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

Self-management education for hypertension, diabetes, and dyslipidemia as major risk factors for cardiovascular disease: Insights from stakeholders' experiences and expectations

BACKGROUND

Cardiovascular disease (CVD) is a leading cause of premature death, with hypertension, diabetes, and dyslipidemia as major risk factors. Effective self-management (SM) is crucial for controlling these conditions and improving quality of life. This study examines stakeholders' experiences and expectations of SM education to enhance program development.

METHODS

This study employed a qualitative grounded theory approach to explore the perspectives of three stakeholder groups: 19 patients with hypertension, type 2 diabetes, and dyslipidemia, 11 primary healthcare providers, and five provincial health policymakers and managers. Data were collected via semi-structured patient interviews and focus group discussions(FGDs) with health professionals. Coding and analysis were conducted separately using Corbin and Strauss principles with ATLAS. ti version 9.0 software.

RESULTS

Most patients were women (68%) aged 50-60 years (37%), with education levels from illiterate to master's degree; 32% had completed primary school. Most were housewives (52%), and 12 had multiple chronic diseases. Healthcare providers included six community health workers and five primary care physicians, with average experience of 12 and 19 years, respectively. Health policymakers and managers averaged 25 years of experience. Patient interviews and FGDs resulted in 12 and 13 subthemes, respectively, with five subthemes common to both sources. These subthemes were grouped into broader main themes, including "effective content design," "effective presentation and delivery," "characteristics and conditions of involved parties," and "educational needs," collectively reflect the central concept of "effective self-management education".

CONCLUSION

Although the core concept and its main themes were evident and consistent across stakeholder groups, significant variations in subthemes from each stakeholder emerged. This underscores the importance of considering diverse viewpoints and highlights that, while overarching concepts may seem uniform, exploring the details of stakeholder perspectives is crucial for understanding their nuanced opinions. Effective education should integrate these insights, focusing on tailored communication, interactivity, and active monitoring.

Developing a Tailored eHealth Self-Management Intervention for Patients With Chronic Kidney Disease in China: Intervention Mapping Approach

BACKGROUND

Chronic kidney disease (CKD) is a major public health concern. Adequate self-management skills are vital to reduce CKD burden, optimize patient health outcomes, and control health care expenditures. Using eHealth to support CKD self-management has the potential to promote healthy behaviors and improve health outcomes of patients with CKD. However, knowledge of the implementation of such interventions in general, and in China specifically, is still limited.

OBJECTIVE

This study aims to develop a tailored eHealth self-management intervention for patients with CKD in China based on the Dutch Medical Dashboard (MD) eHealth self-management intervention.

METHODS

We used an intervention mapping approach. In phase 1, a systematic review and 2 qualitative studies were conducted to examine the needs, beliefs, and perceptions of patients with CKD and health care professionals regarding CKD self-management and eHealth interventions. Afterward, key factors gathered from the aforementioned studies were categorized following the 5 domains of the Consolidated Framework for Implementation Research (CFIR). In phase 2, we specified program outcomes, performance objectives, determinants, theory-based methods, and practical strategies. Knowledge obtained from previous results was combined to complement core components of the MD self-management intervention and adapt them for Chinese patients with CKD. Additionally, the CFIR-Expert Recommendations for Implementing Change Matching Tool was pragmatically used to generate a list of potential implementation strategies to address the key factors influencing the implementation of eHealth CKD self-management interventions, and implementation strategies were discussed and finalized with the intervention monitoring group.

RESULTS

An overview of the CFIR domains showed the essential factors influencing the implementation of eHealth CKD self-management interventions in Chinese settings, including "knowledge and beliefs" in the domain "individual characteristics," "quality and advantage of eHealth intervention" in the domain "intervention characteristics," "compatibility" in the domain "inner setting," and "cultural context" in the domain "outer setting." To ensure the effectiveness of the Dutch MD-based self-management intervention, we did not change the core self-management intervention components of MD that underlie its effectiveness, such as self-monitoring. We identified surface-level cultural adaptations involving customizing intervention content, messages, and approaches to the observable cultural characteristics of the local population to enhance the intervention's appeal, receptivity, and feasibility, such as providing video or voice call options to support interactions with health care professionals. Furthermore, the adapted modules such as Knowledge Center and My Self-Monitoring were developed in a mobile health app.

