One size does not fit all: the different experiences of those with chronic heart failure, type 2 diabetes and chronic obstructive pulmonary disease

Factors influencing the integration of self-management in daily life routines in chronic conditions: a scoping review of qualitative evidence

OBJECTIVE

Self-management of chronic diseases is regarded as dynamic experience which is always evolving and that requires constant adjustment. As unexpected and new shifts in diseases occur, patients tend to abandon acquired behaviours calling into question their sustainability over time. Developing a daily self-management routine as a response to lifestyle changes is considered to facilitate self-management performance. However, fitting self-management recommendations in one's daily life activities is a constant challenge. In this review, we describe the performance of self-management routines within daily settings in people living with chronic conditions with the aim of identifying factors that challenge its integration in daily life.

DESIGN

Scoping review.

DATA SOURCES

We searched PubMed, Web of Science, CINAHL and PsycINFO on February 2022.

ELIGIBILITY CRITERIA

We included qualitative studies on self-management experience, in English, with adult participants, original and peer-reviewed, and depicting the performance of self-management activities in one's own environment.

DATA EXTRACTION AND SYNTHESIS

Two reviewers independently screened titles and abstracts. After agreement, one reviewer screened the full text of relevant articles and extracted the data. The data were synthesised and analysed thematically. PRISMA Extension for Scoping Reviews checklist was used for reporting the steps.

RESULTS

Twenty-two studies were included. The thematic analysis brought up two overreaching themes. The first one is the Environment support with three subthemes: family and cultural norms; health professionals and guiding communication; and society and disease perceptions. The second theme is comprehension gap with two subthemes: reading the body and applying information.

CONCLUSIONS

The integration of self-management requirements in a daily routine is affected by the patients' inability to apply disease knowledge in different context and by the challenge of understanding body symptoms and predicting body reactions in advance.

Seeing the Elephant: A Systematic Scoping Review and Comparison of Patient-Centeredness Conceptualizations from Three Seminal Perspectives

“Patient-Centeredness” (PC) is a theoretical construct made up of a diverse constellation of distinct concepts, processes, practices, and outcomes that have been developed, arranged, and prioritized heterogeneously by different communities of professional healthcare practice, research, and policy. It is bound together by a common ethos that puts the holistic individual at the functional and symbolic center of their care, a quality deemed essential for chronic disease management and health promotion. Several important contributions to the PC research space have adeptly integrated seminal PC conceptualizations to improve conceptual clarity, measurement, implementation, and evaluation in research and practice. This systematic scoping review builds on that work, but with a purpose to explicitly identify, compare, and contrast the seminal PC conceptualizations arising from the different healthcare professional groups. The rationale for this work is that a deeper examination of the underlying development and corresponding assumptions from each respective conceptualization will lead to a more informed understanding of and meaningful contributions to PC research and practice, especially for healthcare professional groups newer to the topic area like pharmacy. The literature search identified four seminal conceptualizations from the healthcare professions of Medicine, Nursing, and Health Policy. A compositional comparison across the seminal conceptualizations revealed a shared ethos but also six distinguishing features: (1) organizational structure; (2) predominant level of care; (3) methodological approach; (4) care setting origin; (5) outcomes of interest; and (6) language. The findings illuminate PC’s stable theoretical foundations and distinctive nuances needed to appropriately understand, apply, and evaluate the construct’s operationalization in contemporary healthcare research and practice. These considerations hold important implications for future research into the fundamental aims of healthcare, how it should look when practiced, and what should reasonably be required of it.

Self-management of diabetes and associated comorbidities in rural and remote communities: a scoping review

Chronic health conditions are more prevalent in rural and remote areas than in metropolitan areas; living in rural and remote areas may present particular barriers to the self-management of chronic conditions like diabetes and comorbidities. The aims of this review were to: (1) synthesise evidence examining the self-management of diabetes and comorbidities among adults living in rural and remote communities; and (2) describe barriers and enablers underpinning self-management reported in studies that met our inclusion criteria. A systematic search of English language papers was undertaken in PsycINFO, Medline Complete, Cumulative Index to Nursing and Allied Health Literature (CINAHL) Complete, EMBASE and the Cochrane Database of Systematic Reviews, searching for literature indexed from the beginning of the database until 6 March 2020. Essential key concepts were diabetes, comorbidities, self-management and rural or remote. Twelve studies met the inclusion criteria. Six of these reported interventions to promote self-management for adults with diabetes in rural and remote communities and described comorbidities. These interventions had mixed results; only three demonstrated improvements in clinical outcomes or health behaviours. All three of these interventions specifically targeted adults living with diabetes and comorbidities in rural and remote areas; two used the same telehealth approach. Barriers to self-management included costs, transport problems and limited health service access. Interventions should take account of the specific challenges of managing both diabetes and comorbidities; telehealth may address some of the barriers associated with living in rural and remote areas.

