Training professionals to engage with and promote self-management

Promotion of Self-Management of Chronic Disease in Children and Teenagers: Scoping Review

BACKGROUND

The scientific literature describes that self-management of chronic illness leads to improved health outcomes. Knowledge about interventions that promote self-management behaviors in children and teenagers has been poorly clarified. This study aims to map, in the scientific literature, the nature and extent of interventions that promote self-management of chronic disease, implemented and evaluated in contexts of health care provided to children and teenagers.

METHODS

The guidelines proposed by the Joanna Briggs Institute were followed. The survey was conducted in June 2021, with access to international databases and gray literature, in Portuguese, English, French, and Spanish.

RESULTS

Interventions that promote self-management of children and teenagers can be developed through a local contact or through technological means of support for health care. The use of online supports, such as applications or communication platforms, should be parameterized with health professionals, according to the needs of users.

CONCLUSIONS

The acquisition of self-management skills in pediatrics is a process supported by the family, health professionals and the community, in which the nurse, in partnership, can promote communication and health education through cognitive strategies, behavioral programs included in physical or online programs, adjusted to the patients' needs.

Clinical communication in inflammatory bowel disease: a systematic review of the study of clinician-patient dialogue to inform research and practice

OBJECTIVES

This systematic review aims to investigate what is currently known about the characteristics of interactions between patients with inflammatory bowel disease (IBD) and their clinicians and its effect on patient outcomes.

DATA SOURCES

Scopus, PubMed, Embase, Communication Abstracts, Health & Society, Linguistics and Language Behaviour Abstracts and PsycINFO were systematically searched from inception to June 2021.

STUDY ELIGIBILITY CRITERIA

Peer-reviewed journal articles and book chapters in English investigating the characteristics of naturally occurring interactions between clinicians that manage IBD and patients with IBD during recorded consultations were included.

STUDY APPRAISAL AND SYNTHESIS METHODS

Risk of bias was assessed using a specifically developed quality assessment tool, grounded in linguistic theory and the Mixed Methods Appraisal Tool. A narrative synthesis guided by the linguistic concept of metafunction was performed to synthesise the findings.

RESULTS

Of the 2883 abstracts reviewed five formed the basis of the review. Interactions between IBD nurses and patients have been mostly characterised in terms of information provision regarding prescribed medications without consideration of the interpersonal aspect. Discussing online medical information with nurses has been shown to improve patient satisfaction. Analyses of gastroenterologist-patient interactions have concentrated on the clinical relationship which has been shown to be disease-centred. Shared decision making in ulcerative colitis has been shown to be compromised due to lack of transparency regarding treatment goals.

LIMITATIONS

This review did not include articles in languages other than English. Cumulative evidence could not be produced due to the small number of included studies and the diversity of contexts, theories and data types.

CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS

There is a paucity of systematic research on naturally occurring clinical communication in IBD and its effect on outcomes. Further research needs to be done to address this knowledge gap.

PROSPERO REGISTRATION NUMBER

CRD42020169657.

Clinical communication in inflammatory bowel disease: a systematic literature review protocol

INTRODUCTION

Evidence regarding effective communication between clinicians and patients with inflammatory bowel disease (IBD) is limited. Studies that investigate clinical communication in IBD are much fewer in number than studies that investigate the perceptions of patients and clinicians about communication in clinical encounters. The current review aims to identify, organise and summarise systematically what is currently known about (1) the characteristics of interactions between clinicians who manage IBD and patients with IBD, and (2) how clinical discussion affects health outcomes in IBD.

METHODS AND ANALYSIS

Scopus, PubMed, Embase, Communication Abstracts, Health & Society, Linguistics and Language Behavior Abstracts and PsycINFO will be systematically searched for studies that investigate the characteristics of IBD clinical interactions during recorded consultations, from earliest available dates within each database to May 2020. A specifically developed quality assessment tool, grounded in linguistic theory, will be used to critically assess the evidence. In addition, a data extraction template will be developed and utilised to provide a description of the characteristics of IBD clinical communication as well as an estimation of its effect on health outcomes in a narrative synthesis.

ETHICS AND DISSEMINATION

Ethical review and approval is not required for this systematic review as no primary data will be collected. The results will be published in peer-reviewed journals and presented at academic conferences.

PROSPERO REGISTRATION NUMBER

International Prospective Register of Systematic Reviews (PROSPERO) on 28 April 2020 (registration number: CRD42020169657).

Questionnaire assessment helps the self-management of patients with inflammatory bowel disease during the outbreak of Coronavirus Disease 2019

Objective: This study aimed to assess the disease conditions of patients with inflammatory bowel disease (IBD) in Hubei Province during the outbreak of Coronavirus Disease 2019 (COVID-19) by questionnaire online and guide their self-management during this epidemic.

Results: A total of 102 eligible questionnaires were included. No patient we surveyed reported a diagnosis of COVID-19. Our result showed that 67.86% of patients with ulcerative colitis (UC) and 80.43% of patients with Crohn's disease (CD) were in remission, 85.29%of patients had a good quality of life. Part of the patients (21.57%) reported their disease conditions worsening. The reduction in physical exercise was a risk factor for worsening conditions (OR=17.593, p=0.009). Some patients reported an alteration of medication regimens during the epidemic.

Conclusions: The epidemic of COVID-19 might have a certain impact on many aspects of Hubei IBD patients within four weeks after the traffic control. Doctors could utilize the results from our questionnaire to guide IBD patients’ self-management.

Methods: A questionnaire was designed containing the Harvey-Bradshaw Index (HBI), the 6-point Mayo Score, the short inflammatory bowel disease questionnaire (SIBDQ) and distributed to Hubei IBD patients online within four weeks of traffic control after the outbreak, it also included questions about patients’ self-reported disease conditions and their epidemiological features of COVID-19.

The Effects of Group Discussion Based Education on the Promotion of Self-Management Behaviors in Hemodialysis Patients

Introduction: Improving self-management of the patients undergoing hemodialysis is an effective way to reduce complications and to improve the quality of life of them. The current study aims to assess the effects of group discussion on the promotion of self-management behaviors in hemodialysis patients.

Methods: In this quasi -experimental clinical trial study (with experimental and control groups) 60 patients were arranged in two experimental and control groups through using convenience sampling with random allocation. Self-management interventions were conducted on the experimental group during 3 to 4 sessions of group discussion. The control group received routine interventions. The data were collected through Li and colleagues' self-management standard questionnaire before and 3 months after the intervention. The data were analyzed via SPSS software version 13 and chi-square, t-test, Mann-Whitney, and Wilcoxon test.

Results: The results showed that the mean scores of four dimension of self-management including participation with the medical team, problem solving, self-care and emotional management after the implementation of group were significantly different between the experimental and control groups.

Conclusion: Based on the findings, group discussion was an effective educational method to promote self-management of chronic hemodialysis patients. Therefore, holding group discussion to reinforce the self- management behaviors in patients undergoing hemodialysis is recommended.

The Evaluation of Physicians' Communication Skills From Multiple Perspectives

PURPOSE

To examine how family physicians', patients', and trained clinical raters' assessments of physician-patient communication compare by analysis of individual appointments.

METHODS

Analysis of survey data from patients attending face-to-face appointments with 45 family physicians at 13 practices in England. Immediately post-appointment, patients and physicians independently completed a questionnaire including 7 items assessing communication quality. A sample of videotaped appointments was assessed by trained clinical raters, using the same 7 communication items. Patient, physician, and rater communication scores were compared using correlation coefficients.

