Delineating the concept of self-management in chronic conditions: a concept analysis

Indocyanine Green Lymphography in Conservative Lymphedema Management: An Exploration of the Impact on Lymphedema Therapy Plans

OBJECTIVES

Information from indocyanine green (ICG) lymphography (ICG-L) can be used to guide an individual's lymphedema therapy plan. However, the mechanisms for this clinical translation are not well described. This study proposes a novel clinical decision support tool for translating ICG-L findings into individualized lymphedema therapy plans and describes subsequent changes in plan features of manual lymphatic drainage and compression.

METHODS

This before-after study compared specific therapy plan features before and after ICG-L for participants with limb lymphedema. After participants had undergone ICG-L, the individuals' ICG-L findings were translated into an ICG-L-informed therapy plan using a novel clinical decision support tool, ICG-TRANSLATE. A predetermined coding tree was used to identify changes in elements of manual lymphatic drainage and compression therapy plan recommendations.

RESULTS

Following the application of the ICG-TRANSLATE decision support tool, 100% (n = 25) of participants had a change in manual lymphatic drainage recommendations, including elements of terminal nodes, pathway, and technique. Additionally, 88% (n = 22) had a change in compression recommendations, which was most commonly a change in garment limb coverage.

CONCLUSIONS

ICG-L findings informed changes to traditional lymphedema therapy plan modalities of manual lymphatic drainage and compression. Whether this change to individual therapy recommendations translates into improved lymphedema outcomes requires further investigation.

IMPLICATIONS FOR NURSING PRACTICE

A clinical decision support tool may assist practitioners in translating ICG-L findings into individualized lymphedema therapy plans for people with lymphedema. Further exploration is necessary to determine if the management changes derived through ICG-L-informed therapy plans improve outcomes for people with lymphedema.

Implementing primary care concepts in higher education: a mixed method study in Flanders (Belgium)

BACKGROUND

The policy shift towards person-centred integrated primary care systems drives interest in primary care across higher education programs. In Flanders, the Primary Care Academy (PCA) is established to support this policy shift. The PCA focusses on the concepts of goal-oriented care, self-management, and interprofessional collaboration to support the shift towards integrated care and to integrate them in curricula in order to strengthen and develop a futureproof health system. Therefore, the aim of this study is if and how lecturers implement these concepts in the curriculum and what they need for a successful implementation.

METHODS

A sequential explanatory mixed method study design was used combining quantitative and qualitative data. A cross-sectional survey was sent to 276 Flemish health care education programs. Qualitative data was collected through focus groups in which lecturers participated.

RESULTS

The results showed that 89% of the higher education programs address goal-oriented care, self-management, and interprofessional collaboration with regard to primary care. Further analysis of courses within the programs reveals that the concept of self-management is covered in only 58%, while goal-oriented care (73%) and interprofessional collaboration (80%) appear more frequently. The level at which the themes are addressed in the courses are often limited to an introduction. The focus groups revealed that primary care is present in education programs, however lecturers are limited aware where primary care is integrated in their own and other programs. Lectures expressed a need for more collaboration between research, education and practice in developing educational content. When new concepts are introduced, lecturers want them to be translated into educational content, learning objectives and competencies.

CONCLUSIONS

The study shows that the concepts of goal-oriented care, self-management, and interprofessional collaboration are present in higher education programs to a varying degree. Lecturers are eager to implement these new primary concepts but they lack collaboration between education, research and practice. Lecturers indicate the need for a competence profile for primary care professionals as common framework to guide curriculum development.

Psychometric property of the Japanese version of self-efficacy for managing chronic disease scale in individuals with chronic diseases

Background

Although accurately assessing self-efficacy for self-management is crucial in chronic illness care, important, there is a scarcity of validated psychometric properties in Japan. This study aimed to validate a Japanese version of the Self-Efficacy for Managing Chronic Disease (SEMCD-J) scale.

Methods

Individuals with self-reported chronic diseases, symptoms, or conditions for over one year were recruited online. The SEMCD-J was translated through translation, back translation, and cognitive interviews with 15 participants. Patient Health Questionnaire-9 (PHQ-9) and Center for Disease Control and Prevention Healthy Days Core Module-4 (CDC-HRQOL-4) were used to evaluate the scale's validity. Test-retest reliability was assessed two weeks after the initial measurement.

Results

Of 500 participants, 494 were analyzed and 149 were analyzed for test-retest reliability. The mean item score was 5.54 ± 2.12. Confirmatory factor analysis (CFA) with a 1-factor model showed good fit (CFI = 0.94, TLI = 0.90, RMSEA = 0.23, SRMR = 0.04). CFA with a 2-factor model showed better fit (CFI = 0.99, TLI = 0.98, RMSEA = 0.11, SRMR = 0.01). Cronbach's α of the total, Factor 1, and Factor 2 were 0.97, 0.97, and 0.92. Their item-total correlations ranged from 0.88 to 0.95, 0.93 to 0.97, and 0.92 to 0.93, respectively. Their interclass correlation coefficients were 0.63, 0.58, and 0.66, respectively. The minimum detectable change was 3.56. Pearson's correlation analyses indicated that SEMCD-J was significantly associated with PHQ-9 (r = -0.57, p < 0.001) and the dimensions of CDC-HRQOL-4, namely, the degree of general health (r = -0.55, p < 0.001), physically unhealthy days (r = -0.46, p < 0.001), mentally unhealthy days (r = -0.48, p < 0.001), and functionally unhealthy days (r = -0.50, p = < 0.001).

Conclusion

The validity and reliability of the SEMCD-J were indicated to be acceptable.

Self-Management Among People Living With Endometriosis: A Qualitative Study

Self-management is pivotal for effective chronic disease management. However, this concept remains unexplored among people with endometriosis, who often experience chronic pain and significant impacts on their quality of life. This research explored participants' experience managing endometriosis and their understanding and integration of self-management into their lives. Inductive reflexive thematic analysis was used to analyze transcripts from 15 semi-structured interviews among people with endometriosis. The themes captured many aspects of self-management and included (1) perceptions of control, (2) engaging in self-management behaviors, (3) active decision-makers versus recipients of care, (4) establishing a patient-provider partnership, and (5) support is vital. The extent to which participants engaged in self-management varied, however, is consistent with self-management literature for other chronic conditions suggesting that there is a role for self-management among people living with endometriosis.

Effect of self-efficacy on self-management ability for colorectal cancer patients with stoma: a path analysis

PURPOSE

Colorectal cancer threatens health and causes heavy social burdens. The purpose of this study is to analyze the pathway model for the effect of self-efficacy on self-management ability in colorectal cancer patients with stoma.

METHODS

A cross-sectional study was conducted from December 2022 to April 2023, with a convenience sample of 422 colorectal cancer patients with stoma at six tertiary grade A hospitals in Shandong Province, China. Statistical analysis was undertaken using SPSS 26.0 and Amos 24.0 software. A pathway model based on individual and family self-management theories was developed and analyzed by collecting data through onsite survey and online survey.

RESULTS

Chinese colorectal cancer patient's self-management ability score is 105.19 (17.19), which shows medium-level self-management ability. The self-efficacy of colorectal cancer patients with a stoma is influenced by social support, which ultimately leads to changes in their self-management ability.

CONCLUSION

The findings may help healthcare professionals to identify the factors that influence self-management skills of colorectal cancer patients with stoma and provide a basis for developing interventions.

The first AI-based Chatbot to promote HIV self-management: A mixed methods usability study

BACKGROUND

We developed MARVIN, an artificial intelligence (AI)-based chatbot that provides 24/7 expert-validated information on self-management-related topics for people with HIV. This study assessed (1) the feasibility of using MARVIN, (2) its usability and acceptability, and (3) four usability subconstructs (perceived ease of use, perceived usefulness, attitude towards use, and behavioural intention to use).

METHODS

In a mixed-methods study conducted at the McGill University Health Centre, enrolled participants were asked to have 20 conversations within 3 weeks with MARVIN on predetermined topics and to complete a usability questionnaire. Feasibility, usability, acceptability, and usability subconstructs were examined against predetermined success thresholds. Qualitatively, randomly selected participants were invited to semi-structured focus groups/interviews to discuss their experiences with MARVIN. Barriers and facilitators were identified according to the four usability subconstructs.

RESULTS

From March 2021 to April 2022, 28 participants were surveyed after a 3-week testing period, and nine were interviewed. Study retention was 70% (28/40). Mean usability exceeded the threshold (69.9/68), whereas mean acceptability was very close to target (23.8/24). Ratings of attitude towards MARVIN's use were positive (+14%), with the remaining subconstructs exceeding the target (5/7). Facilitators included MARVIN's reliable and useful real-time information support, its easy accessibility, provision of convivial conversations, confidentiality, and perception as being emotionally safe. However, MARVIN's limited comprehension and the use of Facebook as an implementation platform were identified as barriers, along with the need for more conversation topics and new features (e.g., memorization).

CONCLUSIONS

The study demonstrated MARVIN's global usability. Our findings show its potential for HIV self-management and provide direction for further development.

