Self-efficacy in chronic illness: the juxtaposition of general and regimen-specific efficacy

“It Depends on the Situation”: How Hearing-Specific Contexts Affect the Way Adults With Hearing Loss Report Their Personal Attributes

Purpose:

This study examined how adults with untreated hearing loss respond to surveys about their self-efficacy, personality traits, and affective states when assessed “in general” and in listening-related contexts. We also explored the associations between hearing aid self-efficacy (HASE) and listening-related personality traits and affective states.

Method:

Sixty-two adults with self-reported hearing difficulties and no experience with hearing aids (HAs) participated in this descriptive study. Participants self-reported their self-efficacy, personality, and affective states in general and in listening-related contexts. Paired t tests and repeated measures with Holm–Šídák corrections were performed to explore differences between reports of patient traits in different contexts. Multiple regression analyses were conducted to explore significant associations.

Results:

On average, there were no significant differences between general and listening-related self-efficacy or personality traits. However, our participants indicated significantly more negative affective states in listening-related situations compared to in general. There was a small positive association between HASE and reported affective states in “General” and “Listening at Home” contexts.

Conclusions:

This study confirms that context-specific measures are not required to accurately assess self-efficacy and personality traits in the initial stages of the hearing health journey. However, reported affective states were listening dependent for this sample. Although reported affective states were related to HASE, context-dependent measures did not provide additional insight into participants' self-efficacy for successful HA use. This suggests that rehabilitation protocols designed to promote HASE and positive affect in general and listening-related situations could facilitate HA success.

Supporting self-management in women with pre-existing diabetes in pregnancy: a protocol for a mixed-methods sequential comparative case study

INTRODUCTION

For women with pre-existing type 1 and type 2 diabetes, glycaemic targets are narrow during the preconception and prenatal periods to optimise pregnancy outcomes. Women aim to achieve glycaemic targets during pregnancy through the daily tasks of diabetes self-management. Diabetes self-management during pregnancy involves frequent self-monitoring of blood glucose and titration of insulin based on glucose measures and carbohydrate intake. Our objective is to explore how self-management and support experiences help explain glycaemic control among women with pre-existing diabetes in pregnancy.

METHODS AND ANALYSIS

We will conduct a four-phased mixed-methods sequential comparative case study. Phase I will analyse the data from a prospective cohort study to determine the predictors of glycaemic control during pregnancy related to diabetes self-management among women with pre-existing diabetes. In phase II, we will use the results of the cohort analysis to develop data collection tools for phase III. Phase III will be a qualitative description study to understand women's diabetes education and support needs during pregnancy. In phase IV, we will integrate the results of phases I and III to generate unique cases representing the ways in which self-management and support experiences explain glycaemic control in pregnancy.

ETHICS AND DISSEMINATION

The phase I cohort study received approval from our local ethics review board, the Hamilton Integrated Ethics Review Board. We will seek ethics approval for the phase III qualitative study prior to its commencement. Participants will provide informed consent before study enrolment. We plan to publish our results in peer-reviewed journals and present our findings to stakeholders at relevant conferences/symposia.

Comorbidities Associated With Poor Outcomes Following Operative Hammertoe Correction in a Geriatric Population

Background:

Although complications following hammertoe correction surgery are rare, older patients with comorbid conditions are often considered poorer operative candidates compared with younger, healthier patients because of a suspected increased risk of adverse outcomes. The aim of this study was to determine if the presence of multiple comorbidities was associated with increased complications or unsuccessful patient-reported outcomes following operative hammertoe correction in geriatric patients.