CONCLUSIONS

Our study resulted in the delivery of a culturally tailored, standardized eHealth self-management intervention for patients with CKD in China that has the potential to optimize patients' self-management skills and improve health status and quality of life. Moreover, our study's research approach and results can inform future research on the tailoring and translation of evidence-based, eHealth self-management interventions to various contexts.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04212923; https://classic.clinicaltrials.gov/ct2/show/NCT04212923.

Needs and Constraints for Cardiac Rehabilitation Among Patients with Coronary Heart Disease Within a Community-Based Setting: A Study Based on Focus Group Interviews

Objective

This study aimed to explore the needs and constraints to cardiac rehabilitation (CR) among patients diagnosed with coronary heart disease (CHD) in a community-based setting, and thereby facilitating the implementation of effective CR programs for this population.

Methods

Focus group interviews were used as the primary research methodology. A total of 11 community-dwelling individuals diagnosed with CHD were selected from a community hospital to participate in in-depth interviews, aiming to discern and analyze their requirements and constraints experienced concerning medical resources and healthcare agency. The textual data underwent examination using Colaizzi's method of descriptive data analysis.

Results

Deficits existed in the perceptions of patients with CHD within a community-based setting about their condition and CR, and in the social support for this disease. Patients expressed expectations for professional guidance during CR, gained an understanding about the beneficial effects of emotional stability on cognitive function. Patients expressed their thoughts and feelings regarding the diversity of physical exercise options. Two main themes and seven sub-themes were identified: (a) "Insufficient CR resources for patients": Lack of awareness about CHD; inadequate knowledge about secondary prevention/CR; insufficient support from family and friends. (b) "Patient CR initiative": Patient self-adjustment; expectation of professional rehabilitation guidance; stable emotions improving cognition; diverse attitudes and awareness of exercise.

Conclusion

For more effective CR, community-based medical teams should provide more comprehensive and individualized rehabilitation programs. They should focus on individual variations and preferences of patients, as well as enhance the autonomy of patients and improve their self-care ability through effective empowerment measures.

The impact of mobile health applications on the outcomes of patients with chronic kidney disease: a systematic review and meta-analysis

Chronic kidney disease is one of the main causes of mortality worldwide. It affects more than 800 million patients globally, accounting for approximately 10% of the general population. The significant burden of the disease prompts healthcare systems to implement adequate preventive and therapeutic measures. This systematic review and meta-analysis aimed to provide a concise summary of the findings published in the existing body of research about the influence that mobile health technology has on the outcomes of patients with the disease. A comprehensive systematic literature review was conducted from inception until March 1st, 2023. This systematic review and meta-analysis included all clinical trials that compared the efficacy of mobile app-based educational programs to that of more conventional educational treatment for the patients. Eleven papers were included in the current analysis, representing 759 CKD patients. 381 patients were randomly assigned to use the mobile apps, while 378 individuals were assigned to the control group. The mean systolic blood pressure was considerably lower in the mobile app group (MD -4.86; 95%-9.60, -0.13; p=0.04). Meanwhile, the mean level of satisfaction among patients who used the mobile app was considerably greater (MD 0.75; 95% CI 0.03, 1.46; p=0.04). Additionally, the mean self-management scores in the mobile app groups were significantly higher (SMD 0.534; 95% CI 0.201, 0.867; p=0.002). Mobile health applications are potentially valuable interventions for patients. This technology improved the self-management of the disease, reducing the mean levels of systolic blood pressure with a high degree of patient satisfaction.