RESULTS

Included were 503 physician-patient pairs; of those, 55 appointments were also evaluated by trained clinical raters. Physicians scored themselves, on average, lower than patients (mean physician score 74.5; mean patient score 94.4); 63.4% (319) of patient-reported scores were the maximum of 100. The mean of rater scores from 55 appointments was 57.3. There was a near-zero correlation coefficient between physician-reported and patient-reported communication scores (0.009, P = .854), and between physician-reported and trained rater-reported communication scores (-0.006, P = .69). There was a moderate and statistically significant association, however, between patient and trained-rater scores (0.35, P = .042).

CONCLUSIONS

The lack of correlation between physician scores and those of others indicates that physicians' perceptions of good communication during their appointments may differ from those of external peer raters and patients. Physicians may not be aware of how patients experience their communication practices; peer assessment of communication skills is an important approach in identifying areas for improvement.

Shifting mindsets: a realist synthesis of evidence from self-management support training

CONTEXT

Accompanying the growing expectation of patient self-management is the need to ensure health care professionals (HCPs) have the required attitudes and skills to provide effective self-management support (SMS). Results from existing training interventions for HCPs in SMS have been mixed and the evidence base is weaker for certain settings, including supporting people with progressive neurological conditions (PNCs). We set out to understand how training operates, and to identify barriers and facilitators to training designed to support shifts in attitudes amongst HCPs.

METHODS

We undertook a realist literature synthesis focused on: (i) the influence of how HCPs, teams and organisations view and adopt self-management; and (ii) how SMS needs to be tailored for people with PNCs. A traditional database search strategy was used alongside citation tracking, grey literature searching and stakeholder recommendations. We supplemented PNC-specific literature with data from other long-term conditions. Key informant interviews and stakeholder advisory group meetings informed the synthesis process. Realist context-mechanism-outcome configurations were generated and mapped onto the stages described in Mezirow's Transformative Learning Theory.

RESULTS

Forty-four original articles were included (19 relating to PNCs), from which seven refined theories were developed. The theories identified important training elements (evidence provision, building skills and confidence, facilitating reflection and generating empathy). The significant influence of workplace factors as possible barriers or facilitators was highlighted. Embracing SMS often required challenging traditional professional role boundaries.

CONCLUSION

The integration of SMS into routine care is not an automatic outcome from training. A transformative learning process is often required to trigger the necessary mindset shift. Training should focus on how individual HCPs define and value SMS and how their work context (patient group and organisational constraints) influences this process. Proactively addressing potential contextual barriers may facilitate implementation. These findings could be applied to other types of training designed to shift attitudes amongst HCPs.

A randomised controlled trial, cost-effectiveness and process evaluation of the implementation of self-management for chronic gastrointestinal disorders in primary care, and linked projects on identification and risk assessment

Background

Chronic gastrointestinal disorders are major burdens in primary care. Although there is some evidence that enhancing self-management can improve outcomes, it is not known if such models of care can be implemented at scale in routine NHS settings and whether or not it is possible to develop effective risk assessment procedures to identify patients who are likely to become chronically ill.

Objectives

What is the clinical effectiveness and cost-effectiveness of an intervention to enhance self-management support for patients with chronic conditions when translated from research settings into routine care? What are the barriers and facilitators that affect the implementation of an intervention to enhance self-management support among patients, clinicians and organisations? Is it possible to develop methods to identify patients at risk of long-term problems with functional gastrointestinal disorders in primary care? Data sources included professional and patient interviews, patient self-report measures and data on service utilisation.

Design

A pragmatic, two-arm, practice-level cluster Phase IV randomised controlled trial evaluating outcomes and costs associated with the intervention, with associated process evaluation using interviews and other methods. Four studies around identification and risk assessment: (1) a general practitioner (GP) database study to describe how clinicians in primary care record consultations with patients who experience functional lower gastrointestinal symptoms; (2) a validation of a risk assessment tool; (3) a qualitative study to explore GPs’ views and experiences; and (4) a second GP database study to investigate patient profiles in irritable bowel syndrome, inflammatory bowel disease and abdominal pain.

Setting

Salford, UK.

Participants

People with long-term conditions and professionals in primary care.

Interventions

A practice-level intervention to train practitioners to assess patient self-management capabilities and involve them in a choice of self-management options.

Main outcome measures

Patient self-management, care experience and quality of life, health-care utilisation and costs.

Results

No statistically significant differences were found between patients attending the trained practices and those attending control practices on any of the primary or secondary outcomes. The intervention had little impact on either costs or effects within the time period of the trial. In the practices, self-management tools failed to be normalised in routine care. Full assessment of the predictive tool was not possible because of variable case definitions used in practices. There was a lack of perceived clinical benefit among GPs.

Limitations

The intervention was not implemented fully in practice. Assessment of the risk assessment tool faced barriers in terms of the quality of codting in GP databases and poor recruitment of patients.

Conclusions

The Whole system Informing Self-management Engagement self-management (WISE) model did not add value to existing care for any of the long-term conditions studied.

Future work

The active components required for effective self-management support need further study. The results highlight the challenge of delivering improvements to quality of care for long-term conditions. There is a need to develop interventions that are feasible to deliver at scale, yet demonstrably clinically effective and cost-effective. This may have implications for the piloting of interventions and linking implementation more clearly to local commissioning strategies.

Trial registration

Current Controlled Trial ISRCTN90940049.

Funding

This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full inProgramme Grants for Applied Research; Vol. 6, No. 1. See the NIHR Journals Library website for further project information.

Spotlight on the Patient Health Engagement model (PHE model): a psychosocial theory to understand people's meaningful engagement in their own health care

The concept of patient engagement in health care is gaining more and more attention not only in the scientific literature, but also as a requirement in the everyday practices of health care organizations. In general terms, the growing body of literature devoted to patient engagement is mainly inspired by the sociological and public health perspectives, which have generated various theories and models trying to explain how people become active agents in their health and care management. However, theories focusing on the psychosocial dimensions intervening in the patient engagement experience are still limited. This paper proposes a psychosocial perspective on patient engagement and discusses the Patient Health Engagement model, which is an evidence-based psychological theory built on extensive qualitative narrative research and literature analysis aimed at explaining patient engagement and its development in the patients' perspective. The model has been applied to orient patient and professional educational interventions and has contributed to the generation of the first scientific measure of the psychological experience of patients' engagement in their own care (Patient Health Engagement scale). According to this theory, patient engagement is a developmental process that involves the recovered patients' ability to have a life projectuality and goal directedness - even if living with a disease. The paper will also discuss the theoretical origins of this model and will conduct a critical comparison of the theory with the Transtheoretical Model of Change developed by Prochaska and the five-stage grief theory by Kubler-Ross.

"Was that a success or not a success?": a qualitative study of health professionals' perspectives on support for people with long-term conditions

Background

Support for self-management (SSM) is a prominent strand of health policy internationally, particularly for primary care. It is often discussed and evaluated in terms of patients’ knowledge, skills and confidence, health-related behaviours, disease control or risk reduction, and service use and costs. However, these goals are limited, both as guides to professional practice and as indicators of its quality. In order to better understand what it means to support self-management well, we examined health professionals’ views of success in their work with people with long-term conditions. This study formed part of a broader project to develop a conceptual account of SSM that can reflect and promote good practice.