Methods:

Prospectively collected data was reviewed on 78 patients aged 60 years or older who underwent operative correction of hammertoe deformity. Patient demographics, comorbidities, and postoperative complications were recorded. Patient-reported outcomes were assessed using preoperative and postoperative visual analog scale for pain and Short Form Health Survey Physical and Mental Component Summary with 1 year of follow-up. Patients were divided into 2 groups based on number of comorbidities (0 or 1 vs > 2) and then compared. The average age of patients was 69.4 years and the prevalence of comorbidities in the study population was as follows: 11.5% smokers, 25.6% on blood thinners, 15.4% with rheumatoid arthritis, 7.7% with diabetes mellitus, 2.6% with peripheral arterial disease, 6.4% with chronic obstructive pulmonary disease, 11.5% with coronary artery disease, and 23.1% with osteoporosis.

Results:

Fifty-three patients (67.9%) had 0 or 1 comorbidity and 25 (32.1%) had 2 or more comorbidities. Compared to the 0 or 1 comorbidity group, the presence of multiple comorbidities was associated with an adjusted odds ratio (OR) for superficial wound infection of 4.18 (P = .045) and deformity recurrence requiring surgery OR of 23.15 (P = .032). Patient-reported outcomes were similar between comorbidity groups.

Conclusions:

This study further informs foot and ankle specialists to maintain increased surveillance for postoperative complications and unsuccessful outcomes in patients with multiple comorbidities. Although geriatric patients still report significant improvements in both pain and function, patients with underlying medical conditions should be counseled about their increased risks when pursuing operative hammertoe correction.

Level of Evidence:

Level III, retrospective comparative series.

The Negotiation and Use of Personal Assistance by Women with Chronic Arthritis

The aim of this study was to gain a greater understanding of the impact of chronic arthritis on the functional ability of women, the strategies that they used to maintain their function and the integration of these strategies into their lifestyles. A qualitative approach was adopted, using semi-structured interviews, personal diaries and focus groups. Twelve women with chronic arthritis participated over a period of 2 years. All the interviews and focus group discussions were transcribed and coded. The data analysis involved the development of a thematic framework to identify recurring themes and their relationships.

The negotiation and use of personal assistance emerged as an important strategy used by the women. It was highlighted as a complex strategy owing to the number of factors influencing its use, the personal connotations of being a recipient of assistance and the need to negotiate levels of assistance with other family members. Insights into the women's use of assistance have the potential to inform the way in which this strategy is approached in educational programmes and also highlight the need to address how people with chronic arthritis communicate their need for assistance and negotiate help within the family.

Women's Perceptions on Managing Chronic Arthritis

The development of self-management strategies is an important aspect of living with chronic arthritis and an intervention to which occupational therapists devote a significant amount of time. Within this context, the evidence base is informed predominantly by research undertaken from a psychological perspective. Sociological approaches to living with chronic illness provide valuable insights into the personal perspectives of living with and managing chronic illness. Located within a sociological perspective and focusing on women with chronic arthritis, this study aimed to gain a greater understanding of the strategies that the women used to maintain activity and the integration of such strategies into their lifestyles.

A longitudinal qualitative study using interviews, diaries and focus groups was conducted over a period of 2 years. The interviews and focus groups were recorded, transcribed and analysed to identify key themes and concepts. The diaries were analysed to provide insights into the daily activities of the women. Three interrelated themes were identified: the embodied experience of living with chronic arthritis, the development and use of strategies and the integration of the strategies into the women's evolving personal context. This paper explores these themes and discusses their implications for the development of self-management programmes informed by the experiences of people living with these impairments.

Interpreting outcome following foot surgery in people with rheumatoid arthritis

Background

Foot surgery is common in RA but the current lack of understanding of how patients interpret outcomes inhibits evaluation of procedures in clinical and research settings. This study aimed to explore which factors are important to people with RA when they evaluate the outcome of foot and ankle surgery.

Methods and Results

Semi structured interviews with 11 RA participants who had mixed experiences of foot surgery were conducted and analysed using thematic analysis. Responses showed that while participants interpreted surgical outcome in respect to a multitude of factors, five major themes emerged: functional ability, participation, appearance of feet and footwear, surgeons’ opinion, and pain. Participants interpreted levels of physical function in light of other aspects of their disease, reflecting on relative change from their preoperative state more than absolute levels of ability. Appearance was important to almost all participants: physical appearance, foot shape, and footwear were closely interlinked, yet participants saw these as distinct concepts and frequently entered into a defensive repertoire, feeling the need to justify that their perception of outcome was not about cosmesis.