Gamification in eHealth for Chronic Disease Self-Management in Youth: A Systematic Review

This systematic review primarily aims to provide a summary of the game mechanics implemented in eHealth tools supporting young people's self-management of their chronic diseases. This review secondarily investigates the rationale for implementing game mechanics and the effects of these tools. A systematic search was conducted in Embase, Medline, PsycINFO, and Web of Science, from inception until August 30, 2022. Studies were eligible if focus was on the utilization of gamification in eHealth self-management interventions for young people (age = 10-25 years) with chronic diseases. Primary quantitative, qualitative, and mixed-method studies written in English were included. We identified 34 eHealth tools, of which 20 (59%) were gamified tools and 14 (41%) were serious games. We found that 55 unique game mechanics were implemented. The most commonly used were rewards (50%), score (44%), creative control (41%), and social interaction (32%). In comparison with gamified tools, the number and diversity of game mechanics applied were higher in serious games. For most tools (85%), a general rationale was provided for utilizing gamification, which often was to promote engaging experiences. A rationale for using specific game mechanics was less commonly provided (only for 45% of the game mechanics). The limited availability of experimental research precludes to test the effectiveness of using gamification in eHealth to support self-management in young people with chronic diseases. In this study, we highlight the importance of reporting the rationale for utilizing specific game mechanics in eHealth tools to ensure a proper alignment with evidence-based practice and the need of conducting experimental research. PROSPERO: CRD42021293037.

Living well: Evidence-based self-management of chronic diseases for community-dwelling older adults

ABSTRACT

Self-management of chronic diseases, which increase with age, is vital. This article discusses the benefits of chronic disease self-management and how nurses and other healthcare professionals can provide supportive care. It also presents an evidence-based intervention project that promoted chronic disease self-management among community-dwelling older adults.

Self-management support program delivered in the sub-acute phase after traumatic injury-study protocol for a pragmatic randomized controlled trial

BACKGROUND

Traumatic injuries, defined as physical injuries with sudden onset, are a major cause of distress and disability, with far-reaching societal consequences. A significant proportion of trauma survivors report persistent symptoms and difficulties after the injury, and studies show unmet health care needs. Self-management programs delivered in the sub-acute phase after traumatic injuries are scarcely evaluated. The aim of the present study is to evaluate the effectiveness of a self-management program (SEMPO), delivered 3-4 months after moderate-to-severe traumatic injury.

METHODS

This study protocol describes a pragmatic randomized controlled trial (RCT) with two classical RCT arms (intervention and control) and an explorative self-selection arm. 220 patients will be recruited from Oslo University Hospital, the largest Trauma Referral Centre in Norway. Patients aged 18-72 years residing in the south-east region of Norway, admitted to the Trauma Centre directly or within 72 h after having sustained a moderate to severe traumatic injury, defined as a New Injury Severity Score > 9, having at least 2 days hospital stay, and reporting injury-related symptoms and impairment at discharge from the acute hospital will be included. Patients will be randomly assigned to either a classical RCT randomization arm (intervention or control arm) or to a self-selection arm. In the randomization arm, participants are further randomized into intervention or control group. Participants allocated to the self-selection arm will choose to partake either in the intervention or control arm. The primary outcome is the level of self-efficacy in trauma coping assessed 6 months after completion of the intervention, with a similar time point for the control group. Secondary outcomes include symptom burden, physical functioning and disability, return to work and health care utilization, health-related quality of life, and communication competency. In addition, patients will be asked to nominate one domain-related measurement as their preferred outcome measure.

DISCUSSION

This RCT will determine the effect of a self-management program tailored to patients with moderate to severe physical trauma, and the self-selection arm incorporates the potential influence of patient treatment preferences on intervention results. If the intervention proves effective, cost-effectiveness and cost-utility analyses will be performed and thereby provide important information for clinicians and policy makers.

TRIAL REGISTRATION

The study is registered in Clinical Trials with the identifier: NCT06305819. Registered on March 05, 2004.

Home self-testing of complete blood counts in patients with breast cancer during chemotherapy: A proof-of-concept cohort study in e-oncology

BACKGROUND

Before administration of myelosuppressive chemotherapy, complete blood counts (CBC) collected at the hospital/nursing stations are evaluated to avoid severe bone marrow suppression. This maintains disease fixation which often reduces their quality of life. This mixed-method study examined at home self-testing of CBC, the test quality, and the effects on patients' mental well-being.

METHODS

Patients with breast cancer receiving chemotherapy were recruited and trained to perform capillary finger prick CBC testing at home using the HemoScreen Point-of-Care instrument and to upload the test results to the hospital's IT system subsequently. A venous reference CBC sample was taken and tested at the hospital on the day of self-testing. Semi-structured interviews with open-ended components were performed to investigate the user experience and the impact of self-testing on the patients' everyday lives.

RESULTS

Thirty-nine patients completed the self-testing education using the HemoScreen instrument. Eight patients withdrew, while the remaining 31 patients performed 161 home tests (2-11 tests per patient) over a 4-month period. The test results compared well with the venous reference CBCs except for platelet counts (correlation coefficient 0.26). Qualitative interviews with nine of the 31 patients emphasized that the patients were comfortable using the self-testing instrument and becoming an active partner in their own treatment.

INTERPRETATION

CBC self-testing at home produced clinically valid hemoglobin and white blood cell counts with the added benefit that the patients became active partners in their own treatment course, which was of great importance for the patients and increased their wellbeing.

Hotspots and Global Trends of Nursing Research on Mobile Applications in Nursing From 2012 to 2023: A Bibliometric Analysis

The rapid integration of mobile applications in healthcare has prompted an evolutionary change in nursing domain. This study aimed to systematically analyze the basic publication characteristics, research priorities, emerging trends, and thematic evolutions concerning mobile applications in nursing, providing an overview of the field's developmental trajectory and future directions. This was a descriptive bibliometric study. Data were collected on July 5, 2023, from the Web of Science database and analyzed by using the Bibliometrix package in R software. The search strategy yielded 417 documents authored by 1969 researchers, cited 12 595 references, and featured 1213 author keywords, spanning from 2012 to 2023. Research on mobile applications in nursing exhibited several key trends: (1) substantial collaboration among authors; (2) significant growth in the number of publications; (3) self-management was the most prominent hot topic; and (4) an evolution of research themes from general topics to a more specific focus on people-centered and problem-centered research. The corpus of literature pertaining to research on mobile applications within the nursing domain is anticipated to expand continually. Future research and practice in the nursing field are expected to benefit significantly from multidisciplinary collaboration and advancements in emerging technologies, including artificial intelligence.

Nurse-led web-based self-management program to improve patient activation and health outcomes in patients with chronic low back pain: an acceptability and feasibility pilot study

BACKGROUND

Patients with chronic low back (cLBP) pain report reduced physical function and ability to participate in social roles and are more likely to use opioid pain medications. While self-management interventions have been shown to support these patients, their effectiveness has been limited due to poor patient engagement. "Patient activation" encompasses the skills, knowledge, and motivation that a person has to manage their health. Supporting patient activation may improve the effectiveness of self-management for cLBP.

METHODS

In this single-masked pilot study of adults with cLBP, patients were randomized to receive either no intervention (control) or 6 weekly sessions of an evidence-based web-based self-management program (SMP) with or without health behavior change counseling (HBCC) using motivational interviewing. Participants were assessed at baseline and at 12 and 26 weeks using the Patient Activation Measure, Oswestry Disability Index and PROMIS physical function, social role participation, and pain interference. We assessed acceptability and feasibility based on recruitment, session attendance, and follow-up.

RESULTS

Of 187 individuals screened, 105 were eligible and 34 were randomized to control (n = 12), SMP (n = 4), or SMP + HBCC (n = 18). The population had 19 women, 22 patients married or living with significant other, 13 Black or African American patients, and 4 Hispanic or Latino patients. Participants had a mean (SD) Oswestry Disability Index score of 42 (12), moderate impairments in physical function (40 (6.6)) and social roles (45 (10)), and moderately severe pain interference (61 (6.7)). Of 22 participants receiving SMP sessions, 20 participated in at least 1, 15 participated in at least 3, and 7 participated in all 6 sessions. Loss to follow-up was 6 over the 26-week study. Participants in the SMP and SMP + HBCC groups had at least medium effect size improvements in Patient Activation Measures and small-to-medium effect size improvements in Oswestry Disability Index scores and physical function and large effect size improvement in social roles at 12 weeks. Improvements persisted in the SMP + HBCC group at 26 weeks.

CONCLUSIONS

A web-based SMP is acceptable and feasible in this population. Participants who received augmentation with HBCC had persistent improvements in health outcomes at 26 weeks.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier NCT06236529 (2/1/2024 - retrospectively registered).

LEVEL OF EVIDENCE: 3

Self-Management Using eHealth Technologies for Liver Transplant Recipients: Scoping Review

BACKGROUND

Liver transplantation has become increasingly common as a last-resort treatment for end-stage liver diseases and liver cancer, with continually improving success rates and long-term survival rates. Nevertheless, liver transplant recipients face lifelong challenges in self-management, including immunosuppressant therapy, lifestyle adjustments, and navigating complex health care systems. eHealth technologies hold the potential to aid and optimize self-management outcomes, but their adoption has been slow in this population due to the complexity of post-liver transplant management.

OBJECTIVE

This study aims to examine the use of eHealth technologies in supporting self-management for liver transplant recipients and identify their benefits and challenges to suggest areas for further research.

METHODS

Following the Arksey and O'Malley methodology for scoping reviews, we conducted a systematic search of 5 electronic databases: PubMed, CINAHL, Embase, PsycINFO, and Web of Science. We included studies that (1) examined or implemented eHealth-based self-management, (2) included liver transplant recipients aged ≥18 years, and (3) were published in a peer-reviewed journal. We excluded studies that (1) were case reports, conference abstracts, editorials, or letters; (2) did not focus on the posttransplantation phase; (3) did not focus on self-management; and (4) did not incorporate the concept of eHealth or used technology solely for data collection. The quality of the selected eHealth interventions was evaluated using (1) the Template for Intervention Description and Replication guidelines and checklist and (2) the 5 core self-management skills identified by Lorig and Holman.