Designing family-based interventions in kidney failure: The perspectives of the triad 'patients on haemodialysis/family caregivers/healthcare professionals

OBJECTIVES

This study explored the perspectives of people undergoing in-centre haemodialysis, family caregivers, and healthcare professionals about the development and implementation of family-based interventions in renal care settings.

DESIGN

A qualitative exploratory study was carried out combining purposive and snowball sampling techniques.

METHODS

Semi-structured interviews were submitted to thematic analysis.

RESULTS

A total of 82 individuals (27 adults on haemodialysis, 32 family caregivers, and 23 healthcare professionals) participated in this study. Five major themes were identified: (i) educational needs (improve disease and treatment-related knowledge; acquire better clarification on dialysis-related health behaviours); (ii) support needs (easier access to available community resources and professional psychological support; additional emotional and instrumental support from family members); (iii) expected barriers (concerns about participating in a group format; availability of the person on haemodialysis/family caregiver dyad; travel to the intervention site and associated costs); (iv) expected benefits (mutual emotional validation and support; improve family coping skills and involvement); and (v) preferences for content and format (interdisciplinary and moderated by health psychologists) and timing of the intervention (weekends and/or non-dialysis days).

CONCLUSIONS

Findings suggested that interventions focused on the family system in kidney failure need to follow an interdisciplinary approach, combining psychosocial support with an educational component. Future research is needed to minimize barriers to the conjoint participation of the person on haemodialysis/caregiver dyad. This study identifies important intervention goals to inform the design of family-based interventions for people receiving haemodialysis and their family caregivers.

Self-management from the perspective of people with stroke - An interview study

OBJECTIVE

Self-management support can improve quality of life, mood, self-efficacy, and physical function following a stroke. Knowledge of how people with stroke understand and experience self-management in different contexts is crucial to developing effective self-management support. This study explored how people with stroke understand and practice self-management during the post-acute phase.

METHOD

A descriptive study using qualitative content analysis to explore data from semistructured interviews RESULTS: Eighteen participants were interviewed. Most participants interpreted self-management as 'taking care of their business' and 'being independent". However, they encountered difficulties performing daily activities, for which they felt unprepared. Although interest in implementing self-management support increases, participants did not report receiving specific advice from healthcare professionals.

CONCLUSION

People continue to feel unprepared to manage everyday activities after hospital discharge and must largely work things out for themselves. There is an overlooked opportunity to start the process of self-management support earlier in the stroke pathway, with healthcare professionals and people with stroke combining their skills, ideas and expertise. This would enable confidence to self-management to flourish rather than decrease during the transition from hospital to home.

PRACTICAL IMPLICATIONS

Individual tailored self-management support could help people with stroke more successfully manage their daily lives post-stroke.

A rapid mixed-methods evaluation of remote home monitoring models during the COVID-19 pandemic in England

Background

Remote home monitoring services were developed and implemented for patients with COVID-19 during the pandemic. Patients monitored blood oxygen saturation and other readings (e.g. temperature) at home and were escalated as necessary.

Objective

To evaluate effectiveness, costs, implementation, and staff and patient experiences (including disparities and mode) of COVID-19 remote home monitoring services in England during the COVID-19 pandemic (waves 1 and 2).

Methods

A rapid mixed-methods evaluation, conducted in two phases. Phase 1 (July-August 2020) comprised a rapid systematic review, implementation and economic analysis study (in eight sites). Phase 2 (January-June 2021) comprised a large-scale, multisite, mixed-methods study of effectiveness, costs, implementation and patient/staff experience, using national data sets, surveys (28 sites) and interviews (17 sites).