Surgeons’ post-operative evaluation of the procedure was highly influential and made a lasting impression, irrespective of how the outcome compared to the participants’ initial goals. Whilst pain was important to almost all participants, it had the greatest impact upon them when it interfered with their ability to undertake valued activities.

Conclusions

People with RA interpret the outcome of foot surgery using multiple interrelated factors, particularly functional ability, appearance and surgeons’ appraisal of the procedure. While pain was often noted, this appeared less important than anticipated. These factors can help clinicians in discussing surgical options in patients.

Electronic supplementary material

The online version of this article (doi:10.1186/s13047-016-0153-6) contains supplementary material, which is available to authorized users.

Development and Psychometric Evaluation of the Diabetes Self-Efficacy Scale

Background and Purpose: No scales measure self-efficacy in women with Type 2 diabetes. A scale was developed and tested. Methods: Items generated, content validity index (CVI) assessed by experts, the 2-part Diabetes Self-Efficacy Scale (DSLF-I and DSLF-II) was piloted with 62 women, administered to 208 women, and then readministered to 30 women to determine initial reliability. Factor analysis was conducted for construct validity. Discriminant, convergent, and predictive validity was examined. Results: The CVI index was 98%. Cronbach’s alphas were 0.88 (DSLF-I) and 0.82 (DSLF-II; pilot) and 0.87 and 0.86, respectively (main study); test–retest correlation was .60 (DSLF-I) and .69 (DSLF-II). There were 3 factors that emerged: diabetes knowledge of self-care activity, diabetes diet self-care, and diabetes medication self-care. Conclusions: The Diabetes Self-Efficacy Scale demonstrates good initial reliability and validity.

Self-efficacy and arthritis disability: An updated synthesis of the evidence base and its relevance to optimal patient care

Self-efficacy, denoting the degree of confidence an individual has in carrying out a specific activity, was initially discussed in the 1970s as a potential correlate of disease outcomes. Drawn from 35 years of related research, this review provides an updated understanding of the concept of self-efficacy and its relevance for arthritis management. There is a consistent link between self-efficacy, arthritis pain and disability, and adherence to recommended therapeutic strategies. A wide variety of intervention strategies improve arthritis self-efficacy, as well as outcomes. Steps to assess and intervene thoughtfully to maximize self-efficacy beliefs are likely to impact arthritis disability outcomes quite favorably and significantly, regardless of disease type, duration, or sociodemographic factors.

Self-management support needs of patients with chronic illness: do needs for support differ according to the course of illness?

OBJECTIVE

To determine whether chronically ill patients' needs for self-management support depend on their course of illness.

METHODS

Cross-sectional and longitudinal linear regression analyses were conducted using data from 1300 patients with chronic disease(s) who participated in a nationwide Dutch panel-study. Self-management support needs were assessed by the Patient Assessment of Self-management Tasks questionnaire (PAST). Course of illness was operationalized as: illness duration, patients' perception of the course of illness and changes in self-rated general health (RAND-36).

RESULTS

Self-management support needs are not related to illness duration. Patients who perceive their illness as episodic and/or progressively deteriorating have greater self-management support needs than patients who perceive their illness as stable. Deterioration of self-rated health is related to increased support needs. The effect of the course of illness on support needs depends on the type of self-management activities.

CONCLUSION

How chronically ill patients perceive the course of illness and actual changes in self-rated health are predictive for their need for support for self-management activities. Illness duration is not.

PRACTICE IMPLICATIONS

Helping patients to self-manage should not be confined to the first years after diagnosis. Healthcare providers should be alert to patients' own perceptions of their course of illness and health status.