RESULTS

Of 1461 articles, 15 (1.03%) studies were included in the final analysis. Our findings indicate that eHealth-based self-management strategies for adult liver transplant recipients primarily address lifestyle management, medication adherence, and remote monitoring, highlighting a notable gap in alcohol relapse interventions. The studies used diverse technologies, including mobile apps, videoconferencing, and telehealth platforms, but showed limited integration of decision-making or resource use skills essential for comprehensive self-management. The reviewed studies highlighted the potential of eHealth in enhancing individualized health care, but only a few included collaborative features such as 2-way communication or tailored goal setting. While adherence and feasibility were generally high in many interventions, their effectiveness varied due to diverse methodologies and outcome measures.

CONCLUSIONS

This scoping review maps the current literature on eHealth-based self-management support for liver transplant recipients, assessing its potential and challenges. Future studies should focus on developing predictive models and personalized eHealth interventions rooted in patient-generated data, incorporating digital human-to-human interactions to effectively address the complex needs of liver transplant recipients. This review emphasizes the need for future eHealth self-management research to address the digital divide, especially with the aging liver transplant recipient population, and ensure more inclusive studies across diverse ethnicities and regions.

Multidimensional Frailty, Quality of Life and Self-Management in Aging Hispanics Living With HIV

An observational cross-sectional study was conducted to examine multidimensional frailty and its potential impact on quality of life (QOL) in aging Hispanic people living with HIV (PLWH) and assess the extent to which HIV self-management moderates this association. The sample included 120 Hispanic PLWH aged 50 years and older (M = 59.11; SD = 7.04). The structural equation modeling analyses demonstrated that multidimensional frailty was significantly related to QOL in its two dimensions, physical and mental (p < .001). The relationship between multidimensional frailty and mental and physical QOL remained significant even after controlling for confounders (age and gender). The moderator analyses indicated no statistically significant moderator effect of HIV self-management on multidimensional frailty and mental or physical QOL. These study results have practical implications that highlight the need for early screening for frailty with a multidimensional focus. Age-appropriate and culturally tailored interventions to prevent or mitigate multidimensional frailty may improve QOL.

Development and impact of a tailored eHealth resource on fibromyalgia patient's self-management and self-efficacy: A mixed methods approach

Aim

To develop an eHealth resource to support fibromyalgia patients and explore it for usability and impact on their self-management and self-efficacy.

Background

Fibromyalgia is a complex, non-progressive chronic condition characterised by a bewildering array of symptoms for patients to self-manage. International guidelines recommend patients receive illness-specific information once diagnosed to promote self-management and improve health-related quality of life.

Design

A 3-phase mixed methods exploratory sequential design.

Methods

Qualitative interviews explored the information and self-management needs of fibromyalgia patients attending a large tertiary hospital in Dublin. Identified themes together with an extensive review of the literature of interventions proven to be impactful by patients with fibromyalgia were utilised in the design and development of the eHealth resource. The resource was tested for usability and impact using pre and post-intervention outcomes measures.

Results

Patient interviews highlighted a lack of easy accessible evidenced information to support self-management implicating the urgent need for a practical solution through development of a tailored eHealth resource. Six themes emerged for inclusion; illness knowledge, primary symptoms, treatment options, self-management strategies, practical support and reliable resources. Forty-five patients who tested the site for usability and impact demonstrated a statistically significant improvement in self-efficacy after 4 weeks access with a medium positive effect size. Patients with the most severe fibromyalgia impact scores pre-intervention demonstrated the most improvement after 4 weeks. Patients gave the resource a System Usability Score A rating, highly recommending it for fellow patients diagnosed with fibromyalgia.

Conclusions

The study demonstrated how the development of a novel eHealth resource positively impacted fibromyalgia patients' self-efficacy to cope with this debilitating condition.

Impact

This study suggests that access to eHealth can positively impact patients self-efficacy, has the potential to be a template for eHealth development in other chronic conditions, supporting advanced nurse practitioners working in chronic disease management.

"Standing alone": understanding the self-management of family caregivers of persons post-stroke at the time of acute care

PURPOSE

To support family caregivers of persons post-stroke adequately from the start and to develop self-management interventions, we aim to gain a better understanding of family caregivers experiences at the time of acute care and therefore achieve a better understanding of how they manage their new situation.

METHODS AND MATERIALS

We chose a qualitative descriptive methodology using individual semi-structured interviews with eleven family caregivers of persons post-stroke. We conducted interviews retrospectively, between 2 and 10 months post-stroke, and analysed transcripts using thematic analysis.

RESULTS

The themes (1) being in survival mode, (2) feeling supported by family and friends, (3) feeling left alone by the treatment team and (4) insisting on information emerged from the data.

CONCLUSION

During acute care, many self-management skills are required from family caregivers but are just starting to be developed. This development can first be observed as co-management with the social network and is often combined with shared decision-making. Information-sharing, foundational for developing self-management, is essential for family caregivers and should be supported proactively by health professionals from the beginning. Further, from the start, health professionals should raise awareness about role changes and imbalances of activities among family caregivers to prevent negative influences on their health.

Development and psychometric testing of the lymphedema self-management support scale for breast cancer survivors

Objective

Effective self-management support should be tailored to the individual. To provide personalized and targeted self-management support, a rigorous assessment tool is needed to screen the actual degree of lymphedema self-management support received by breast cancer survivors. This study aims to develop and psychometrically test the Lymphedema Self-Management Support Scale for Breast Cancer Survivors (LSMS-BCs).

Methods

This study involves two phases: scale development and psychometric testing. In the scale development phase, preliminary items and domains were identified through a qualitative meta-synthesis, a quantitative systematic review, and reference to previous similar scales. Expert consultation and pilot study were conducted to refine the scale and evaluate the content validity. The psychometric characteristics were tested with 447 participants using item analysis, exploratory factor analysis (EFA), confirmatory factor analysis (CFA), reliability assessments, as well as measurement invariance.

Results

A preliminary 21-item scale with four domains, basic management support, management support for limb volume reduction, role management support, and emotional management support, was constructed in the scale development phase and well supported by EFA and CFA. The scale-level content validity index was 0.983. Cronbach's α coefficient for overall scale and subscales ranged from 0.732 to 0.949. McDonald's ω ranged from 0.848 to 0.955. Excellent known-groups validity, concurrent validity, predictive validity, and measurement invariance were demonstrated.

Conclusions

The LSMS-BCs is psychometrically valid and reliable. It can serve as a valuable tool for assessing and understanding the lymphedema self-management support received by breast cancer survivors.

Knowledge, Skills, and Experience With Technology in Relation to Nutritional Intake and Physical Activity Among Older Adults at Risk of Falls: Semistructured Interview Study

BACKGROUND

More than one-third of older adults (aged ≥65 y) experience falls every year. The prevalent modifiable risk factors for falling are malnutrition and physical inactivity, among others. The involvement of older adults in the prevention of falls can decrease injuries, hospitalizations, and dependency on health care professionals. In this regard, eHealth can support older adults' self-management through more physical activity and adequate food intake. eHealth must be tailored to older adults' needs and preferences so that they can reap its full benefits. Therefore, it is necessary to gain insight into the knowledge, skills, and mindset of older adults living at home who are at risk of falls regarding eHealth.

OBJECTIVE

This qualitative study aims to explore older adults' use of everyday digital services and technology and how they acquire knowledge about and manage their nutritional intake and physical activity in relation to their health.

METHODS

Semistructured interviews were conducted with 15 older adults (n=9, 60% women; n=6, 40% men; age range 71-87 y) who had all experienced falls or were at risk of falling. These individuals were recruited from a geriatric outpatient clinic. The interviews were analyzed using deductive content analysis based on a modification of the Readiness and Enablement Index for Health Technology framework.

RESULTS

The qualitative data showed that the informants' social networks had a positive impact on their self-management, use of technology, and mindset toward nutritional intake and physical activity. Although the informants generally lived active lives, they all lacked knowledge about how their food intake influenced their physical health, including their risk of falling. Another finding was the large diversity in the use of technology among the informants, which was related to their mindset toward technology.

CONCLUSIONS

Older adults can use technology for everyday purposes, but some need additional introduction and support to be able to use it for managing their health. They also need to learn about the importance of proper nutritional intake and physical activity in preventing falls. Older adults need a more personalized introduction to technology, nutrition, and physical activity in their contact with health professionals.

The roles and experiences of adolescents with cystic fibrosis and their parents during transition: A qualitative interview study

PURPOSE

Inadequate participation of Adolescents and Young Adults (AYAs) and parents are well-established barriers of transition. Shifts in roles are mandatory with increasing responsibilities for AYAs and decreasing involvement of parents in care. This study explores the shifts in roles of AYAs and their parents and its association with the subjective experience of transition.

METHODS

We conducted in-depth semi-structured interviews with AYAs living with Cystic Fibrosis and parents. Participants were recruited through patient organizations via convenience sampling and questioned on which roles they assumed during transition. Three authors performed an interpretative phenomenological analysis, establishing separate code trees for AYAs and parents. Data saturation was achieved.