Methods

Semi-structured individual interviews (n = 26) and subsequent group discussions (n = 5 groups, 30 participants) with diverse health professionals working with people with diabetes and/or Parkinson’s disease in NHS services in London, northern England or Scotland. The interviews explored examples of more and less successful work, ways of defining success, and ideas about what facilitates success in practice. Subsequent group discussions considered the practical implications of different accounts of SSM. Interviews and group discussions were audio-recorded, transcribed and analysed thematically.

Results

Participants identified a wide range of interlinked aspects or elements of success relating to: health, wellbeing and quality of life; how well people (can) manage; and professional-patient relationships. They also mentioned a number of considerations that have important implications for assessing the quality of their own performance. These considerations in part reflect variations in what matters and what is realistically achievable for particular people, in particular situations and at particular times, as well as the complexity of questions of attribution.

Conclusions

A nuanced assessment of the quality of support for self-management requires attention to the responsiveness of professional practice to a wide, complex range of personal and situational states, as well as actions and interactions over time. A narrow focus on particular indicators can lead to insensitive or even perverse judgements and perhaps counterproductive effects. More open, critical discussions about both success and the assessment of quality are needed to facilitate good professional practice and service improvement initiatives.

Electronic supplementary material

The online version of this article (doi:10.1186/s12875-017-0611-7) contains supplementary material, which is available to authorized users.

An Educational Intervention to Train Professional Nurses in Promoting Patient Engagement: A Pilot Feasibility Study

Introduction: Growing evidence recognizes that patients who are motivated to take an active role in their care can experience a range of health benefits and reduced healthcare costs. Nurses play a critical role in the effort to make patients fully engaged in their disease management. Trainings devoted to increase nurses' skills and knowledge to assess and promote patient engagement are today a medical education priority. To address this goal, we developed a program of nurse education training in patient engagement strategies (NET-PES). This paper presents pilot feasibility study and preliminary participants outcomes for NET-PES. Methods: This is a pilot feasibility study of a 2-session program on patient engagement designed to improve professional nurses' ability to engage chronic patients in their medical journey; the training mainly focused on passing patient engagement assessment skills to clinicians as a crucial mean to improve care experience. A pre-post pilot evaluation of NET-PES included 46 nurses working with chronic conditions. A course specific competence test has been developed and validated to measure patient engagement skills. The design included self-report questionnaire completed before and after the training for evaluation purposes. Participants met in a large group for didactic presentations and then they were split into small groups in which they used role-play and case discussion to reflect upon the value of patient engagement measurement in relation to difficult cases from own practice. Results: Forty-six nurses participated in the training program. The satisfaction questionnaire showed that the program met the educational objectives and was considered to be useful and relevant by the participants. Results demonstrated changes on clinicians' attitudes and skills in promoting engagement. Moreover, practitioners demonstrated increases on confidence regarding their ability to support their patients' engagement in the care process. Conclusions: Learning programs teaching nurses about patient engagement strategies and assessment measures in clinical practice are key in supporting the realization of patient engagement in healthcare. Training nurses in this area is feasible and accepted and might have an impact on their ability to engage patients in the chronic care journey. Due to the limitation of the research design, further research is needed to assess the effectiveness of such a program and to verify if the benefits envisaged in this pilot are maintained on a long-term perspective and to test results by employing a randomized control study design.

Institutional logic in self-management support: coexistence and diversity

The prevalence of chronic conditions in Europe has been the subject of health-political reforms that have increasingly targeted collaboration between public, private and voluntary organisations for the purpose of supporting self-management of long-term diseases. The international literature describes collaboration across sectors as challenging, which implies that their respective logics are conflicting or incompatible. In line with the European context, recent Norwegian health policy advocates inter-sectorial partnerships. The aim of this policy is to create networks supporting better self-management for people with chronic conditions. The purpose of our qualitative study was to map different understandings of self-management support in private for-profit, volunteer and public organisations. These organisations are seen as potential self-management support networks for individuals with chronic conditions in Norway. From December 2012 to April 2013, we conducted 50 semi-structured interviews with representatives from relevant health and well-being organisations in different parts of Norway. According to the theoretical framework of institutional logic, representatives' statements are embedded with organisational understandings. In the analysis, we systematically assessed the representatives' different understandings of self-management support. The institutional logic we identified revealed traits of organisational historical backgrounds, and transitions in understanding. We found that the merging of individualism and fellowship in contemporary health policy generates different types of logic in different organisational contexts. The private for-profit organisations were concerned with the logic of a healthy appearance and mindset, whereas the private non-profit organisations emphasised fellowship and moral responsibility. Finally, the public, illness-oriented organisations tended to highlight individual conditions for illness management. Different types of logic may attract different users, and simultaneously, a diversity of logic types may challenge collaboration at the user's expense. Moral implications embed institutional logic implying a change towards individual responsibility for disease. Policy makers ought to consider complexities of logic in order to tailor the different needs of users.

Challenges in Shifting Management Responsibility From Parents to Adolescents With Sickle Cell Disease

This study explored the challenges faced by adolescents with sickle cell disease (SCD) and their parents and the work they engage in to progressively shift from parent management to independent adolescent self-management.

DESIGN AND METHODS

A qualitative descriptive focus-group design with semi-structured interviews was used with adolescents (11-18 years) with SCD (HbSS genotype) and their parents/primary caregivers. Interviews were analyzed using content analysis.

RESULTS

Two adolescent focus groups, with a total of 14 adolescents, and two parent focus groups, with a total of 15 parents, described adaptive challenges. Adolescents' adaptive challenges included mastering complex symptom management, communicating about SCD and symptoms, and maintaining control. Parents' adaptive challenges included giving over the complex management, communicating the management with the adolescent, balancing protection against risk with fostering independence, changing a comfortable rhythm, and releasing the adolescent into an "SCD-naive" world. Adolescents' adaptive work included pushing back at parents, defaulting back to parental care, stepping up with time, learning how SCD affects them, and educating friends about SCD. Parents' adaptive work included engaging the adolescent in open dialogue and co-managing with the adolescent.

CONCLUSIONS

Shifting management responsibility from parents to adolescents imposes adaptive challenges for both. Future research is needed to develop and test interventions that improve adaptive capacity in adolescents and parents.

PRACTICE IMPLICATIONS

Health care providers need to assess the parent-child relationship and their progress in shifting the management responsibility, facilitate discussions to arrive at a shared understanding of the challenges, and collaborate on adaptive work to address these challenges.

EHealth Technologies in Inflammatory Bowel Disease: A Systematic Review

BACKGROUND AND AIMS

Electronic-health technologies (eHealth) such as Web-based interventions, virtual clinics, smart-phone applications, and telemedicine are being used to manage patients with inflammatory bowel disease (IBD). We aimed to: (1) Evaluate the impact of eHealth technologies on conventional clinical indices and patient-reported outcome measures (PROs) in IBD; (2) assess the effectiveness, cost-effectiveness and feasibility of using eHealth technologies to facilitate the self-management of individuals with IBD, and; (3) provide recommendations for their design and optimal use for patient care.

METHODS

Relevant publications were identified via a literature search, and 17 publications were selected based on predefined quality parameters.

RESULTS

Six randomized controlled trials and nine observational studies utilizing eHealth technologies in IBD were identified. Compared with standard outpatient-led care, eHealth technologies have led to improvements in: Relapse duration [(n = 1) 18 days vs 77 days, p < 0.001]; disease activity (n = 2); short-term medication adherence (n = 3); quality of life (n = 4); IBD knowledge (n = 2); healthcare costs (n = 4); the number of acute visits to the outpatient clinic due to IBD symptoms (n = 1), and; facilitating the remote management of up to 20% of an IBD cohort (n = 2). Methodological shortcomings of eHealth studies include heterogeneity of outcome measures, lack of clinician/patient input, lack of validation against conventional clinical indices and PROs, and limited cost-benefit analyses.