Influence of psychosocial factors on self-care behaviors and glycemic control in Turkish patients with type 2 diabetes mellitus

PURPOSE

The main purpose of this study was to investigate the direct and indirect effects of psychosocial factors on self-care behavior and glycemic control in Turkish patients with type 2 diabetes mellitus.

METHOD

The study used a cross-sectional questionnaire survey design (N = 350). Data were collected using the Summary of Diabetes Self-Care Activities Scale and the Multidimensional Diabetes Questionnaire. The relationship between the study variables was analyzed using Pearson's correlation coefficient and structural equation modeling.

RESULTS

Self-efficacy was associated with social support, outcome expectancies, perceived interference, educational level, and self-care and A1C. According to the structural equation model, self-efficacy was the predictor variable that influenced both self-care and glycemic control.

CONCLUSIONS

Self-efficacy in achieving desired health outcomes was found to play a central role in Turkish patients. Although interventions are planned and implemented to achieve and maintain self-management in individuals with diabetes, strengthening psychosocial factors, particularly self-efficacy, may contribute to adjustment to disease and good glycemic control in the long term.

Self-care practices of Chinese individuals with diabetes

The aim of this study was to investigate the self-care practices of Chinese individuals with diabetes. Data were collected from 163 Chinese individuals with diabetes using a one-to-one interview approach. The Chinese version of the Summary of Diabetes Self-Care Activities (SDSCA) was used to assess diabetes-related knowledge and self-care practices. The majority of participants were aware of the importance of self-care in managing diabetes. However, only 70 participants (43%) scored >50% in the diabetes-related questionnaires. Mean fasting blood glucose (FBG) levels were higher (P<0.04) for participants who had extra meals per day (46%). The majority of participants took oral hypoglycemic agents (OHAs; 60.1%) and some were also treated with OHA-insulin combination therapy (17.8%). Participants with medication adherence (52%) tended to have lower FBG levels. Only 13% of participants practiced self-monitoring of blood glucose (SMBG). The predictors of a knowledge deficit or poor self-care were a low level of education (P<0.01) or old age (older than 53 years old; P=0.002). Deficits in diabetes-related knowledge and self-care practices existed among the majority of patients with suboptimal blood glucose control. The understanding of the importance of self-care practices requires improvement in individuals with diabetes. The development of effective education strategies to improve the awareness of self-care practices by Chinese individuals with diabetes is necessary.

Cancer Health Empowerment for Living without Pain (Ca-HELP): effects of a tailored education and coaching intervention on pain and impairment

We aimed to determine the effectiveness of a lay-administered tailored education and coaching (TEC) intervention (aimed at reducing pain misconceptions and enhancing self-efficacy for communicating with physicians) on cancer pain severity, pain-related impairment, and quality of life. Cancer patients with baseline "worst pain" of ≥4 on a 0-10 scale or at least moderate functional impairment due to pain were randomly assigned to TEC or enhanced usual care (EUC) during a telephone interview conducted in advance of a planned oncology office visit (265 patients randomized to TEC or EUC; 258 completed at least one follow-up). Patients completed questionnaires before and after the visit and were interviewed by telephone at 2, 6, and 12 weeks. Mixed effects regressions were used to evaluate the intervention adjusting for patient, practice, and site characteristics. Compared to EUC, TEC was associated with increased pain communication self-efficacy after the intervention (P<.001); both groups showed significant (P<.0001), similar, reductions in pain misconceptions. At 2 weeks, assignment to TEC was associated with improvement in pain-related impairment (-0.25 points on a 5-point scale, 95% confidence interval -0.43 to -0.06, P=.01) but not in pain severity (-0.21 points on an 11-point scale, -0.60 to 0.17, P=.27). The improvement in pain-related impairment was not sustained at 6 and 12 weeks. There were no significant intervention by subgroup interactions (P>.10). We conclude that TEC, compared with EUC, resulted in improved pain communication self-efficacy and temporary improvement in pain-related impairment, but no improvement in pain severity.