Unlocking the Value of Literature in Health Co-Design: Transforming Patient Experience Publications into a Creative and Accessible Card Tool

BACKGROUND

A wealth of peer-reviewed data exists regarding people's health experience, yet practical ways of using the data to understand patients' experiences and to inform health co-design are needed.

OBJECTIVE

This study aims to develop an applied and pragmatic method for using patient experience literature in co-design by transforming it into an accessible and creative co-design tool.

METHOD

A scoping literature review of the CINAHL, MEDLINE, PsycINFO and PubMed electronic databases was conducted from January 2011 through August 2016. Qualitative publications regarding the experience of living with diabetes in Australia were selected. The Results section of each paper was extracted and affinity analysis was applied to identify insights into the health experience. These insights were developed into a card tool for use in health co-design activities.

RESULTS

Thirteen relevant papers were identified from the review, and affinity analysis of the Results sections of these papers lead to the identification of 85 insights, from 'Shock of diagnosis' (Insight 1), to 'Delay seeking care' (Insight 9), to 'Assess the quality of care' (Insight 28), to 'Avoid or adapt habits' (Insight 78). Each insight was developed into an individual card, which included a high-level theme, insight, quote and a link back to the literature, together making up the Health Experience Insight Cards, Living with Diabetes Edition.

CONCLUSIONS

This was the first study to develop a method for transforming existing patient experience literature into a creative tool for health improvement. The Health Experience Insight Cards collate the diverse experiences of over 300 people living with diabetes in Australia, from 13 studies. Health improvement teams can use the 'Living with Diabetes Edition' cards or they can follow this pragmatic method to create their own cards focused on other health experiences to facilitate person-focused health improvements.

A qualitative meta-summary using Sandelowski and Barroso’s method for integrating qualitative research to explore barriers and facilitators to self-care in heart failure patients

Background:

Individual qualitative studies provide varied reasons for why heart failure patients do not engage in self-care, yet articles that aggregated primary studies on the subject have methodological weaknesses that justified the execution of a qualitative meta-summary.

Aim:

The aim of this study is to integrate the findings of qualitative studies pertaining to barriers and facilitators to self-care using meta-summary techniques.

Methods:

Qualitative meta-summary techniques by Sandelowski and Barroso were used to combine the findings of qualitative studies. Meta-summary techniques include: (1) extraction of relevant statements of findings from each report; (2) reduction of these statements into abstracted findings and (3) calculation of effect sizes. Databases were searched systematically for qualitative studies published between January 2010 and July 2015. Out of 2264 papers identified, 31 reports based on the accounts of 814 patients were included in the meta-summary.

Results:

A total of 37 statements of findings provided a comprehensive inventory of findings across all reports. Out of these statements of findings, 21 were classified as barriers, 13 as facilitators and three were classed as both barriers and facilitators. The main themes relating to barriers and facilitators to self-care were: beliefs, benefits of self-care, comorbidities, financial constraints, symptom recognition, ethnic background, inconsistent self-care, insufficient information, positive and negative emotions, organizational context, past experiences, physical environment, self-initiative, self-care adverse effects, social context and personal preferences.

Conclusion:

Based on the meta-findings identified in this study, future intervention development could address these barriers and facilitators in order to further enhance self-care abilities in heart failure patients.

Self Managing Heart Failure in Remote Australia - Translating Concepts into Clinical Practice

Congestive heart failure (CHF) is an ambulatory health care condition characterized by episodes of decompensation and is usually without cure. It is a leading cause for morbidity and mortality and the lead cause for hospital admissions in older patients in the developed world. The long-term requirement for medical care and pharmaceuticals contributes to significant health care costs. CHF management follows a hierarchy from physician prescription to allied health, predominately nurse-led, delivery of care. Health services are easier to access in urban compared to rural settings. The differentials for more specialized services could be even greater. Remote Australia is thus faced with unique challenges in delivering CHF best practice. Chronic disease self-management programs (CDSMP) were designed to increase patient participation in their health and alleviate stress on health systems. There have been CDSMP successes with some diseases, although challenges still exist for CHF. These challenges are amplified in remote Australia due to geographic and demographic factors, increased burden of disease, and higher incidence of comorbidities. In this review we explore CDSMP for CHF and the challenges for our region.