CONCLUSIONS

EHealth technologies have the potential for promoting self-management and reducing the impact of the growing burden of IBD on health care resource utilization. A theoretical framework should be applied to the development, implementation, and evaluation of eHealth interventions.

We need to talk about purpose: a critical interpretive synthesis of health and social care professionals' approaches to self-management support for people with long-term conditions

BACKGROUND

Health policies internationally advocate 'support for self-management', but it is not clear how the promise of the concept can be fulfilled.

OBJECTIVE

To synthesize research into professional practitioners' perspectives, practices and experiences to help inform a reconceptualization of support for self-management.

DESIGN

Critical interpretive synthesis using systematic searches of literature published 2000-2014.

FINDINGS

We summarized key insights from 164 relevant papers in an annotated bibliography. The literature illustrates striking variations in approaches to support for self-management and interpretations of associated concepts. We focused particularly on the somewhat neglected question of the purpose of support. We suggest that this can illuminate and explain important differences between narrower and broader approaches. Narrower approaches support people to manage their condition(s) well in terms of disease control. This purpose can underpin more hierarchical practitioner-patient communication and more limited views of patient empowerment. It is often associated with experiences of failure and frustration. Broader approaches support people to manage well with their condition(s). They can keep work on disease control in perspective as attention focuses on what matters to people and how they can be supported to shape their own lives. Broader approaches are currently less evident in practice.

DISCUSSION AND CONCLUSION

Broader approaches seem necessary to fulfil the promise of support for self-management, especially for patient empowerment. A commitment to enable people to live well with long-term conditions could provide a coherent basis for the forms and outcomes of support that policies aspire to. The implications of such a commitment need further attention.

A systematic review of research into black and ethnic minority patients' views on self-management of type 2 diabetes

CONTEXT

Eliciting patients' views of type 2 diabetes self-management provides insights on how policy and services might better support the needs of this population.

OBJECTIVE

To synthesize black and ethnic minority patients' views on the barriers and facilitators influencing the self-management of type 2 diabetes.

SEARCH STRATEGY

A systematic search of international literature published in nine electronic databases was undertaken in 2008. Search strategies used both MeSH and free-text terms. Two relevant journals were also hand searched.

INCLUSION CRITERIA

Any primary empirical study published in the English language since 1986 that reported black and ethnic minority patients' views on type 2 diabetes self-management.

DATA EXTRACTION AND SYNTHESIS

Data were extracted and study quality was formally assessed. Data were analysed using thematic synthesis.

MAIN RESULTS

Fifty-seven studies were included, of qualitative (n = 54), mixed-method (n = 2) or quantitative (n = 1) design. Studies were from North America (n = 41), Europe (n = 14) and Australia (n = 2), including 1735 participants in total. Three analytical themes emerged: 'Importance of identity'; 'Being understood by others' and 'Making sense of condition', all linked conceptually under the overarching theme 'Sense of self'. The quality of the studies varied.

DISCUSSION AND CONCLUSIONS

The findings provide insight into what black and minority ethnic people regard as the barriers to, and facilitators of self-management, as opposed to what health professionals, policy makers and trial researchers may have assumed. Recognition of the views of people with diabetes is essential for the design and delivery of patient-centred care and policies.

British-Pakistani women's perspectives of diabetes self-management: the role of identity

AIMS AND OBJECTIVES

To explore the effects of type 2 diabetes on British-Pakistani women's identity and its relationship with self-management.

BACKGROUND

Type 2 diabetes is more prevalent and has worse outcomes among some ethnic minority groups. This may be due to poorer self-management and an inadequate match of health services to patient needs. The influence that type 2 diabetes has on British-Pakistani women's identity and subsequent self-management has received limited attention.

DESIGN

An explorative qualitative study.

METHODS

Face-to-face semi-structured English and Urdu language interviews were conducted with a purposively selected heterogeneous sample of 15 British-Pakistani women with type 2 diabetes. Transcripts were analysed thematically.

RESULTS

Four themes emerged: Perceived change in self emphasised how British-Pakistani women underwent a conscious adaptation of identity following diagnosis; Familiarity with ill health reflected women's adjustment to their changed identity over time; Diagnosis improves social support enabled women to accept changes within themselves and Supporting family is a barrier to self-management demonstrated how family roles were an aspect of women's identities that was resilient to change. The over-arching theme Role re-alignment enables successful self-management encapsulated how self-management was a continuous process where achievements needed to be sustained. Inter-generational differences were also noted: first generation women talked about challenges associated with ageing and co-morbidities; second generation women talked about familial and work roles competing with self-management.

CONCLUSIONS

The complex nature of British-Pakistani women's self-identification requires consideration when planning and delivering healthcare.

RELEVANCE TO CLINICAL PRACTICE

Culturally competent practice should recognise how generational status influences self-identity and diabetes self-management in ethnically diverse women. Health professionals should remain mindful of effective self-management occurring alongside, and being influenced by, other aspects of life.

Personalised care planning for adults with chronic or long-term health conditions

BACKGROUND

Personalised care planning is a collaborative process used in chronic condition management in which patients and clinicians identify and discuss problems caused by or related to the patient's condition, and develop a plan for tackling these. In essence it is a conversation, or series of conversations, in which they jointly agree goals and actions for managing the patient's condition.

OBJECTIVES

To assess the effects of personalised care planning for adults with long-term health conditions compared to usual care (i.e. forms of care in which active involvement of patients in treatment and management decisions is not explicitly attempted or achieved).

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, PsycINFO, ProQuest, clinicaltrials.gov and WHO International Clinical Trials Registry Platform to July 2013.

SELECTION CRITERIA

We included randomised controlled trials and cluster-randomised trials involving adults with long-term conditions where the intervention included collaborative (between individual patients and clinicians) goal setting and action planning. We excluded studies where there was little or no opportunity for the patient to have meaningful influence on goal selection, choice of treatment or support package, or both.

DATA COLLECTION AND ANALYSIS

Two of three review authors independently screened citations for inclusion, extracted data, and assessed risk of bias. The primary outcomes were effects on physical health, psychological health, subjective health status, and capabilities for self management. Secondary outcomes included effects on health-related behaviours, resource use and costs, and type of intervention. A patient advisory group of people with experience of living with long-term conditions advised on various aspects of the review, including the protocol, selection of outcome measures and emerging findings.