Self-management and symptom monitoring among older adults with chronic obstructive pulmonary disease

AIMS

To describe self-management, symptom monitoring and the associated influences among older adults with chronic obstructive pulmonary disease.

BACKGROUND

Optimal self-management and monitoring of key symptoms in patients with chronic obstructive pulmonary disease reduces dyspnoea and preventable hospitalizations.

METHOD

A prospective, descriptive survey design was used and data collected from patients with moderate severity chronic obstructive pulmonary disease during home interviews between April 2005 and June 2006. Predictors of self-management and symptom monitoring were determined by linear regression analyses.

RESULTS

Patients' (n = 78) mean age was 73.37 years (SD 7.52); 55.1% were male and 66.7% were married. Most (92.3%) had concurrent illnesses, and 48.7% had been admitted to hospital for chronic obstructive pulmonary disease in the past 6 months. Self-management was good to very good, with poorer self-management predicted by lower self-efficacy (beta = -0.21), a weaker sense of coherence (beta = -0.03), and no hospitalization in the past 6 months (beta = -05). Symptom monitoring was not ideal, with more than 20% of patients not monitoring any of the key symptoms. More frequent symptom monitoring occurred among participants who were married (beta = 5.14) and had more severe disease (beta = 0.79).

CONCLUSION

As self-management and symptom monitoring ensure better outcomes among patients with chronic obstructive pulmonary disease, health professionals should encourage these behaviours. Involving partners, promoting self-efficacy and understanding of sense of coherence are helpful in this process.

The evaluation of self-care and self-efficacy in patients undergoing hemodialysis

PURPOSE

The purpose of this study is to assess patients' self-care ability and self-efficacy, to examine the relationship between them and to determine the factors affecting self-care ability and self-efficacy in people undergoing hemodialysis (HD).

METHODS

This research was conducted as a descriptive survey study by 138 people with ESRD who were patients of HD units service in Sivas. The data were collected with a Personal Information Form, Exercise of Self-Care Agency (ESCA) Scale and Self-Efficacy Assessment Form. Data collected from the study were analysed using percent, mean, Tukey test, significance test of two means, one-way variant analysis and Kruskal-Wallis test.

RESULTS

The study results demonstrate that while there is a correlation between self-care ability and education level, work status, income level and frequency of HD application, factors such as age, gender, education level, work status, income level and frequency of HD application determine self-efficacy. Furthermore, a positive correlation was found between patients' self-care ability and self-efficacy. It was determined that as the level of self-care ability increases self-efficacy level also increases.

CONCLUSIONS

Hemodialysis application affects patients' self-care ability and self-efficacy levels. There is a positive correlation between self-care ability and self-efficacy. In view of this study's results, it is recommended to organize education programmes to increase self-care ability and self-efficacy levels of HD patients and prepare comprehensive plans including patients' families.

The role of creative expression in diabetes: an exploration into the meaning-making process

In this narrative exploration of meaning making through the use of creative arts, we recorded the experiences of 8 women with type 1 diabetes. Through a conceptual framework of creative expression as a way of knowing, we designed this study to evoke affective and metaphorical connections to the meaning of diabetes. The initial narrative interview findings reflected the experience of the participants, with three primary themes emerging: experiencing negative emotions about diabetes, putting a positive "spin" on the negative as a way to make meaning, and resisting against diabetes and the medical approach. During the creative arts process, we encouraged further exploration into the meaning-making process using imagery and photographs created by the participants. Final interview findings addressed the need for moving beyond numbers, and attention to the meaning-making process in patient care.

Improvement in diabetes self-efficacy and glycaemic control using telemedicine in a sample of older, ethnically diverse individuals who have diabetes: the IDEATel project

BACKGROUND

with increasing prevalence of diabetes in older people, it is important to understand factors that affect their outcomes. The Informatics for Diabetes Education and Telemedicine (IDEATel) project is a demonstration project to evaluate the feasibility and effectiveness of telemedicine with diverse, medically underserved, older diabetes patients. Subjects were randomised to telemedicine case management or usual care. This intervention has been shown to result in improved medical outcomes and self-efficacy. Self-efficacy refers to one's belief that (s)he can successfully engage in a behaviour. Self-efficacy has been shown to relate to behaviour change and glycaemic control in middle-aged individuals, but not studied in older individuals.