Results

Phase 1 Findings from the review and empirical study indicated that these services have been implemented worldwide and vary substantially. Empirical findings highlighted that communication, appropriate information and multiple modes of monitoring facilitated implementation; barriers included unclear referral processes, workforce availability and lack of administrative support. Phase 2 We received surveys from 292 staff (39% response rate) and 1069 patients/carers (18% response rate). We conducted interviews with 58 staff, 62 patients/carers and 5 national leads. Despite national roll-out, enrolment to services was lower than expected (average enrolment across 37 clinical commissioning groups judged to have completed data was 8.7%). There was large variability in implementation of services, influenced by patient (e.g. local population needs), workforce (e.g. workload), organisational (e.g. collaboration) and resource (e.g. software) factors. We found that for every 10% increase in enrolment to the programme, mortality was reduced by 2% (95% confidence interval: 4% reduction to 1% increase), admissions increased by 3% (-1% to 7%), in-hospital mortality fell by 3% (-8% to 3%) and lengths of stay increased by 1.8% (-1.2% to 4.9%). None of these results are statistically significant. We found slightly longer hospital lengths of stay associated with virtual ward services (adjusted incidence rate ratio 1.05, 95% confidence interval 1.01 to 1.09), and no statistically significant impact on subsequent COVID-19 readmissions (adjusted odds ratio 0.95, 95% confidence interval 0.89 to 1.02). Low patient enrolment rates and incomplete data may have affected chances of detecting possible impact. The mean running cost per patient varied for different types of service and mode; and was driven by the number and grade of staff. Staff, patients and carers generally reported positive experiences of services. Services were easy to deliver but staff needed additional training. Staff knowledge/confidence, NHS resources/workload, dynamics between multidisciplinary team members and patients' engagement with the service (e.g. using the oximeter to record and submit readings) influenced delivery. Patients and carers felt services and human contact received reassured them and were easy to engage with. Engagement was conditional on patient, support, resource and service factors. Many sites designed services to suit the needs of their local population. Despite adaptations, disparities were reported across some patient groups. For example, older adults and patients from ethnic minorities reported more difficulties engaging with the service. Tech-enabled models helped to manage large patient groups but did not completely replace phone calls.

Limitations

Limitations included data completeness, inability to link data on service use to outcomes at a patient level, low survey response rates and under-representation of some patient groups.

Future work

Further research should consider the long-term impact and cost-effectiveness of these services and the appropriateness of different models for different groups of patients.

Conclusions

We were not able to find quantitative evidence that COVID-19 remote home monitoring services have been effective. However, low enrolment rates, incomplete data and varied implementation reduced our chances of detecting any impact that may have existed. While services were viewed positively by staff and patients, barriers to implementation, delivery and engagement should be considered.

Study registration

This study is registered with the ISRCTN (14962466).

Funding

This project was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (RSET: 16/138/17; BRACE: 16/138/31) and NHSEI and will be published in full in Health and Social Care Delivery Research; Vol. 11, No. 13. See the NIHR Journals Library website for further project information. The views expressed in this publication are those of the authors and not necessarily those of the National Institute for Health and Care Research or the Department of Health and Social Care.

How general practitioners and patients discuss type 2 diabetes mellitus and cardiovascular diseases concerns during consultations: Implications for digital health

Objective

To analyse general practitioner-patient consultations about type 2 diabetes mellitus or cardiovascular diseases and describe (i) the nature of self-management discussions; (ii) actions required from patients during and after consultation regarding self-management; and (iii) implications for digital health to support patients during (and after) consultation.

Method

This study screened 281 general practitioner consultations conducted in 2017 within the UK general practice setting from an existing dataset containing videos and transcripts of consultations between GPs and patients. Secondary analysis was conducted using a multi-method approach, including descriptive, content, and visualisation analysis, to inform the nature of self-management discussions, what actions are required from patients, and whether digital technology was mentioned during the consultation to support self-management.

Results

Analysis of eligible 19 consultations revealed a discord between what self-management actions are required of patients during and after consultations. Lifestyle discussions are often discussed in depth, but these discussions rely heavily on subjective inquiry and recall. Some patients in these cohorts are overwhelmed by self-management, to the detriment of their personal health. Digital support for self-management was not a major topic of discussion, however, we identified a number of emergent gaps where digital technology can support self-management concerns.