MAIN RESULTS

We included 19 studies involving a total of 10,856 participants. Twelve of these studies focused on diabetes, three on mental health, one on heart failure, one on end-stage renal disease, one on asthma, and one on various chronic conditions. All 19 studies included components that were intended to support behaviour change among patients, involving either face-to-face or telephone support. All but three of the personalised care planning interventions took place in primary care or community settings; the remaining three were located in hospital clinics. There was some concern about risk of bias for each of the included studies in respect of one or more criteria, usually due to inadequate or unclear descriptions of research methods. Physical healthNine studies measured glycated haemoglobin (HbA1c), giving a combined mean difference (MD) between intervention and control of -0.24% (95% confidence interval (CI) -0.35 to -0.14), a small positive effect in favour of personalised care planning compared to usual care (moderate quality evidence).Six studies measured systolic blood pressure, a combined mean difference of -2.64 mm/Hg (95% CI -4.47 to -0.82) favouring personalised care (moderate quality evidence). The pooled results from four studies showed no significant effect on diastolic blood pressure, MD -0.71 mm/Hg (95% CI -2.26 to 0.84).We found no evidence of an effect on cholesterol (LDL-C), standardised mean difference (SMD) 0.01 (95% CI -0.09 to 0.11) (five studies) or body mass index, MD -0.11 (95% CI -0.35 to 0.13) (four studies).A single study of people with asthma reported that personalised care planning led to improvements in lung function and asthma control. Psychological healthSix studies measured depression. We were able to pool results from five of these, giving an SMD of -0.36 (95% CI -0.52 to -0.20), a small effect in favour of personalised care (moderate quality evidence). The remaining study found greater improvement in the control group than the intervention group.Four other studies used a variety of psychological measures that were conceptually different so could not be pooled. Of these, three found greater improvement for the personalised care group than the usual care group and one was too small to detect differences in outcomes. Subjective health statusTen studies used various patient-reported measures of health status (or health-related quality of life), including both generic health status measures and condition-specific ones. We were able to pool data from three studies that used the SF-36 or SF-12, but found no effect on the physical component summary score SMD 0.16 (95% CI -0.05 to 0.38) or the mental component summary score SMD 0.07 (95% CI -0.15 to 0.28) (moderate quality evidence). Of the three other studies that measured generic health status, two found improvements related to personalised care and one did not.Four studies measured condition-specific health status. The combined results showed no difference between the intervention and control groups, SMD -0.01 (95% CI -0.11 to 0.10) (moderate quality evidence). Self-management capabilitiesNine studies looked at the effect of personalised care on self-management capabilities using a variety of outcome measures, but they focused primarily on self efficacy. We were able to pool results from five studies that measured self efficacy, giving a small positive result in favour of personalised care planning: SMD 0.25 (95% CI 0.07 to 0.43) (moderate quality evidence).A further five studies measured other attributes that contribute to self-management capabilities. The results from these were mixed: two studies found evidence of an effect on patient activation, one found an effect on empowerment, and one found improvements in perceived interpersonal support. Other outcomesPooled data from five studies on exercise levels showed no effect due to personalised care planning, but there was a positive effect on people's self-reported ability to carry out self-care activities: SMD 0.35 (95% CI 0.17 to 0.52).We found no evidence of adverse effects due to personalised care planning.The effects of personalised care planning were greater when more stages of the care planning cycle were completed, when contacts between patients and health professionals were more frequent, and when the patient's usual clinician was involved in the process.

AUTHORS' CONCLUSIONS

Personalised care planning leads to improvements in certain indicators of physical and psychological health status, and people's capability to self-manage their condition when compared to usual care. The effects are not large, but they appear greater when the intervention is more comprehensive, more intensive, and better integrated into routine care.

Implementation of a self-management support approach (WISE) across a health system: a process evaluation explaining what did and did not work for organisations, clinicians and patients

BACKGROUND

Implementation of long-term condition management interventions rests on the notion of whole systems re-design, where incorporating wider elements of health care systems are integral to embedding effective and integrated solutions. However, most self-management support (SMS) evaluations still focus on particular elements or outcomes of a sub-system. A randomised controlled trial of a SMS intervention (WISE-Whole System Informing Self-management Engagement) implemented in primary care showed no effect on patient-level outcomes. This paper reports on a parallel process evaluation to ascertain influences affecting WISE implementation at patient, clinical and organisational levels. Normalisation Process Theory (NPT) provided a sensitising background and analytical framework.

METHODS

A multi-method approach using surveys and interviews with organisational stakeholders, practice staff and trial participants about impact of training and use of tools developed for WISE. Analysis was sensitised by NPT (coherence, cognitive participation, collective action and reflective monitoring). The aim was to identify what worked and what did not work for who and in what context.

RESULTS

Interviews with organisation stakeholders emphasised top-down initiation of WISE by managers who supported innovation in self-management. Staff from 31 practices indicated engagement with training but patchy adoption of WISE tools; SMS was neither prioritised by practices nor fitted with a biomedically focussed ethos, so little effort was invested in WISE techniques. Interviews with 24 patients indicated no awareness of any changes following the training of practice staff; furthermore, they did not view primary care as an appropriate place for SMS.

CONCLUSION

The results contribute to understanding why SMS is not routinely adopted and implemented in primary care. WISE was not embedded because of the perceived lack of relevance and fit to the ethos and existing work. Enacting SMS within primary care practice was not viewed as a legitimate activity or a professional priority. There was failure to, in principle, engage with and identify patients' support needs. Policy presumptions concerning SMS appear to be misplaced. Implementation of SMS within the health service does not currently account for patient circumstances. Primary care priorities and support for SMS could be enhanced if they link to patients' broader systems of implementation networks and resources.

Personalised medicine: the cognitive side of patients

BACKGROUND

Although the fashion for the "personalised" or "stratified" approach to medicine is valuable in exploiting the omic signatures of the individual patient, too little attention has been paid to the influence of psychological and cognitive factors in the care process. The aim of this paper is to highlight the importance of those individual psycho-cognitive components in affecting how people act to prevent, cope and react to illness, decide about different therapeutic options, interact with health care providers, and adhere to treatment.

METHODS

We reviewed the medical and psychological literature about the effect of cognitive and psychological dimensions on treatment efficacy, on patients' global satisfaction, and on treatment compliance.

RESULTS

Psychological dimensions have been proved to impact on treatment efficacy, on patients' global satisfaction, and on compliance to treatment. However, there are substantial individual differences among patients; therefore, it is important that physicians recognise how to apply these general recommendations to each individual patient, alongside the omic information emerging from the molecular diagnostic laboratory.

CONCLUSION

The exam of the current literature allows one to derive several strategies which can help health professionals to improve the patients' understanding of their disease and involvement in the whole care process.

Lay and health care professional understandings of self-management: A systematic review and narrative synthesis

Objectives:

Self-management is widely promoted but evidence of effectiveness is limited. Policy encourages health care professionals to support people with long-term conditions to learn self-management skills, yet little is known about the extent to which both parties share a common understanding of self-management. Thus, we compared health care professional and lay understandings of self-management of long-term conditions.

Methods:

Systematic review and narrative synthesis of qualitative studies identified from relevant electronic databases, hand-searching of references lists, citation tracking and recommendations by experts.

Results:

In total, 55 studies were included and quality was assessed using a brief quality assessment tool. Three conceptual themes, each with two subthemes were generated: traditional and shifting models of the professional–patient relationship (self-management as a tool to promote compliance; different expectations of responsibility); quality of relationship between health care professional and lay person (self-management as a collaborative partnership; self-management as tailored support) and putting self-management into everyday practice (the lived experience of self-management; self-management as a social practice).

Conclusion:

Self-management was conceptualised by health care professionals as incorporating both a biomedical model of compliance and individual responsibility. Lay people understood self-management in wider terms, reflecting biomedical, psychological and social domains and different expectations of responsibility. In different ways, both deviated from the dominant model of self-management underpinned by the concept of self-efficacy. Different understandings help to explain how self-management is practised and may help to account for limited evidence of effectiveness of self-management interventions.