RESULTS

18 AYAs (age 21y±2.9) and 14 parents (age 50y±2.0) were included. We identified five common themes: (1) the reciprocal reliance between AYAs and parents, (2) the policies of physicians and hospitals, (3) the AYAs' changing appeal and need for support, (4) the identification of parents as co-patients, and (5) the enforced changes in the roles of parents. AYAs primarily addressed roles related to self-management, while parents discussed family functioning.

CONCLUSIONS

This study identified motives underlying the assumption of roles by AYAs and parents. Both AYAs and parents addressed similar themes, highlighting their mutual challenges and needs. In contrast to AYAs, parents' desired roles were undefined and a latent sense of responsibility was identified as an important motive. Healthcare providers should acknowledge parents' challenging position and communicate transparently about changing roles. Additionally, healthcare providers should recognize that imposing restrictive roles may result in parental resistance, but can also foster AYAs' skill development. Future research should examine the short- and long-term impact of role-management interventions in AYAs and their parents.

Feasibility of diabetes self-management coaching program for individuals with type 2 diabetes in the Ethiopian primary care setting: a protocol for a feasibility mixed-methods parallel-group randomized controlled trial

BACKGROUND

Diabetes mellitus is the third most prevalent chronic metabolic disorder and a significant contributor to disability and impaired quality of life globally. Diabetes self-management coaching is an emerging empowerment strategy for individuals with type 2 diabetes, enabling them to achieve their health and wellness goals. The current study aims to determine the feasibility of a diabetes self-management coaching program and its preliminary effectiveness on the clinical and psychosocial outcomes in the Ethiopian primary healthcare context.

METHODS

The study will employ a mixed-method feasibility randomized controlled trial design. Forty individuals with type 2 diabetes will be randomly allocated to treatment and control groups using block randomization. The primary feasibility outcomes include acceptability, eligibility, recruitment, and participant retention rates, which will be computed using descriptive analysis. The secondary outcomes are self-efficacy, self-care activity, quality of life, and glycated hemoglobin A1c. For normally distributed continuous variables, the mean difference within and between the groups will be determined by paired sample Student t-test and independent sample Student t-test, respectively. Non-parametric tests such as the Mann-Whitney U test, the Wilcoxon signed rank test, and the Friedman analysis of variance test will determine the median difference for variables that violated the normality assumption. A repeated measure analysis of variance will be considered to estimate the variance between the baseline, post-intervention, and post-follow-up measurements. A sample of 10 volunteers in the treatment group will participate in the qualitative interview to explore their experience with the diabetes self-management coaching program and overall feasibility. The study will follow a qualitative content analysis approach to analyze the qualitative data. Qualitative and quantitative findings will be integrated using a joint display technique.

DISCUSSION

Evidence reveals diabetes self-management coaching programs effectively improve HbA1c, self-efficacy, self-care activity, and quality of life. This study will determine the feasibility of a future large-scale randomized controlled trial on diabetes self-management coaching. The study will also provide evidence on the preliminary outcomes and contribute to improving the diabetes self-management experience and quality of life of individuals with type 2 diabetes.

TRIAL REGISTRATION

The trial was registered online at ClinicalTrials.gov on 12/04/2022 and received a unique registration number, NCT05336019, and the URL of the registry is https://beta.

CLINICALTRIALS

gov/study/NCT05336019 .

Balancing feeling 'prepared' without feeling 'devoured': A qualitative study of self-care from the perspective of self-empowered persons living with Parkinson's disease in Sweden

INTRODUCTION

Parkinson's Disease (PD) is a complex neurodegenerative disease resulting in a wide range of motor and nonmotor symptoms for which the treatment regimen is often complex. People with Parkinson's (PwP) spend time daily on self-care practices including self-tracking signs and symptoms or seeking disease-specific knowledge. Research suggests self-care interventions yield promising care and health outputs for PwP, yet most research focuses on the provider perspective rather than that of those conducting the self-care. This study explores the meaning of self-care, disease-specific knowledge, and self-tracking from the perspective of PwP in Sweden.

METHODS

Qualitative data from three data sets were analyzed and compared using qualitative content analysis: one focus group on self-care (n = 14), one free-text survey on disease-specific knowledge (n = 197) and one free-text survey on self-tracking (n = 33).

FINDINGS

The analysis resulted in three categories: illness-related tasks, internal resources and external resources. Illness-related tasks describe various tasks PwP carry out in self-care, including lifestyle choices, treatments, and self-tracking. Internal resources include personal knowledge/skills as well as mindsets which could facilitate or challenge completing these tasks. Finally, external resources include other PwP, literature, clinicians and other sources of disease-specific knowledge. Self-care was found to fluctuate between beneficial and burdensome depending on such resources.

CONCLUSIONS

In conclusion, self-care needs to be acknowledged and discussed more often in PD and other complex conditions. Future self-care interventions should consider self-tracking and disease-specific knowledge as well as internal and external resources in their design and implementation.

PATIENT OR PUBLIC CONTRIBUTION

A researcher with PD was actively involved in all phases of the research: study design, data collection and analysis, and preparing the manuscript.

Journey Through Healthcare of People With Complications of Type 2 Diabetes: A Qualitative Study of Lived Experiences

Background

Despite its overall good performance, the Belgium healthcare system scores less well in providing equal access to healthcare compared to other European countries. This increases the risk of people worse off to receive late diagnosis and to get complications of chronic diseases.

Methods

This study aims to achieve a deeper understanding of how people with complications of a chronic disease - diabetes type 2 - experience care in the Belgium health system through semi-structured interviews with extreme case study sampling of people with advanced diabetes, and inductive analysis.

Results

The results show that most respondents were diagnosed late in the course of their disease. There are variations in treatment and type of provider. People appreciate the personal and long-lasting contact with a medical doctor, while the contact with and role of paramedical providers was less recognized. Disease management has a significant impact on their financial budget and some respondents experienced barriers to obtain additional financial support.

Discussion

Non-medical costs are not reimbursed, presenting a high burden to people. Self-management is tedious and hampered by other worries that people may have, such as financial constraints and coping with important life events. To conclude this study highlighted the need to improve diabetes screening. We suggest to enhance the role of paramedical professionals, integrate a social care worker, reduce financial constraints, and increase health literacy through more patient-centered, goal-oriented care.

Classifying self-management clusters of patients with mild cognitive impairment associated with diabetes: A cross-sectional study

AIMS AND OBJECTIVES

This study aims to propose a self-management clusters classification method to determine the self-management ability of elderly patients with mild cognitive impairment (MCI) associated with diabetes mellitus (DM).

BACKGROUND

MCI associated with DM is a common chronic disease in old adults. Self-management affects the disease progression of patients to a large extent. However, the comorbidity and patients' self-management ability are heterogeneous.

DESIGN

A cross-sectional study based on cluster analysis is designed in this paper.

METHOD

The study included 235 participants. The diabetes self-management scale is used to evaluate the self-management ability of patients. SPSS 21.0 was used to analyse the data, including descriptive statistics, agglomerative hierarchical clustering with Ward's method before k-means clustering, k-means clustering analysis, analysis of variance and chi-square test.

RESULTS

Three clusters of self-management styles were classified as follows: Disease neglect type, life oriented type and medical dependence type. Among all participants, the percentages of the three clusters above are 9.78%, 32.77% and 57.45%, respectively. The difference between the six dimensions of each cluster is statistically significant.

CONCLUSION(S)

This study classified three groups of self-management styles, and each group has its own self-management characteristics. The characteristics of the three clusters may help to provide personalized self-management strategies and delay the disease progression of MCI associated with DM patients.

RELEVANCE TO CLINICAL PRACTICE

Typological methods can be used to discover the characteristics of patient clusters and provide personalized care to improve the efficiency of patient self-management to delay the progress of the disease.

PATIENT OR PUBLIC CONTRIBUTION

In our study, we invited patients and members of the public to participate in the research survey and conducted data collection.

Self-management support (SMS) in primary care practice: a qualitative focus group study of care professionals' experiences

BACKGROUND

To support self-management of chronically ill persons, innovative approaches of care practice are being developed. Unfortunately, many self-management supporting interventions struggle to achieve reliable and consistent improvements at various levels (patient, provider and healthcare system level). One possible strategy to facilitate translating theory into practice, is to consider the healthcare professionals' perspective prior to the development of new interventions. An exploration of their knowledge and opinion about barriers and facilitators is necessary before employing any self-management support (SMS) intervention. Therefore, our study aims to explore care professionals' perspectives about SMS within the Flemish primary care setting.

METHODS

This study used a qualitative study design to examine SMS in primary care setting. Five focus groups were conducted, grouped into three waves. Participants were healthcare professionals in Flanders representing different disciplines and settings. A maximum variation purposive sampling was used to recruit participants. For the data analysis, the framework of thematic networks by Attride-Stirling was applied.

RESULTS

A total of 34 healthcare professionals participated. Three global themes related to SMS were derived from the thematic analysis: (1) Characteristics, (2) Support strategies, (3) Barriers and facilitators. SMS was characterised as a collaboration-based and person-centred approach. A variety of supporting strategies were mentioned by the focus group participants. Most strategies consisted of informing and educating patients. Complementary to individual strategies, collaborative strategies were deemed necessary to support self-management. Regarding barriers and facilitators, different patient-related factors were identified. Additionally, competencies of healthcare providers and external factors seem to hinder the implementation of SMS in practice.

CONCLUSIONS

This focus group study highlights the importance of a collaborative, person-centred approach to SMS in the context of chronic diseases. Our findings point to the need for interventions that raise awareness and address barriers associated with SMS. Since generic SMS does not exist, the road to success is a growth process in which support must be adapted to the individual patient.