OBJECTIVES

to assess whether (a) diabetes self-efficacy relates to the primary medical outcome of glycaemic control, and to secondary outcomes (blood pressure and cholesterol), and (b) whether, after an intervention, change in diabetes self-efficacy relates to change in these medical outcomes in a group of older, ethnically diverse individuals.

METHODS

three waves of longitudinal data from participants in IDEATel were analysed.

RESULTS

diabetes self-efficacy at baseline correlated with glycaemic control, blood pressure and cholesterol. An increase in diabetes self-efficacy over time was related to an improvement in glycaemic control (P < 0.0001), but not in blood pressure and lipid levels. The intervention was significantly related to improved self-efficacy over time (P < 0.0001), and both directly (P = 0.022) and indirectly through self-efficacy (P < 0.001) to improved glycaemic control. The mediation effect of self-efficacy was also significant (P< 0.004).

CONCLUSIONS

diabetes self-efficacy is a relevant construct for older diabetes patients. Thus, interventions that target enhanced self-efficacy may also result in improved glycaemic control.

Self-efficacy, outcome expectations and self-care behaviour in people with type 2 diabetes in Taiwan

AIMS

To explore differences in self-care behaviour according to demographic and illness characteristics; and relationships among self-care behaviour and demographic and illness characteristics, efficacy expectations and outcome expectations of people with type 2 diabetes in Taiwan.

BACKGROUND

Most people with diabetes do not control their disease appropriately in Taiwan. Enhanced self-efficacy towards managing diseases can be an effective way of improving disease control as proposed by the self-efficacy model which provides a useful framework for understanding adherence to self-care behaviours.

DESIGN AND METHODS

The sample comprised 145 patients with type 2 diabetes aged 30 years or more from diabetes outpatient clinics in Taipei. Data were collected using a self-administered questionnaire for this study. One-way anova, t-tests, Pearson product moment correlation and hierarchical regression were analysed for the study.

RESULTS

Significant differences were found: between self-care behaviour and complications (t = -2.52, p < 0.01) and patient education (t = -1.96, p < 0.05). Self-care behaviour was significantly and positively correlated with duration of diabetes (r = 0.36, p < 0.01), efficacy expectations (r = 0.54, p < 0.01) and outcome expectations (r = 0.44, p < 0.01). A total of 39.1% of variance in self-care behaviour can be explained by duration of diabetes, efficacy expectations and outcome expectations.

CONCLUSIONS

Findings support the use of the self-efficacy model as a framework for understanding adherence to self-care behaviour.

RELEVANCE TO CLINICAL PRACTICE

Using self-efficacy theory when designing patient education interventions for people with type 2 diabetes will enhance self-management routines and assist in reducing major complications in the future.

Self-care of women growing older with HIV and/or AIDS

The purpose of this report is to describe the ways older women living with HIV perceive of and practice self-care. Data are taken from a culturally diverse subsample of 9 women age 50 years or older who participated in a larger longitudinal qualitative study of women who were HIV infected. During a period of 2 years, 10 semistructured narrative interviews were conducted with each of the 9 participants to gain an in-depth understanding of their experiences with symptom management, adherence to medical regimens, reduction of HIV risk, access to health care and social services, and personal efforts to maintain their health. Transcribed data were managed using Nvivo software and analyzed using multistaged narrative analysis. Findings suggest that mature women living with HIV integrate actions to maintain bodily comfort and improve physical well-being with actions that champion and conserve the existential self. Excerpts from their interviews illustrate this dialectical understanding of self-care.