Effect of a health coaching self-management program for older adults with multimorbidity in nursing homes

BACKGROUND AND AIMS

Although a growing number of older people are suffering from multimorbidity, most of the health problems related to multimorbidity can be improved by self-management. The aim of this study was to examine the effectiveness of a health coaching self-management program for older adults with multimorbidity in nursing homes.

METHODS

Older adults with multimorbidity from one nursing home in Korea were randomly allocated to either an intervention group (n=22) or conventional group (n=21). Participants in the intervention group met face to face with the researchers twice a week for 8 weeks, during which time the researchers engaged them in goal setting and goal performance using the strategies in the health coaching self-management program. Regular care was provided to the other participants in the conventional group.

RESULTS

Participants in the intervention group had significantly better outcomes in exercise behaviors (P=0.015), cognitive symptom management (P=0.004), mental stress management/relaxation (P=0.023), self-rated health (P=0.002), reduced illness intrusiveness (P<0.001), depression (P<0.001), and social/role activities limitations (P<0.001). In addition, there was a significant time-by-group interaction in self-efficacy (P=0.036). According to the goal attainment scales, their individual goals of oral health and stress reduction were achieved.

CONCLUSION

The health coaching self-management program was successfully implemented in older adults with multimorbidity in a nursing home. Further research is needed to develop and evaluate the long-term effects of an intervention to enhance adherence to self-management and quality of life for older adults with multimorbidity.

Interventions to assist health consumers to find reliable online health information: a comprehensive review

Background

Health information on the Internet is ubiquitous, and its use by health consumers prevalent. Finding and understanding relevant online health information, and determining content reliability, pose real challenges for many health consumers.

Purpose

To identify the types of interventions that have been implemented to assist health consumers to find reliable online health information, and where possible, describe and compare the types of outcomes studied.

Data Sources

PubMed, PsycINFO, CINAHL Plus and Cochrane Library databases; WorldCat and Scirus ‘gray literature’ search engines; and manual review of reference lists of selected publications.

Study Selection

Publications were selected by firstly screening title, abstract, and then full text.

Data Extraction

Seven publications met the inclusion criteria, and were summarized in a data extraction form. The form incorporated the PICOS (Population Intervention Comparators Outcomes and Study Design) Model. Two eligible gray literature papers were also reported.

Data Synthesis

Relevant data from included studies were tabulated to enable descriptive comparison. A brief critique of each study was included in the tables. This review was unable to follow systematic review methods due to the paucity of research and humanistic interventions reported.

Limitations

While extensive, the gray literature search may have had limited reach in some countries. The paucity of research on this topic limits conclusions that may be drawn.

Conclusions

The few eligible studies predominantly adopted a didactic approach to assisting health consumers, whereby consumers were either taught how to find credible websites, or how to use the Internet. Common types of outcomes studied include knowledge and skills pertaining to Internet use and searching for reliable health information. These outcomes were predominantly self-assessed by participants. There is potential for further research to explore other avenues for assisting health consumers to find reliable online health information, and to assess outcomes via objective measures.

Exploring the experience of facilitating self-management with minority ethnic stroke survivors: a qualitative study of therapists' perceptions

PURPOSE

The utility of self-management with people from minority ethnic backgrounds has been questioned, resulting in the development of culturally specific tools. Yet, the use of stroke specific self-management programmes is underexplored in these high risk groups. This article presents the experience of stroke therapists in using a stroke specific self-management programme with stroke survivors from minority ethnic backgrounds.

METHODS

26 stroke therapists with experience of using the self-management programme with stroke survivors from minority ethnic backgrounds participated in semi-structured interviews. These were audio recorded, transcribed verbatim and analysed thematically.

RESULTS

Three themes were identified. One questioned perceived differences in stroke survivors interaction with self-management based on ethnicity. The other themes contrasted with this view demonstrating two areas in which ethnic and cultural attributes were deemed to influence the self-management process both positively and negatively. Aspects of knowledge of health, illness and recovery, religion, family and the professionals themselves are highlighted.

CONCLUSIONS

This study indicates that ethnicity should not be considered a limitation to the use of an individualized stroke specific self-management programme. However, it highlights potential facilitators and barriers, many of which relate to the capacity of the professional to effectively navigate cultural and ethnic differences.

A conceptual model of verbal exchange health literacy

OBJECTIVE

To address a gap in understanding of verbal exchange (oral and aural) health literacy by describing the systematic development of a verbal exchange health literacy (VEHL) definition and model which hypothesizes the role of VEHL in health outcomes.

METHODS

Current health literacy and communication literature was systematically reviewed and combined with qualitative patient and provider data that were analyzed using a grounded theory approach.

RESULTS

Analyses of current literature and formative data indicated the importance of verbal exchange in the clinical setting and revealed various factors associated with the patient-provider relationship and their characteristics that influence decision making and health behaviors. VEHL is defined as the ability to speak and listen that facilitates exchanging, understanding, and interpreting of health information for health-decision making, disease management and navigation of the healthcare system. A model depiction of mediating and influenced factors is presented.

CONCLUSION

A definition and model of VEHL is a step toward addressing a gap in health literacy knowledge and provides a foundation for examining the influence of VEHL on health outcomes.

PRACTICE IMPLICATIONS

VEHL is an extension of current descriptions of health literacy and has implications for patient-provider communication and health decision making.

Organizing person-centred care in paediatric diabetes: multidisciplinary teams, long-term relationships and adequate documentation

Background

Type 1 diabetes is one of the most frequent long-term endocrine childhood disorders and the Swedish National Diabetes Register for children states that adolescents (12–18 years) constitute the most vulnerable patient group in terms of metabolic control. The aim of this study was to examine how a multidisciplinary team functions when caring for adolescents with type 1 diabetes.

Methods

Qualitative interviews were performed with 17 health professionals at a Paediatric Diabetes Care Unit in a Swedish university hospital. The interviews were analysed to gain insight into a multidisciplinary care team’s experiences of various organizational processes and circumstances related to the provision of person-centred paediatric diabetes care.

Results

Building long-term relationships with adolescents, the establishment of a multidisciplinary care team and ensuring adequate documentation are vital for the delivery of person-centred care (PCC). Furthermore, a PCC process and/or practice requires more than the mere expression of person-centred values. The contribution of this study is that it highlights the necessity of facilitating and safeguarding the organization of PCC, for which three processes are central: 1. Facilitating long-term relationships with adolescents and their families; 2. Facilitating multi-professional teamwork; and 3. Ensuring adequate documentation.

Conclusion

Three processes emerged as important for the functioning of the multidisciplinary team when caring for adolescents with type 1 diabetes: building a long-term relationship, integrating knowledge by means of multidisciplinary team work and ensuring adequate documentation. This study demonstrates the importance of clearly defining and making use of the specific role of each team member in the paediatric diabetes care unit (PDCU). Team members should receive training in PCC and a PCC approach should form the foundation of all diabetes care. Every adolescent suffering from type 1 diabetes should be offered individual treatment and support according to her/his needs. However, more research is required to determine how a PCC approach can be integrated into adolescent diabetes care, and especially how PCC education programmes for team members should be implemented.

From dictatorship to a reluctant democracy: stroke therapists talking about self-management

PURPOSE

Self-management is being increasingly promoted within chronic conditions including stroke. Concerns have been raised regarding professional ownership of some programmes, yet little is known of the professional's experience. This paper aims to present the views of trained therapists about the utility of a specific self-management approach in stroke rehabilitation.

METHOD

Eleven stroke therapists trained in the self-management approach participated in semi-structured interviews. These were audio recorded, transcribed verbatim and analysed thematically.