Self-Management Interventions for Facilitating Life Participation for Persons with Kidney Failure: A Systematic Review

BACKGROUND

For persons with kidney failure, life participation is a critically important outcome, strongly linked to quality of life and mortality. To support patients' self-management abilities, three domains are typically emphasized: medical management, emotional management, and management of everyday life ( i.e. , role management). Although role management is strongly linked to life participation, there is currently limited research on interventions designed to support it. We explored existing self-management interventions that aim to support everyday life functioning, rather than only medical management.

METHODS

In this systematic review and qualitative meta-synthesis, we searched MEDLINE, Embase, CINAHL, PsycINFO, Web of Science, and CENTRAL up to April 2022 for interventional studies involving self-management interventions designed, at least partly, to support management of everyday life. The guidelines by Sandelowski and Barosso were used to analyze and synthesize the results. A taxonomy of everyday self-management strategies was used to further explore intervention content. Study quality was assessed using the Cochrane Collaboration risk-of-bias tools. Evidence of effectiveness was summarized, and a meta-analysis of eligible outcomes was conducted.

RESULTS

Of 22,667 records, 53 studies were included in the meta-synthesis. Most self-management interventions focused on medical management. Included interventions involved strategies to support eight domains: Activities of daily living, Work and school life, Meaningful occupations, Leisure activities, Mobility and travel, Interpersonal relationships, Role functioning, and Social participation. Major interventions focused on providing education, skill training, counseling, and cognitive behavioral therapy. Evidence of effectiveness was reported across a wide range of patient-reported outcomes, including (health-related) quality of life, depression, and self-efficacy. Studies were geographically concentrated and were of moderate to low quality.

CONCLUSIONS

Despite its well-recognized importance, research on interventions to improve life participation mostly consisted of pilot and feasibility studies and studies of low quality. Interventions were reported heterogeneously, limiting comparability, and were restricted to specific regions and cultures, limiting generalizability.

Biopsychosocial rehabilitation in the working population with chronic low back pain: a concept analysis

OBJECTIVE

To identify the essential attributes of biopsychosocial rehabilitation for chronic low back pain in the working population.

DESIGN

A concept analysis was conducted according to the 8-step method of Walker and Avant. This framework provides a clear concept and theoretical and operational definitions.

METHODS

Five databases were searched, followed by a systematic screening. Subsequently, attributes, illustrative cases, antecedents, consequences and empirical referents were formulated.

RESULTS

Of the 3793 studies identified, 42 unique references were included. Eleven attributes were identified: therapeutic exercise, psychological support, education, personalization, self-management, participation, follow-up, practice standard, goal-setting, social support, and dietary advice. Subsequently, illustrative cases were described. Antecedents, such as motivation, preparedness and a multidisciplinary team, were found, together with consequences such as decreased pain, less sick-leave and increased function and work status. Finally, examples of empirical referents were given.

CONCLUSION

This study identified the attributes that are necessary to develop biopsychosocial rehabilitation intervention programmes for chronic low back pain. The defined concept of biopsychosocial rehabilitation for chronic low back pain may serve as a solid base to further develop and apply interventions. Future research should focus on the objectification of biopsychosocial rehabilitation and conceptualization regarding how personalization is done.

Mapping the Cardiometabolic Patient Experience and Self-Care Behaviors to Inform Design, Implementation, and Persistent Use of Digital Health Care Solutions: Mixed Methods Study

BACKGROUND

Cardiometabolic conditions including acute coronary syndrome (ACS) and type 2 diabetes (T2D) require comprehensive care and patient engagement in self-care behaviors, and the drivers of those behaviors at the individual and health system level are still poorly understood.

OBJECTIVE

We aim to gain insights into self-care behaviors of individuals with cardiometabolic conditions.

METHODS

A convenience sample of 98 adult patients with ACS and T2D was recruited in the United States, Germany, and Taiwan to participate in a mixed methods study using ethnographic methods. All participants completed 7-day web-based diaries tracking their level of engagement, and 48 completed 90-minute web-based semistructured interviews between February 4, 2021, and March 27, 2021, focusing on themes including moments of engagement. Qualitative analysis identified factors influencing self-care practices and a Patient Mind States Model prototype.

RESULTS

Patient reports indicate that many patients feel social pressure to adhere to treatment. Patients' experience can be understood within 5 categories defined in terms of their degree of engagement and adherence ("ignoring," "struggling," "juggling," "controlling," and "reframing").

CONCLUSIONS

For people living with ACS and T2D, the self-care journey is defined by patterns of patient experiences, which can identify areas that tailored digital health care interventions may play a meaningful role.

Energy Management Education in Persons with Long COVID-Related Fatigue: Insights from Focus Group Results on Occupational Therapy Approach

BACKGROUND

Long COVID is a growing condition among individuals, with fatigue being one of the main symptoms experienced. Energy Management Education (EME) is a structured occupational therapy group intervention that aims to reduce the impact of fatigue in daily life.

METHODS

This study utilized focus groups to explore the experiences of individuals with post-COVID-related fatigue who participated in the EME program. Six participants engaged in discussions about the program immediately after its completion and again two months later. Additionally, five occupational therapists shared their experiences.

RESULTS

Former participants reported implementing strategies learned in the program to manage their condition effectively. They emphasized the importance of understanding fatigue and found the support provided by the peer group valuable. Occupational therapists highlighted the unique challenges faced by individuals with post-COVID-related fatigue compared to other populations with similar fatigue symptoms. Furthermore, insights were obtained regarding the ways individuals live and cope with post-COVID-related fatigue.

CONCLUSION

EME participants were involved in a dynamic and complex occupational therapy process and were experiencing a slow change towards having more control over their daily routines. The study gathered valuable feedback and suggestions from participants and occupational therapists which can be used to optimize the EME program.

Grounded Theory Approach to Understand Self-Management of Opioid Recovery Through Pregnancy and Early Parenting

OBJECTIVE

To develop a theory to explain the processes women use to self-manage recovery from opioid use disorder during pregnancy, the postpartum period, and early parenting.

DESIGN

Constructivist grounded theory approach.

PARTICIPANTS

Women (N = 16) who gave birth during the past 12 months and used medication for opioid use disorder for recovery through pregnancy and the postpartum period.

METHODS

We recruited participants through seven medication-assisted treatment clinics in a mid-size Midwestern city and the surrounding suburbs and through online parenting and recovery community groups with national-based memberships. We conducted semistructured, individual audio interviews from November 2020 to July 2021. Interviews continued until we reached theoretical and meaning saturation. We used constant comparative methods during initial and intermediate coding.

RESULTS

Participants described a central process, Growing as a Healthy Dyad, that included six processes they used to self-manage recovery: Maintaining Vigilance, Performing Self-Care, Putting in the Work of Recovery, Advocating, Navigating Social Support, and Acquiring Skills and Knowledge. These processes were affected by personal and social contextual factors.

CONCLUSIONS

The grounded theory, Self-Management of Opioid Recovery Through Pregnancy and Early Parenting, can be used to explain the unique processes of self-management by women in opioid recovery and highlights the need for a strengths-based approach to caring for the maternal-infant dyad.

Navigating the COVID-19 pandemic: Experiences and self-management approaches adopted by people with interstitial lung disease

BACKGROUND

People with interstitial lung disease (ILD) were deemed more vulnerable to the SARS-CoV-2 virus and isolated as a means of reducing risk of infection. This study examined the impact of the pandemic on daily life, psychological wellbeing and access to healthcare and identified approaches undertaken to remain safe.

METHODS

Four specialist clinics in tertiary centres in Australia (Victoria: two sites; New South Wales: one site; Western Australia: one site) recruited patients with ILD during an 8-week period from March 2021. Semi-structured telephone interviews were conducted with transcripts analysed using principles of grounded theory.

RESULTS

Ninety participants were interviewed between April and December 2021. Participants were predominantly female, former smokers with an average age of 66 years. IPF and connective tissue-ILD being the most common subtypes. Five main themes were identified: vulnerability reduced social interaction and isolation, access to healthcare services and support, staying active, emotional and psychological impact. Self-management strategies included staying active both physically and mentally.

DISCUSSION

Self-management was key to managing the impact of the pandemic. In combination with advances in technology, implementation of strategies for monitoring wellbeing and support for self-management provides an opportunity to leverage the lessons learnt to ensure a more individualised model of care for people with ILD.

Role of community-based health clubs in promoting patients' health education for diabetes self-care management: an interventional qualitative study in a Ugandan urban setting

BACKGROUND

Self-care management support is a core component of the Chronic Care Model that emphasises the need for empowering and preparing patients to manage their healthcare. In diabetes mellitus (DM) management, health education towards self-care empowers patients to make day-to-day decisions on their own disease and live with a healthy lifestyle. Although several strategies have been undertaken to improve the management of DM in Uganda, little has been done to empower patients to manage their own health. Community-based health clubs have been suggested as a novel way of improving diabetes management especially in settings with uneven distribution of healthcare facilities and inaccessibility to healthcare services that limit patients' awareness of the disease and self-care management. This interventional study was aimed at exploring the role of community-based health clubs in promoting patients' health education for diabetes self-care management.

METHODS

A cross-sectional qualitative study was conducted among 20 participants using focus group discussions with each having six to eight members. Only patients with diabetes who seek routine diabetes healthcare services at Wakiso Health Centre IV and had participated in the 8-week community-based health clubs' health education sessions were recruited for the study. The audio-recordings were transcribed verbatim and translated into English; thematic data analysis was conducted to generate codes and themes. Similar codes were merged and a group consensus was reached on coding discrepancies.