Self-efficacy and its interrelation with family environment and metabolic control in Turkish adolescents with type 1 diabetes

OBJECTIVE

To explore the relationship between self-efficacy, family environment (cohesion and organization) and metabolic control.

RESEARCH DESIGN AND METHODS

A total of 100 adolescents with diabetes were assessed on a single occasion. Eligibility criteria were an age range of 11-18 yr, diagnosis of type 1 diabetes of at least 1 yr duration, and ability to complete the questionnaire unaided. Adolescents completed self-efficacy and family environment questionnaires. Metabolic control was assessed by HbA1c. Statistical analysis was performed using Statistical Package for the Social Sciences (SPSS) Version 10.0. Independent paired t-tests and Pearson's correlation coefficient were used as test methods.

RESULTS

Boys and girls were comparable on self-efficacy, and self-efficacy scores were quite satisfactory for both boys and girls. There was a significant positive correlation between self-efficacy and family cohesion in girls, but self-efficacy was not related to the family environment (cohesion and organization) and metabolic control in the total sample.

CONCLUSION

In the present study, there was no relationship between self-efficacy, family environment, and metabolic control in the total sample, but in girls, self-efficacy and family cohesion was positively correlated.

Fears and worries associated with hypoglycaemia and diabetes complications: perceptions and experience of Hong Kong Chinese clients

AIM

This paper reports the second phase of a study that explored the perceptions and experience of Hong Kong Chinese insulin-treated clients who demonstrated fear of hypoglycaemia and worry about diabetes complications.

BACKGROUND

The first phase of the study, a descriptive survey (n = 120), identified 15% of respondents as simultaneously sustaining fears and worries associated with hypoglycaemia and diabetes complications. Although a small percentage, given the increasing number of clients using insulin treatment, this finding suggests a pocket of clients suffering from undesirable emotional health. However, a search of the literature identified few studies exploring Chinese clients' perceptions and experience in this area.

DESIGN

The second phase of the study employed a purposive sampling method and semi-structured interviews to collect data from 13 participants experiencing these fears and worries. FINDINGS; Two researchers independently used content analysis to code and categorize data. Six categories identified were: the influence of perceptions of glycaemic control on emotion, hypo- and hyperglycaemia as a constant threat, keeping optimal glycaemic control or maintaining a working life, financial and psychological burden of blood glucose self-monitoring, being alone with the threat and finally distancing as the coping method. An overriding issue, a sense of losing control, emerged from the findings that described participants' perceptions and experience. This issue and two major health needs, developing self-efficacy and emotional support from nurses, were drawn from the findings for discussion. It is suggested that self-efficacy theory can be adopted as a conceptual framework to guide nursing practice for enhancing clients' capacity to exercise control over diabetes self-management.

CONCLUSIONS

Findings obtained from the second phase of the study illuminated those from the first phase. Implications for nursing practice were identified, including facilitating both technical and psychosocial self-efficacy, assessing clients' total life situation, strengthening competence in counselling skills and forming alliances with clients.

A policy analysis of the Expert Patient in the United Kingdom: self-care as an expression of pastoral power?

The rise in chronic illness and comorbidity in Western society has resulted in an increasing emphasis on self-care initiatives. In the United Kingdom this is exemplified by the Expert Patient policy. This paper discusses the Expert Patient initiative as an example of the State's third way approach to public health. The extent to which this policy challenges conventional power relationships between professional and patient, and fosters equal partnership is examined. In particular, how expert is defined and whether a professional understanding of the term is reconcilable with a patient's expertise is debated. The paper argues that the Expert Patient initiative is unlikely to reconstruct chronic illness and may further complicate the State's responsibility in meeting the needs of those with chronic illness. Issues of power within self-care are explored to illuminate the policy, and this paper argues that the Expert Patient initiative is an example of Foucault's notion of pastoral power. Although the Expert Patient policy focuses on the rights and responsibilities of those with chronic illness, this paper concludes that there is no corresponding strategy to challenge professionals' assumptions toward those with chronic illness.