RESULTS

Two overriding themes emerged. The first was the sense that in normal practice therapists act as "benign dictators", committed to help their patients, but most comfortable when they, the professional, are in control. Following the adoption of the self-management approach therapists challenged themselves to empower stroke survivors to take control of their own recovery. However, therapists had to confront many internal and external challenges in this transition of power resulting in the promotion of a somewhat "reluctant democracy".

CONCLUSIONS

This study illustrates that stroke therapists desire a more participatory approach to rehabilitation. However, obstacles challenged the successful delivery of this goal. If self-management is an appropriate model to develop in post stroke pathways, then serious consideration must be given to how and if these obstacles can be overcome.

IMPLICATIONS FOR REHABILITATION

Stroke therapists perceive that self-management is appropriate for encouraging ownership of rehabilitation post stroke. Numerous obstacles were identified as challenging the implementation of self-management post stroke. These included: professional models, practices and expectations; institutional demands and perceived wishes of stroke survivors. For self-management to be effectively implemented by stroke therapists, these obstacles must be considered and overcome. This should be as part of an integrated therapy service, rather than as an add-on.

Self-care in primary care: findings from a longitudinal comparison study

AIM

To examine the effects of self-care training workshops for primary healthcare workers on frequently attending patients.

BACKGROUND

Interventions to promote self-care in frequent users of primary care services have had mixed results. This paper reports an evaluation of a self-care initiative that aimed to develop a practice-based strategy to support self-care.

METHODS

A 12-month longitudinal-matched comparison study was carried out in seven intervention and four comparison practices. The intervention was a multidisciplinary training package delivered to Primary Care Trusts (PCTs) and practice staff in three workshops, over a three- to six-month period. Twenty-one managers, health professionals and other staff from participating practices and PCTs and 1454 patients were involved in the study. 'Frequently attending' patients were defined as having visited the practice more than eight times in the previous year, and were identified from practice registers and recruited by letter. Three sets of data were obtained: psychometric scores and other data from structured questionnaires; routinely collected data on use of healthcare services; and self-care beliefs and behaviour from qualitative interviews. Findings Study recruitment rate was 20% and retention rate 75%. Of those recruited 66% were female and the majority (94.8%) were White. There was poor uptake of the training programme within the participating practices, with few changes agreed or implemented. Few healthcare professionals consented to take part in the evaluation. No significant changes were seen in patients' use of health services, psychometric scores or self-care beliefs or behaviour.

CONCLUSION

The initiative did not show any effects during its pilot phase. Uptake and implementation were adversely affected by competing pressures for time and resources in primary care, coupled with a lack of engagement from primary health care professionals.

'It's coming at things from a very different standpoint': evaluating the 'Supporting Self-Care in General Practice Programme' in NHS East of England

AIM

To undertake a service evaluation of the NHS East of England Supporting Self-Care in General Practice programme.

BACKGROUND

The number of people purported to live with long-term conditions continues to rise generating increasing policy emphasis on the importance of self-care. Previous work has highlighted barriers to implementing self-care interventions in general practice, including a lack of organisational approaches to providing self-care and limited engagement and training of healthcare professionals. In response to these barriers and policy drivers, NHS East of England Strategic Health Authority developed and commenced the Supporting Self-care in General Practice (SSCiGP) programme, which seeks to transform the relationships between people with long-term conditions and primary care practitioners.

METHODS

This was a mixed methods study, carried out over two phases, which included interviews, survey work and practice-based case studies.

RESULTS

This paper focuses on findings related to clinician and practice level change. Clinicians reported changes in their perceptions and in consultation practices following attendance on the SSCiGP programme. These changes were linked to empathy and patient-centredness that mirrored what patients valued in interactions with clinicians. There were qualitative and descriptive differences, but no statistically significant differences between clinicians who had and had not attended the SSCiGP programme. Time was recognised as a significant barrier to implementing, and sustaining skills learnt from the SSCiGP programme. Greater impact at practice level could be achieved when there was whole practice commitment to values that underpinned the SSCiGP programme. There was evidence that such approaches are being incorporated to change practice systems and structures to better facilitate self-care, particularly in practices who were early programme adopters.

CONCLUSION

This evaluation demonstrates that training around clinician change can be effective in shifting service delivery when sat within a cultural framework that genuinely situates patients at the centre of consultations and practice activity.

A cluster randomised controlled trial of the clinical and cost-effectiveness of a 'whole systems' model of self-management support for the management of long- term conditions in primary care: trial protocol

BACKGROUND

Patients with long-term conditions are increasingly the focus of quality improvement activities in health services to reduce the impact of these conditions on quality of life and to reduce the burden on care utilisation. There is significant interest in the potential for self-management support to improve health and reduce utilisation in these patient populations, but little consensus concerning the optimal model that would best provide such support. We describe the implementation and evaluation of self-management support through an evidence-based 'whole systems' model involving patient support, training for primary care teams, and service re-organisation, all integrated into routine delivery within primary care.

METHODS

The evaluation involves a large-scale, multi-site study of the implementation, effectiveness, and cost-effectiveness of this model of self-management support using a cluster randomised controlled trial in patients with three long-term conditions of diabetes, chronic obstructive pulmonary disease (COPD), and irritable bowel syndrome (IBS). The outcome measures include healthcare utilisation and quality of life. We describe the methods of the cluster randomised trial.

DISCUSSION

If the 'whole systems' model proves effective and cost-effective, it will provide decision-makers with a model for the delivery of self-management support for populations with long-term conditions that can be implemented widely to maximise 'reach' across the wider patient population.

TRIAL REGISTRATION NUMBER

ISRCTN: ISRCTN90940049.

Psychological interventions for treatment of inflammatory bowel disease

BACKGROUND

The effect of psychological interventions in inflammatory bowel diseases (IBD) is controversial.

OBJECTIVES

To assess the effects of psychological interventions (psychotherapy, patient education, relaxation techniques) on health related quality of life, coping, emotional state and disease activity in IBD.

SEARCH STRATEGY

We searched the specialized register of the IBD/FBD Group, CENTRAL (Issue 5, 2010) and from inception to April 2010: Medline, Embase, LILACS, Psyndex, CINAHL, PsyInfo, CCMed, SOMED and Social SciSearch. Conference abstracts and reference lists were also checked.

SELECTION CRITERIA

Randomized, quasi-randomized and non randomized controlled trials of psychological interventions in children or adults with IBD with a minimum follow up time of 2 months.

DATA COLLECTION AND ANALYSIS

Data were extracted and study quality was independently assessed by two raters. Pooled standardized mean differences (SMD) and 95% confidence intervals (CI) were calculated using a random effects model.

MAIN RESULTS

Twenty-one studies were eligible for inclusion (1745 participants, 8 RCT, 4 QRCT, 8 NRCT; 19 in adults, 2 in adolescents). Most studies used multimodular approaches. The risk of bias was high for all studies.In adults, psychotherapy had no effect on quality of life at around 12 months (3 studies, 235 patients, SMD -0.07; 95% CI -0.33 to 0.19), emotional status (depression, 4 studies, 266 patients, SMD 0.03; 95% CI -0.22 to 0.27) or proportion of patients not in remission (5 studies, 287 patients, OR 0.85; 95% CI 0.48 to 1.48). Results were similar at 3 to 8 months. There was no evidence for statistical heterogeneity or subgroup effects based on type of disease or intensity of the therapy. In adolescents, there were positive short term effects of psychotherapy on most outcomes assessed including quality of life (2 studies, 71 patients, SMD 0.70; 95% CI 0.21 to 1.18) and depression (1 study, 41 patients, SMD -0.62; 95% CI -1.25 to 0.01).Educational interventions were ineffective with respect to quality of life at 12 months (5 studies, 947 patients, SMD 0.11; 95% CI -0.02 to 0.24), depression (3 studies, 378 patients, SMD -0.08; 95% CI -0.29 to 0.12) and proportion of patients not in remission (3 studies, 434 patients, OR 1.00; 95% CI 0.65 to 1.53).