RESULTS

Three major themes on the role of health clubs in promoting patients' health education were merged from the study. These include promoting sharing of experiences among patients, improving awareness of healthy self-care practices and offering sufficient patient-health worker interaction time.

CONCLUSIONS

This is the first publication reporting on the role of community-based health clubs in promoting patients' health education towards diabetes self-care management in Uganda. The ability to share experiences among patients, improve patients' awareness on healthy living practices and the increased health worker-patient interaction time contribute heavily to the capacity-building for self-care among patients.

Self-Management Analysis in Chronic Conditions (SMACC) checklist: an international consensus-based tool to develop, compare and evaluate self-management support programmes

OBJECTIVES

The Self-Management Analysis in Chronic Conditions (SMACC) checklist was developed as a guidance tool to support the development, comparison and evaluation of self-management support programmes for persons with a chronic condition. The checklist was based on a previously performed concept analysis of self-management. The aim of this study was to validate its content using an international Delphi study and to deliver a final version.

DESIGN

A two-round Delphi study was conducted between October 2022 and January 2023. Using the researchers' networks, professionals with research or clinical expertise in self-management support and chronic conditions were recruited via online purposive snowball sampling. Participants were asked to score each item of the checklist (16 items total) on 3 content validity indicators: (1) clarity and comprehensibility, (2) relevance and importance and (3) degree of alignment with the overall goal of the checklist to promote adequate and comprehensive self-management support programmes. A consensus threshold of 75% agreement was used. The participants were also asked general questions about the checklist as a whole and were asked to provide feedback considering its refinement.

RESULTS

Fifty-four professionals with an average 14.5 years of experience participated in round 1, 48 with an average 12.5 years of experience participated in round 2. The majority of professionals were from Western Europe. For the majority of items consensus was reached after round 1. In round 2, 3 of the 4 remaining items reached consensus, 1 last item was retained based on highly recurring feedback.

CONCLUSIONS

The SMACC checklist was considered a valid and comprehensive tool to aid the development, evaluation and comparison of self-management support programmes. It was acknowledged as a useful instrument to supplement existing frameworks and was seen as feasible to implement in both research and clinical settings. Further validation in the field, with input from patients and peer experts, will be valuable.

Instruments for measuring self-management and self-care in geriatric patients - a scoping review

Introduction

With demographic changes, prioritizing effective care for geriatric patients to maintain functionality, independence, and quality of life is crucial. Well-developed self-management or self-care abilities, which can be maintained and improved through interventions, are of the utmost importance. To implement these interventions tailored and effectively, a thorough assessment of the individual's self-management and self-care abilities is required.

Objective

This scoping review aimed to identify self-management and self-care instruments suitable for geriatric patients, their underlying theories and definitions of self-management and self-care, and their similarities and differences in item content.

Methods

A systematic search of the PubMed and CINAHL databases was conducted to identify retrievable full-text articles published in English in the medical and nursing fields since the 1970s, which were validated on a sample with an average age of at least 70 years, used generic rather than disease-specific items, and addressed the broad range of self-management and self-care abilities.

Results

Of the 20 included articles, six instruments were identified that were based on different theories and offered varying definitions of self-management or self-care. Despite these differences, all emphasize empowered individuals taking an active role in their care. Most address actual behavior and abilities referring to lifestyle factors and (anticipated) adjustment behavior. However, crucial aspects, such as psychological factors, (instrumental) activities of daily living, and social environment are not fully addressed in these instruments, nor are the types of execution to which the items refer, such as wants, feelings, confidence, or attitudes.

Conclusion

To fully understand how geriatric patients implement daily self-management or self-care, a combination of instruments covering the important factors of self-management and self-care and addressing multiple types of item execution, such as behaviors, abilities, wants, or attitudes, is recommended. This review provides the first comprehensive overview of self-management and self-care instruments suitable for geriatric patients.

Psychometric properties of self-reported measures of self-management for chronic heart failure patients: a systematic review

AIMS

The aim of this study is to identify and assess the psychometric properties of patient-reported outcome measures (PROMs) of self-management for chronic heart failure (CHF) patients.

METHODS AND RESULTS

Eleven databases and two websites were searched from the inception to 1 June 2022. The COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) risk of bias checklist was used to assess the methodological quality. The COSMIN criteria were used to rate and summarize the psychometric properties of each PROM. The modified Grading of Recommendation Assessment, Development, and Evaluation was used to assess the certainty of evidence. In total, 43 studies reported on the psychometric properties of 11 PROMs. Structural validity and internal consistency were the parameters evaluated most frequently. Limited information was identified on hypotheses testing for construct validity, reliability, criterion validity, and responsiveness. No data regarding measurement error and cross-cultural validity/measurement invariance were achieved. High-quality evidence on psychometric properties was provided for Self-care of Heart Failure Index (SCHFI) v6.2, SCHFI v7.2, and European Heart Failure Self-care Behavior Scale 9-item (EHFScBS-9).

CONCLUSION

Based on the findings from the included studies, SCHFI v6.2, SCHFI v7.2, and EHFScBS-9 could be recommended to evaluate self-management for CHF patients. Further studies are necessary to evaluate more psychometric properties, such as measurement error, cross-cultural validity/measurement invariance, responsiveness, and criterion validity, and carefully evaluate the content validity.

REGISTRATION

PROSPERO CRD42022322290.

Analysis of factors that promote the participation of patients with chronic diseases in shared decision making on medication: a cross-sectional survey in Hubei Province, China

BACKGROUND

Shared decision making (SDM) improves the health status of patients with chronic diseases, especially in the condition of poly-medicated patients. This study aims to find the factors associated with participation of patients with chronic diseases in SDM on medication.

METHODS

A total of 1,196 patients with chronic diseases were selected in Hubei Province of China using cluster sampling methods. The random forest method was applied to rank the importance of independent variables by Mean Decrease Gini and out-of- bag (OOB) curve. Multivariate logistic regression was used to explore the independent variables' effect direction and relative hazard.

RESULTS

In this study, 5.18% of patients used patient-directed decision making (PDM, a decision-making model led by patients), 37.79% of patients used SDM (a collaborative decision-making model by patients and doctors), and 57.02% of patients used doctor-directed decision making (DDM, or paternalistic decision making, a decision-making model led by doctors). The random forest analysis demonstrated that the top 5 important factors were age, education, exercise, disease course, and medication knowledge. The OOB curve showed that the error rate reached minimum when top 5 variables in importance ranking composed an optimal variable combination. In multivariate logistic regression, we chose SDM as a reference group, and identified medication knowledge (OR = 2.737, 95%CI = 1.524 ~ 4.916) as the influencing factor between PDM and SDM. Meanwhile, the influencing factors between DDM and SDM were age (OR = 0.636, 95%CI = 0.439 ~ 0.921), education (OR = 1.536, 95%CI = 1.122 ~ 2.103), exercise (OR = 1.443, 95%CI = 1.109 ~ 1.877), disease course (OR = 0.750, 95%CI = 0.584 ~ 0.964), and medication knowledge (OR = 1.446, 95%CI = 1.120 ~ 1.867).

CONCLUSION

Most Chinese patients with chronic diseases used DDM during their medication decision-making, and some patients used PDM and SDM. The participation in SDM should be taken seriously among elderly patients with lower education levels. The SDM promotion should focus on transformation of patients' traditional perception and enhance their medication knowledge.

Diabetes self-management and social support during the COVID-19 pandemic: Perspectives of older adults living in Barbados

Purpose

Diabetes mellitus (diabetes) is a major health concern in Barbados. In 2013, the reported prevalence (18.7%) was double global levels, with diabetes accounting for 10.4% of total deaths in 2016. Barbados has a rapidly aging population and older adults living with diabetes are more at risk of developing complications. Poorly managed diabetes represents a high burden for individuals and society due to direct healthcare costs for treatment, and to indirect costs due to loss of productivity from disability and premature mortality. Good diabetes self-management promotes glycemic control. Self-management is enhanced by social support and challenged by external shocks. This study explored the role of social support in diabetes self-management among older people in Barbados during the COVID-19 pandemic.

Methods

Qualitative secondary thematic analysis of semi-structured individual telephone interviews with adults aged 65-84 years living with diabetes in Barbados during a partial COVID-19 lockdown period. Sampling was purposive, aided by gatekeepers who provide services to elderly people. Verbatim interview transcripts coded using an inductive method were subjected to thematic analysis by three qualitative researchers using NVIVO software.

Results

Four organising themes: "Balance", "Social Capital", "Resilience", and "Adaptations to COVID-19", informed the global theme "Adaptive Diabetes Self-Management Response", which captures resilience mechanisms of older adults who balanced facilitators including self-reliance and religious faith, and barriers such as perceived ageist discrimination in workplace policies designed to reduce COVID-19 exposure. Accordingly, elderly Barbadians living with diabetes were resilient, selectively incorporating available social support mechanisms to maintain self-management and overall well-being during the COVID-19 pandemic.

Conclusion

The emergent evidence for resilience among older persons in this setting is important for informing health system interventions to improve quality of life for PLWD. The views of the elderly should be explicitly considered in policies designed to enhance the self-management of chronic health conditions.