Conclusion

There is potential for digital technology to reconcile what actions are required of patients during and after consultations. Furthermore, a number of emergent themes around self-management have implications for digitalisation.

An optimal model of long-term post-stroke care

Stroke is a major healthcare challenge that is increasing worldwide. The burden of stroke is significant for the affected individuals as well as for the general population; high-quality care is needed to reduce its negative impacts. This article synthesized information from systematic reviews, guidelines, and primary literature on stroke care and post-stroke rehabilitation and proposes an optimal strategy for long-term post-stroke care. It also highlights the unmet needs of patients who experienced a stroke in terms of early diagnosis of complications and adequate, comprehensive therapy.

Self-efficacy in disadvantaged communities: Perspectives of healthcare providers and clients

OBJECTIVE

Most chronic disease self-management interventions emphasise the integral role of self-efficacy in achieving behaviour change. We explored the applicability of this model in a low-income setting, from the perspective of both patients and clinicians.

METHODS

Interviews with multimorbid patients and their health providers at two rural community health centres in Victoria, Australia. We used a phenomenological methodology, exploring themes of confidence to manage health, outcome expectations and goals.

RESULTS

Many assumptions in which the self-efficacy model is grounded did not apply to this population. Past experiences and resource constraints, especially poverty and healthcare access, influenced confidence, expectations and the ability to achieve desired outcomes.

DISCUSSION

The focus of traditional self-management support on individual behaviour change disadvantages rural low-income patients, who face barriers related to life experience and resource constraints. For this group, self-management support needs to return to its roots, moving away from a narrow conception of behaviour change and reinstating the role of 'support' into 'self-management support' interventions. Health providers working in rural low-income settings should recognise the limits inherent in self-efficacy focussed interventions and think broadly about engaging with their clients in whatever way supports them to find a life with meaning and purpose.

Generational perspective on asthma self-management in the Bangladeshi and Pakistani community in the United Kingdom: A qualitative study

BACKGROUND

Self-management strategies improve asthma outcomes, although interventions for South Asian populations have been less effective than in White populations. Both self-management and culture are dynamic, and factors such as acculturation and generation have not always been adequately reflected in existing cultural interventions. We aimed to explore the perspectives of Bangladeshi and Pakistani people in the United Kingdom, across multiple generations (first, second and third/fourth), on how they self-manage their asthma, with a view to suggesting recommendations for cultural interventions.

METHODS

We purposively recruited Bangladeshi and Pakistani participants, with an active diagnosis of asthma from healthcare settings. Semi-structured interviews in the participants' choice of language (English, Sylheti, Standard Bengali or Urdu) were conducted, and data were analysed thematically.

RESULTS

Twenty-seven participants (13 Bangladeshi and 14 Pakistani) were interviewed. There were generational differences in self-management, influenced by complex cultural processes experienced by South Asians as part of being an ethnic minority group. Individuals from the first generation used self-management strategies congruent to traditional beliefs such as 'sweating' and often chose to travel to South Asian countries. Generations born and raised in the United Kingdom learnt and experimented with self-management based on their fused identities and modified their approach depending on whether they were in familial or peer settings. Acculturative stress, which was typically higher in first generations who had migration-related stressors, influenced the priority given to asthma self-management throughout generations. The amount and type of available asthma information as well as social discussions within the community and with healthcare professionals also shaped asthma self-management.

CONCLUSIONS

Recognizing cultural diversity and its influence of asthma self-management can help develop effective interventions tailored to the lives of South Asian people.

PATIENT OR PUBLIC CONTRIBUTION

Patient and Public Involvement colleagues were consulted throughout to ensure that the study and its materials were fit for purpose.