AUTHORS' CONCLUSIONS

There is no evidence for efficacy of psychological therapy in adult patients with IBD in general. In adolescents, psychological interventions may be beneficial, but the evidence is limited. Further evidence is needed to assess the efficacy of these therapies in subgroups identified as being in need of psychological interventions, and to identify what type of therapy maybe most useful.

Poor adherence to antibiotic prescribing guidelines in acute otitis media--obstacles, implications, and possible solutions

Many countries now have guidelines on the clinical management of acute otitis media. In almost all, the public health goal of containing acquired resistance in bacteria through reduced antibiotic prescribing is the main aim and basis for recommendations. Despite some partial short-term successes, clinical activity databases and opinion surveys suggest that such restrictive guidelines are not followed closely, so this aim is not achieved. Radical new solutions are needed to tackle irrationalities in healthcare systems which set the short-term physician-patient relationship against long-term public health. Resolving this opposition will require comprehensive policy appraisal and co-ordinated actions at many levels, not just dissemination of evidence and promotion of guidelines. The inappropriate clinical rationales that underpin non-compliance with guidelines can be questioned by evidence, but also need specific developments promoting alternative solutions, within a framework of whole-system thinking. Promising developments would be (a) physician training modules on age-appropriate analgesia and on detection plus referral of rare complications like mastoiditis, and (b) vaccination against the most common and serious bacterial pathogens.

Conceptualising health literacy from the patient perspective

OBJECTIVE

A person's health literacy, i.e., their ability to seek, understand and use health information, is a critical determinant of whether they are able to actively participate in their healthcare. The objective of this study was to conceptualise health literacy from the patient perspective.

METHODS

Using comprehensive qualitative methods 48 individuals were interviewed across three distinct groups in Australia: those with a chronic condition, the general community and individuals who had recently presented to a metropolitan public hospital emergency department. Purposeful sampling was employed to ensure a range of experiences was captured.

RESULTS

Seven key abilities were identified: knowing when to seek health information; knowing where to seek health information; verbal communication skills; assertiveness; literacy skills; capacity to process and retain information; application skills.

CONCLUSION

This study identifies key abilities patients identified as critical to seek, understand and utilise information in the healthcare setting. These abilities are not reflected in existing measures for health literacy. Future measures of health literacy could consider incorporating abilities identified in this study and may provide guidance in developing health interventions to assist patients to participate effectively in their health.

PRACTICE IMPLICATIONS

More comprehensive measures to assess patient's health literacy are needed.

Delivering the WISE (Whole Systems Informing Self-Management Engagement) training package in primary care: learning from formative evaluation

Background

The WISE (Whole System Informing Self-management Engagement) approach encompasses creating, finding, and implementing appropriate self-care support for people with long-term conditions. A training package for primary care to introduce the approach was developed and underwent formative evaluation. This entailed exploring the acceptability of the WISE approach and its effectiveness in changing communication within consultations. The study aimed to refine the patient, practitioner, and patient level components of the WISE approach and translate the principles of WISE into an operational intervention deliverable through National Health Service training methods.

Methods

Normalisation Process Theory provided a framework for development of the intervention. Practices were recruited from an inner city Primary Care Trust in NW England. All practice staff were expected to attend two afternoon training sessions. The training sessions were observed by members of the training team. Post-training audio recordings of consultations from each general practitioner and nurse in the practices were transcribed and read to provide a narrative overview of the incorporation of WISE skills and tools into consultations. Face-to-face semi-structured interviews were conducted with staff post-training.

Results

Two practices out of 14 deemed eligible agreed to take part. Each practice attended two sessions, although a third session on consultation skills training was needed for one practice. Fifty-four post-training consultations were recorded from 15 clinicians. Two members of staff were interviewed at each practice. Significant elements of the training form and methods of delivery fitted contemporary practice. There were logistical problems in getting a whole practice to attend both sessions, and administrative staff founds some sections irrelevant. Clinicians reported problems incorporating some of the tools developed for WISE, and this was confirmed in the overview of consultations, with limited overt use of WISE tools and missed opportunities to address patients' self-management needs.

Conclusions

The formative evaluation approach and attention to normalisation process theory allowed the training team to make adjustments to content and delivery and ensure appropriate staff attended each session. The content of the course was simplified and focussed more clearly on operationalising the WISE approach. The patient arm of the approach was strengthened by raising expectations of a change in approach to self-care support by their practice.

Active listening in medical consultations: development of the Active Listening Observation Scale (ALOS-global)

OBJECTIVE

Active listening is a prerequisite for a successful healthcare encounter, bearing potential therapeutic value especially in clinical situations that require no specific medical intervention. Although generally acknowledged as such, active listening has not been studied in depth. This paper describes the development of the Active Listening Observation Scale (ALOS-global), an observation instrument measuring active listening and its validation in a sample of general practice consultations for minor ailments.

METHODS

Five hundred and twenty-four videotaped general practice consultations involving minor ailments were observed with the ALOS-global. Hypotheses were tested to determine validity, incorporating patients' perception of GPs' affective performance, GPs' verbal attention, patients' self-reported anxiety level and gender differences.

RESULTS

The final 7-item ALOS-global had acceptable inter- and intra-observer agreement. Factor analysis revealed one homogeneous dimension. The scalescore was positively related to verbal attention measured by RIAS, to patients' perception of GPs' performance and to their pre-visit anxiety level. Female GPs received higher active listening scores.

CONCLUSION

The results of this study are promising concerning the psychometric properties of the ALOS-global. More research is needed to confirm these preliminary findings.

PRACTICE IMPLICATIONS

After establishing how active listening differentiates between health professionals, the ALOS-global may become a valuable tool in feedback and training aimed at increasing listening skills.

Medication beliefs among patients with inflammatory bowel disease who report low quality of life: a qualitative study

Background

Non-adherence to drug therapy is common in Inflammatory Bowel Disease (IBD). Patients' beliefs about treatment have an important influence on adherence. An in-depth understanding of this area is, therefore, important for patient-centred care. The aim of the study was to assess patients' perspectives and beliefs about their medication and to determine how this relates to medicine taking and other related health behaviour as part of a larger qualitative study on health care related behaviour in patients with IBD.

Methods

Individual semi-structured interviews and focus groups. An iterative approach following principles of grounded theory was applied to data collection and analysis.

Results

Main emerging themes were: balance of perceived necessity versus concerns, perceived impact of symptoms and willingness to self-manage medication. There was a clear distinction made between steroids and other preparations. Concerns included the fear of both short and long-term side-effects (mainly steroids), uncertainties about drug interactions and development of long-term immunity. Adapting to and accepting medication use was linked to acceptance of IBD.

Conclusion

A concordant approach including flexible and pro-active support as well as accurate information is important in assisting patients with IBD to self-manage their medication effectively. Health professionals should be aware that attitudes to medicine taking and other related behaviours may be medicine specific and change over time.