Development and assessment of a self-management intervention for urinary incontinence among patients with prostate cancer: protocol for a randomized feasibility study

BACKGROUND

Urinary incontinence is a common complication among patients with prostate cancer who have undergone radical prostatectomy. Guided by social cognitive theory and a framework for the recovery of health and well-being, we propose to develop and test a self-management intervention for patients with prostate cancer who experience urinary incontinence after undergoing radical prostatectomy.

METHODS

In this study, a self-management intervention for urinary incontinence (SMI-UI) is developed, comprising a mobile self-management application, a self-management handbook, and professional support. The feasibility, acceptability, and effectiveness of this intervention will be assessed. Patient data from the urology departments of two hospitals will be collected through convenience sampling by adopting an experimental, parallel, and random assignment research design. Patients experiencing urinary incontinence after undergoing radical prostatectomy will be invited to participate. After completing the pretest questionnaire, patients will be randomly divided into the experimental and attention control groups. The experimental group will undergo a 12-week SMI-UI, whereas the attention control group will receive an intervention consisting of a single dietetic education information package. The two groups will be tested 12 and 16 weeks after the pretest. In this study, we recorded the sociodemographic and clinical variables; recruitment rate; retention rate; satisfaction with the intervention; cancer-related self-efficacy; urination symptoms and disturbance; social participation and satisfaction; resilience; and demoralization.

TRIAL REGISTRATION

ClinicalTrials.gov ID: NCT05335967 [date of registration 04-04-2022].

Breast cancer survivors' experiences of barriers and facilitators to lymphedema self-management behaviors: a theory-based qualitative study

PURPOSE

Lifelong self-management plays a critical role in the prevention and management of lymphedema among breast cancer survivors. However, adherence to lymphedema self-management behaviors has remained suboptimal. Hence, we adopted a theory-informed method to elucidate the facilitators and barriers of lymphedema self-management for breast cancer survivors.

METHODS

In-depth semi-structured interviews were conducted between August and October 2022 in the lymphedema nursing clinic of a tertiary cancer hospital. The maximum variation sampling technique was used to ensure a diverse sample. The ITHBC (Integrated Theory of Health Behavior Change) framework was used to inform the interview outline and data analysis. Interview transcripts were coded line-by-line and mapped to domains in accordance with the ITHBC, using both deductive and inductive content analysis.

RESULTS

A total of 16 participants were interviewed (aged 35 to 67). Twenty-three themes (12 facilitators and 11 barriers) were mapped onto the three domains (knowledge and belief, social facilitation, and self-regulation skill and ability) of ITHBC as facilitators and barriers to lymphedema self-management. Three additional themes including limited treatment resources for lymphedema, inconvenience of lymphedema management, boredom and tedium of lymphedema self-management were categorized under the domain of other barriers.

CONCLUSIONS

Incorporating these findings into the ITHBC framework allows for a more systematic selection of theory-based strategies that may improve the design of effective lymphedema self-management interventions for breast cancer survivors.

IMPLICATIONS FOR CANCER SURVIVORS

Elucidating impact factors, especially facilitators and barriers, for lymphedema self-management adherence is essential for developing effective intervention programs to enhance breast cancer survivors' lymphedema self-management behaviors.

Self-management of geriatric syndromes - an observational study

BACKGROUND

Self-management of health refers to various actions and decisions that impact health outcomes. To improve health, independence, and quality of life (QoL) while reducing healthcare utilization and costs, patients' self-management abilities can be enhanced. However, disease-specific self-management interventions may not be applicable for older adults with multiple illnesses. Instead, focusing on prevalent geriatric syndromes, such as frailty, cognitive decline, pain, incontinence, or impaired mobility, may be more beneficial. To achieve this, a detailed understanding of the specific needs of the older population is crucial.

METHODS

Patients who are 70 years old or older will be chosen from four geriatric hospitals, which include both inpatient and outpatient facilities. At baseline, each participant will undergo a comprehensive geriatric evaluation and answer various questionnaires that focus on their current self-management abilities, self-efficacy, anxiety, aging perception, and QoL. Moreover, extensive data on the presence and impact of geriatric syndromes will be gathered. Three and six months after the initial evaluation, follow-up assessments will be conducted to identify any changes in participants' health, independence in daily activities, geriatric syndromes, cognition and mood, QoL, and self-management.

DISCUSSION

The present investigation aims to assess the factors that may facilitate or impede self-management in older adults afflicted with geriatric syndromes. Instead of concentrating on particular diseases, this study will analyze the association between self-management and geriatric syndromes. The information obtained will contribute to clinical expertise on the self-management habits of older adults and their effects on their well-being, autonomy, and overall QoL, as well as provide insights into geriatric syndromes. This valuable knowledge will be crucial for developing personalised programs to enhance self-management among older adults.

TRIAL REGISTRATION

German Trial Register (Deutsches Register Klinischer Studien) DRKS00031016.

"There are endless areas that they can use it for": speech-language pathologist perspectives of technology support for aphasia self-management

BACKGROUND

Aphasia is a debilitating acquired language disorder that often persists as a chronic condition. However, long-term support options are scarce, necessitating the consideration of alternative approaches. Chronic condition self-management approaches, which aim to build self-efficacy and empower people to take responsibility for the day-to-day management of their health condition, may benefit people with aphasia (PwA). Technology is widely used in chronic condition self-management and investigation is required to determine whether it could play a role in aphasia self-management.

OBJECTIVE

This study aimed to explore speech-language pathologist (SLP) perspectives on the potential use of technology to support aphasia self-management.

METHODS

A qualitative study was conducted with 15 SLPs using semi-structured interviews. Qualitative content analysis was applied to verbatim transcripts to identify codes, categories, and sub-themes which were developed into themes.

RESULTS

Three themes were identified: (1) technology supports holistic aphasia self-management by providing additional avenues for service delivery, overall communication, and learning opportunities thus enhancing independence and life participation; (2) SLP and communication partner (CP) assistance can support PwA to use technology for aphasia self-management; (3) considerations and potential barriers to PwA use of technology for aphasia self-management.

CONCLUSIONS

Technology can support aphasia self-management by expanding service delivery options, allowing for increased frequency and intensity of therapy practise, and facilitating communication and participation. Personal, professional, and organizational barriers should be addressed in the development of technology-enabled aphasia self-management approaches. SLPs and CPs can offer PwA assistance with technology but may themselves need additional support. Solutions for identified barriers should be considered, such as providing training in the use of technology and implementing aphasia-friendly modifications.IMPLICATIONS FOR REHABILITATIONSelf-management approaches are being explored in the area of aphasia management as a means of offering a holistic, sustainable intervention option that meets the long-term needs of people with aphasia.A range of technology-based resources are currently used in chronic condition self-management and in aphasia therapy, and there are many possibilities for the use of technology in aphasia self-management approaches.Speech-language pathologists identified that technology could facilitate aphasia self-management by expanding service delivery options (e.g., real-time and asynchronous telepractice), enabling increased frequency and intensity of therapy through providing a means of independent practise, offering options for augmentative alternative communication, and enhancing life participation by supporting social communication and daily tasks.,Speech-language pathologists are interested in using technology for aphasia self-management; however, barriers related to organizational policies, individual experience and confidence using technology, and technology itself must be addressed.

Self-management of patients with tracheostomy in the home setting: a scoping review

PURPOSE

The aim of this study was to create a model of patient-centered outcomes with respect to self-management tasks and skills of patients with a tracheostomy in their home setting.

METHODS

A scoping review using four search engines was undertaken (Medline, CINAHL, PsycINFO, Cochrane Library) to identify studies relevant to this issue and published since 2000. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses Statements for Scoping Reviews (PRISMA-ScR), the Joanna Briggs Institute (JBI) approach of conducting and reporting a scoping review, and the Participants, Concept, Context (PCC) scheme were employed. The following elements of the framework synthesis study data were screened, and presented based on the self-management model of Lorig and Holman.

RESULTS

34 publications from 17 countries met the criteria for study inclusion: 24 quantitative, 8 qualitative and 2 mixed methods designs. Regarding the dimensions of self-management, 28 articles reported on "managing the therapeutic regimen", 27 articles discussed "managing role and behavior changes", and 16 articles explored "managing emotions". A model of self-management of patients with tracheostomy was developed, which placed the patient in the center, since it is this individual who is completing the tasks and carrying out his or her skill sets.

CONCLUSION

This scoping review represents the first comprehensive overview and modeling of the complex self-management tasks and skills required of patients with tracheostomy in their home setting. The theoretical model can serve as a cornerstone for empirical intervention studies to better support this patient-centered outcome for this population in the future.

Sociocultural and patient-health care professional related factors influencing self-management of multiethnic patients with multimorbidities: A thematic synthesis

Self-management is critical for the general well-being and disease management of individuals with multimorbidities. A better understanding of sociocultural and patient-professional level factors affecting self-management can be valuable for designing individual and community-based strategies to promote optimal self-management. The purpose of this review was to explore sociocultural and patient-health care professional related factors affecting self-management among patients with multimorbidities. A metasynthesis was conducted. Literature was searched in PubMed, CINAHL, Scopus, Web of Science, and OVID databases. In total, 21 qualitative studies published from January 2010-March 2023 were critically appraised and reviewed. Thematic synthesis was used for analysis and eight descriptive and three analytical themes were generated. The analytical themes illustrated that personal and structural vulnerabilities, social and family struggles, and fragmented interpersonal relationships with health care professionals affect health care access, navigation, and self-management of individuals with multimorbidities. Engagement in self-management for individuals with multiple chronic conditions is hampered by under-resourced community and health care environments, structural vulnerabilities, familial and interpersonal conflicts, and disjointed relationships. There is a dire need to ensure optimal community resources to support individuals to address and navigate complexities associated with accessing care and effectively managing their illnesses.

