilitation consult is expected to improve knowledge and uptake of rehabilitation resources and strategies in survivors of head and neck cancer and thereby improve long-term function and quality of life. If the rehabilitation consult is effective in cancer patients with such high and diverse needs, this project will produce a toolkit that will be adaptable for other types of cancer in other jurisdictions.

Clinical Governance Infrastructures and Relational Mechanisms of Control in Healthcare Organizations

This review paper aims to identify and discuss the dominant themes surrounding the governance initiatives in the context of medical markets relying on the two most common search strategies, namely the keyword search technique and the ancestry approach. In an in-depth examination of the recently published research in the field we uncover an emergent decoupling between the governance initiatives formulated at the macro- and micro-levels in today’s institutions of healthcare provision. The macro-level initiatives are associated with clinical governance infrastructures directed towards the attainment of medical performance targets, whereas the micro-level endeavors refer to relational governance mechanisms for overseeing the relationship between the patient and the physician. Acknowledging the importance of monitoring micro-level interactions that may contribute to the achievement of macro-level objectives, a more comprehensive integration of relational governance devices under the broader system of clinical governance is advocated in this paper with the purpose of enhancing the effectiveness of healthcare organizations.

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.