Self-Management and Self-Management Support Outcomes: A Systematic Review and Mixed Research Synthesis of Stakeholder Views

INTRODUCTION

Self-management has received growing attention as an effective approach for long-term condition management. Little is known about which outcomes of supported self-management are valued by patients, their families, health professionals and those who commission self-management services. This study systematically reviewed published empirical evidence in accordance with PRISMA guidelines to determine the outcomes of self-management valued by these key stakeholder groups, using three prominent exemplar conditions: colorectal cancer, diabetes and stroke.

AIM

To systematically review the literature to identify which generic outcomes of self-management have been targeted and are considered important using three exemplar conditions (colorectal cancer, diabetes and stroke), which collectively have a range of features that are likely to be representative of generic self-management issues.

METHODS

Systematic searching of nine electronic databases was conducted in addition to hand searches of review articles. Abstracts were identified against inclusion criteria and appraised independently by two reviewers, using a critical appraisal tool. Synthesis of findings was conducted using mixed research synthesis.

RESULTS

Over 20,536 abstracts were screened. 41 studies which met the review criteria were fully retrieved and appraised. The majority of evidence related to diabetes. Few studies directly focussed on stakeholders' views concerning desired self-management outcomes; the majority of evidence was derived from studies focusing upon the experience of self-management. The views of health care commissioners were absent from the literature. We identified that self-management outcomes embrace a range of indicators, from knowledge, skills, and bio-psychosocial markers of health through to positive social networks.

CONCLUSIONS

Patients', families', health professionals' and commissioners' views regarding which outcomes of self-management are important have not been clearly elicited. The extent to which bio-psychosocial indicators relate to successful self-management from the perspectives of all groups of stakeholders is unknown. Further investigation regarding which self-management outcomes are considered important by all stakeholders is necessary to guide the commissioning and design of future self-management services.

Physician-Patient Concordance in Pharmacological Management of Patients with COPD

A retrospective analysis of a cross-sectional, multicenter survey was conducted in United States (US) medical practices to evaluate the concordance between patients with COPD and their physicians on disease-specific characteristics. Associations between patient and disease-related characteristics with monotherapy, dual therapy, or triple therapy prescribed as COPD maintenance regimens were also examined. Eligible physicians completed patient record forms (PRFs) for up to 6 consecutive patients with COPD. Patients for whom a PRF was completed were invited to complete a patient self-completion (PSC) survey consisting of questions similar to those on the PRF, as well as several validated measures to assess the impact of COPD on patients' lives. A total of 469 patients completed a PSC that was matched with the PRF completed by their physician, forming the sample for the concordance analysis. Moderate agreement (kappa (κ) = 0.41-0.60) was observed for 79% of measures, with the lowest concordance rating corresponding to hemoptysis (κ = 0.22). There were few differences in demographic or clinical characteristics between patients prescribed monotherapy and dual therapy. Triple therapy rather than monotherapy or dual therapy was more often prescribed for patients with greater frequency of symptoms, negative impact of COPD on daily life and interpersonal relationships, and respiratory impairment based on the most recent FEV1. Diverse factors influence US physicians' perceptions of disease and treatment choices, including patient symptoms, quality of life, and disease impact. Our results highlight that concordance between physicians and patients regarding symptoms and physical function may contribute to optimal management of COPD.

Time spent by people managing chronic obstructive pulmonary disease indicates biographical disruption