Best practice guidelines for professional nurses to provide self-management support to adults with tuberculosis-human immunodeficiency virus coinfection: A scoping review

BACKGROUND

Adults with tuberculosis-human immunodeficiency virus coinfection require professional nurses' support to manage their illness, treatment and its effect on their daily lives. This scoping review maps recommendations in clinical or best practice guidelines that guide professional nurses to provide self-management support to adults with tuberculosis-human immunodeficiency virus coinfection in primary healthcare settings.

METHODS

We conducted a scoping review by searching for guidelines in six online databases, guideline clearing houses and search engines from 16th April 2022 to 25th May 2022. The title, abstract and full-text screening of guidelines were conducted independently and in duplicate by two reviewers based on predetermined eligibility criteria. The guidelines were critically appraised with the Appraisal of Guidelines Research and Evaluation (AGREE) II instrument. Relevant data regarding the characteristics of the guideline, recommendations and underlying evidence were extracted, analysed and reported.

RESULTS

The six guidelines on self-management support found were developed in four high-income countries. Five of the guidelines recorded <60% across all six domains of the AGREE II instrument. One high-quality guideline scored >60% in all AGREE II domains but was informed by outdated evidence produced between 1977 to 2010. Twenty-five practice, education and organisational/policy recommendations were extracted from the high-quality guideline. The guidelines did not report evidence-to-decision frameworks and the strength of the recommendations. The guidelines also lacked direct underlying evidence on the effectiveness and cost of self-management support. Lastly, the review found a paucity of contextual (equity, acceptability and feasibility) evidence on self-management support among adults with tuberculosis-human immunodeficiency virus in the guidelines.

CONCLUSION

There is a dearth of updated and relevant high-quality guidelines that guide healthcare professionals to provide self-management support to adults with tuberculosis-human immunodeficiency virus coinfection in primary healthcare settings. Systematic reviews of effectiveness, economic and contextual evidence related to self-management support interventions are required for guideline production.

The self-management instrument for breast cancer patients undergoing adjuvant therapy: Development and psychometric testing using the COSMIN methodology

Objective

This study aims to develop and test the self-management instrument for breast cancer patients undergoing adjuvant therapy (SMAT-B).

Methods

After a qualitative interview with 29 patients and two rounds of Delphi expert consultation with 15 experts, 49 items were initially generated. Before item reduction, another structured interview was conducted for content validity. Item analysis and exploratory factor analysis (n ​= ​377) were used for item reduction. After that, internal consistency, split-half reliability, test-retest reliability (n ​= ​30), measurement error, construct validity, and structural validity (n ​= ​342) were preliminarily evaluated using the COnsesus-based Standards for the selection of health Measurements INstruments guidelines.

Results

The final version of SMAT-B includes 7 dimensions and 31 items after item reduction. The testing results suggested that SMAT-B had good internal consistency (Total Cronbach's α ​= ​0.952), good split-half reliability (Spearman-Brown coefficient ​= ​0.904), good stability (Total intraclass correlation coefficient = ​0.797), acceptable measurement error (SEM ​= ​5.28), and acceptable construct validity (Standardized root mean square residual ​= ​0.055). The hypotheses of construct validity were all verified to a certain extent (r ​> ​0.20, P ​< ​0.01).

Conclusions

The 31-item SMAT-B, developed in interviews with patients and consultation with experts, demonstrated good psychometric properties and can be recommended for researchers and clinicians for further validity testing and evaluation of the self-management ability of breast cancer patients.

Trial registration

ChiCTR2100052868.

Characteristics of self-management support (SMS) interventions and their impact on Quality of Life (QoL) in adults with chronic diseases: An umbrella review of systematic reviews

OBJECTIVE

To provide an overview of types and characteristics of self-management support (SMS) interventions in adults with chronic disease and to assess the impact on the patient reported outcome Quality of Life (QoL).

METHODS

An umbrella review of systematic reviews was conducted. We searched PubMed, Embase, Web of Science, CINAHL and the Cochrane Library from January 2016 to November 2020 for reviews on SMS interventions for chronic diseases, assessing the impact on the patient reported outcome QoL. Quality assessment was based on the JBI Critical Appraisal Checklist for Systematic reviews and Research Syntheses tool.

RESULTS

28 reviews were included. The extensive literature review revealed a variety of SMS interventions. The most frequently cited target group for the interventions were individuals with diabetes. Interventions primarily took place in the home setting. Interventional components that were often incorporated were education, eHealth and mHealth technologies, and coaching techniques. Telephone communication was regularly reported as a type of intervention follow-up. The impact on QoL was mixed and no firm conclusions can be drawn. However, our review revealed a beneficial effect of education.

CONCLUSIONS AND PRACTICAL IMPLICATIONS

Interventions including educational components seem promising for supporting self-management and showed a beneficial effect on QoL. More research is needed to explore where, by whom and how interventions are ideally delivered.

Promoting Self-Management and Independent Living of Older Individuals with Chronic Diseases through Technology: A Study of Self-Reported Needs, Priorities, and Preferences

Background and Objectives: Older patients' needs are rarely examined beforehand, and thus, although technology-based tools can enhance self-management, acceptability rates are still low. This study aimed to examine and compare self-reported needs, priorities, and preferences of older patients with heart failure (HF), diabetes mellitus type II (DM2), and chronic obstructive pulmonary disease (COPD) toward technology use to enhance self-management. Materials and Methods: A convenience sample of 473 participants over 60 s (60.5% females), diagnosed with HF (n= 156), DM2 (n = 164), or COPD (n = 153) was recruited. They were administered a questionnaire about the usefulness of technology in general and in specific areas of disease management. Results: Most participants (84.7%) admitted that technology is needed for better disease management. This was equally recognized across the three groups both for the overall and specific areas of disease management (in order of priority: "Information", "Communication with Physicians and Caregivers", and "Quality of Life and Wellbeing"). Sociodemographic differences were found. Cell phones and PCs were the devices of preference. The four common features prioritized by all three groups were related to 'information about disease management' (i.e., monitoring symptoms, reminders for medication intake, management and prevention of complications), whereas the fifth one was related to 'communication with physicians and caregivers (i.e., in case of abnormal or critical signs). The top disease-specific feature was also monitoring systems (of respiratory rate or blood sugar or blood pressure, and oxygen), whereas other disease-specific features followed (i.e., maintaining normal weight for HF patients, adjusting insulin dose for DM2 patients, and training on breathing exercises for COPD patients). Conclusions: Older individuals in these three groups seem receptive to technology in disease management. mHealth tools, incorporating both common and disease-specific features and addressing different chronic patients, and also being personalized at the same time, could be cost-saving and useful adjuncts in routine clinical care to improve self-management.

Self-Care in Korean Immigrants with Chronic Diseases: A Concept Analysis

Chronic illnesses among Korean immigrants (KIs) in the United States have been rapidly increasing, yet the concept of chronic disease self-care in this group has not been delineated. The aim of this study was to review previous research on self-care among KIs with chronic diseases and describe the concept in cultural context. Using Rodgers' Evolutionary Method, a total of 24 articles were analyzed. The definition and conceptual model of self-care in KIs with chronic diseases were proposed. The antecedents included knowledge and health literacy; social and family support; resources; patient-health care provider partnership; and elimination of cultural misbeliefs and disclosure of the disease. The attributes of the concept were aging well with diseases; treatment adherence; control and restriction; the acculturation process; care built on traditional Korean gender roles; and maintenance of mental health. The consequences involved positive physiological outcomes; self-efficacy; quality of life; and reducing worry about becoming a burden to the family. While the studied concept encompassed universal characteristics of chronic disease self-care, distinctive cultural features emerged. The findings contribute to a better understanding of chronic illness self-care in this population and the development of culturally sensitive and practical self-care interventions for KIs with chronic diseases.

Identifying opportunities for hepatic encephalopathy self-management: A mixed methods systematic review and synthesis

Background

Hepatic encephalopathy (HE) in cirrhosis is an extremely challenging complication for patients and care partners. To identify potentially modifiable factors to enhance HE self-management strategies, we conducted a synthesis of quantitative and qualitative research about real-world HE behaviours, knowledge, and experiences.

Methods

Using the EPPI-Centre's mixed methods synthesis procedure, a systematic literature search in five databases was completed; methods of selected articles underwent critical appraisal followed by descriptive analysis and coded line-by-line of content. Through refutational translation, the findings from the quantitative and qualitative syntheses were juxtaposed to highlight congruencies, incongruencies, or gaps. These findings informed generation of cross-analytical themes that were transformed into action statements.

Results

The quantitative narrative review of synthesis (n = 17) generated four themes (patients had low awareness of HE and low treatment adherence rates, physicians had a non-uniform approach to non-pharmaceutical therapies). Meta-aggregation of qualitative data from six articles yielded three themes (patients and care partners had low levels of HE awareness, were unfamiliar with HE self-management, and were adherent to treatments). Comparison of findings revealed three congruencies, two gaps, and one incongruency. The combined synthesis yielded two self-management themes: universal patient-oriented cirrhosis HE education and ensuring each health care encounter systematically addresses HE to guarantee health care is continuously modified to meet their needs.

Conclusions

By drawing on elements of Bloom's Taxonomy and distributed knowledge networks, deliberate patient-oriented HE messaging at all health care encounters is greatly needed to improve health outcomes and reduce care burdens related to HE.