Since Bury’s 1982 proposal that chronic illness creates biographical disruption for those who are living with it, there has been no effort to quantitatively measure such disruption. “Biographical disruption” refers to the substantial and directive influence that chronic illness can have over the course of a person’s life. Qualitative research and time use studies have demonstrated that people with chronic illnesses spend considerable amounts of time managing their health, and that these demands may change over time. This study was designed to measure the time that older people with chronic illnesses spend on selected health practices as one indicator of biographical disruption. We look specifically at the time use of people with chronic obstructive pulmonary disease (COPD). As part of a larger time use survey, a recall questionnaire was mailed to 3,100 members of Lung Foundation Australia in 2011. A total of 681 responses were received (22.0% response rate), 611 of which were from people with COPD. Descriptive analyses were undertaken on the amount of time spent on selected health-related activities including personal care, nonclinical health-related care, and activity relating to health services. Almost all people with COPD report spending some time each day on personal or home-based health-related tasks, with a median time of 15 minutes per day spent on these activities. At the median, people also report spending about 30 minutes per day exercising, 2.2 hours per month (the equivalent of 4.4 minutes per day) on nonclinical health-related activities, and 4.1 hours per month (equivalent to 8.2 minutes per day) on clinical activities. Excluding exercise, the median total time spent on health-related activities was 17.8 hours per month (or 35.6 minutes per day). For people in the top 10% of time use, the total amount of time was more than 64.6 hours per month (or 2.2 hours per day) excluding exercise, and 104 hours per month (or 3.5 hours per day) including exercise. The amount of time spent on health-related activity, such as engaging in personal care tasks, may be regular and predictable. The execution of these tasks generally takes relatively small amounts of time, and might be incorporated into daily life (biography) without causing significant disruption. Other activities may require large blocks of time, and they may be disruptive in a practical way that almost inevitably disrupts biography. The amount of time required does not appear to alter in relation to the time since diagnosis. The scale of time needed to manage one’s health could easily be interpreted as disruptive, and for some people, even overwhelming.

The development of a mobile monitoring and feedback tool to stimulate physical activity of people with a chronic disease in primary care: a user-centered design

Background

Physical activity is an important aspect in the treatment of patients with chronic obstructive pulmonary disease or type-2 diabetes. A monitoring and feedback tool combined with guidance by a primary care provider might be a successful method to enhance the level of physical activity in these patients. As a prerequisite for useful technology, it is important to involve the end-users in the design process from an early stage.

Objective

The aim of this study was to investigate the user requirements for a tool to stimulate physical activity, embedded in primary care practice. The leading principle of this tool is to change behavior by self-monitoring, goal-setting, and feedback.

Methods

The research team collected qualitative data among 15 patients, 16 care professionals, and several experts. A prototype was developed in three stages. In stage 1, the literature was searched to identify end-users and context. In stage 2, the literature, experts and patient representatives were consulted to set up a use case with the general idea of the innovation. In stage 3, individual interviews and focus groups were held to identify the end-user requirements. Based on these requirements a prototype was built by the engineering team.

Results

The development process has led to a tool that generally meets the requirements of the end-users. A tri-axial activity sensor, worn on the hip, is connected by Bluetooth to a smartphone. In an app, quantitative feedback is given about the amount of activity and goals reached by means of graphical visualization, and an image shows a sun when the goal is reached. Overviews about activity per half an hour, per day, week, and month are provided. In the menu of the app and on a secured website, patients can enter information in individual sessions or read feedback messages generated by the system. The practice nurse can see the results of all patients on a secure webpage and can then discuss the results and set personalized goals in consultation with the patient.

Conclusions

This study demonstrates that a user-centered approach brings in valuable details (such as the requirements for feedback in activity minutes per day) to improve the fit between the user, technology, and the organization of care, which is important for the usability and acceptability of the tool. The tool embedded in primary care will be evaluated in a randomized controlled trial.

Time spent on health related activity by older Australians with diabetes

AIMS

There is little information available about what people do to look after their health, or how long people spend on health activities. This study identifies key health related activities and time taken as part of self management by people with diabetes. Management planning often lacks information that this study provides that would help clinicians and patients to create manageable and do-able plans that patients can follow.

METHODS

Data were collected in 2010 using a national survey of people aged 50 years the National Diabetes Services Scheme. Respondents provided recall data on time used for personal health care, non-clinical health activity; and health service interactions. Data were analysed using Stata 12 and SPSS 19.

RESULTS

While most people with diabetes spend on average less than 30 minutes a day on health-related activities (excluding exercise), the highest decile of respondents averaged over 100 minutes. Time spent increased with the number of co-existent conditions. Taking medication and sitting in waiting rooms were the most frequently reported activities. The greatest amount of time was spent on daily personal health care activities.

CONCLUSION

The time demands of diabetes for older people can be substantial. Better patient engagement in self management might result from a better match in care planning between the illness demands and the patient time availability, with potential to reduce admissions for hospital care.