Patients' experiences of, and engagement with, remote home monitoring services for COVID-19 patients: A rapid mixed-methods study

INTRODUCTION

Remote home monitoring models were implemented during the COVID-19 pandemic to shorten hospital length of stay, reduce unnecessary hospital admission, readmission and infection and appropriately escalate care. Within these models, patients are asked to take and record readings and escalate care if advised. There is limited evidence on how patients and carers experience these services. This study aimed to evaluate patient experiences of, and engagement with, remote home monitoring models for COVID-19.

METHODS

A rapid mixed-methods study was carried out in England (conducted from March to June 2021). We remotely conducted a cross-sectional survey and semi-structured interviews with patients and carers. Interview findings were summarized using rapid assessment procedures sheets and data were grouped into themes (using thematic analysis). Survey data were analysed using descriptive statistics.

RESULTS

We received 1069 surveys (18% response rate) and conducted interviews with patients (n = 59) or their carers (n = 3). 'Care' relied on support from staff members and family/friends. Patients and carers reported positive experiences and felt that the service and human contact reassured them and was easy to engage with. Yet, some patients and carers identified problems with engagement (e.g., hesitancy to self-escalate care). Engagement was influenced by patient factors such as health and knowledge, support from family/friends and staff, availability and ease of use of informational and material resources (e.g., equipment) and service factors.

CONCLUSION

Remote home monitoring models place responsibility on patients to self-manage symptoms in partnership with staff; yet, many patients required support and preferred human contact (especially for identifying problems). Caring burden and experiences of those living alone and barriers to engagement should be considered when designing and implementing remote home monitoring services.

PATIENT OR PUBLIC CONTRIBUTION

The study team met with service users and public members of the evaluation teams throughout the project in a series of workshops. Workshops informed study design, data collection tools and data interpretation and were conducted to also discuss study dissemination. Public patient involvement (PPI) members helped to pilot patient surveys and interview guides with the research team. Some members of the public also piloted the patient survey. Members of the PPI group were given the opportunity to comment on the manuscript, and the manuscript was amended accordingly.

Understanding the Social and Emotional Dimensions of HIV Self-Management: A Qualitative Study of Newly Diagnosed People Living With HIV in Queensland, Australia

ABSTRACT

Understanding of HIV self-management increasingly focuses on treatment adherence and associated health-related behaviors, yet people living with HIV (PLWH) seldom perform these actions in a social vacuum. Thus, delivering comprehensive self-management support programs for PLWH requires an understanding of the social and emotional dimensions of HIV self-management. Through thematic analysis of in-depth interviews with 35 newly diagnosed PLWH, this descriptive qualitative study highlights these dimensions and their effect on experiences of HIV diagnosis and care. HIV self-management involves interpersonal interactions that affect efforts to seek support and reimagine one's personal identity in a changed reality. Managing disclosures and navigating stigma constitute everyday work for many PLWH. Because stigma continues to impede care engagement and well-being for PLWH, health practitioners must extend focus beyond viral suppression and prioritize support for emotional and social self-management. Nurses can create safe, nonstigmatizing spaces for conversations about HIV, uphold the rights of PLWH around disclosure, and ensure that PLWH are connected to peer support services.

Health care providers' understanding of self-management support for people with chronic low back pain in Ethiopia: an interpretive description

BACKGROUND

Healthcare providers play a key role in supporting people with chronic low back pain to self-manage their condition. The study aimed at exploring how health care providers understand and conceptualize self-management and how they provide self-management support for people with chronic low back pain in Ethiopia.

METHODS

Health care providers who have supported people with low back pain, including medical doctors and physiotherapists, were approached and recruited from three hospitals in Ethiopia. This study employed an interpretive descriptive approach using semi-structured interviews.

FINDINGS

Twenty-four participants (7 women; 17 men) with a median age of 28 (range 24 to 42) years and a median of 9.5 years (range 1 to 11 years) of helping people with chronic low back pain were interviewed. Seven major themes related to health care providers' understanding of self-management support for people with chronic low back pain in Ethiopia emerged. The findings show that self-management was a new concept to many and health care providers' had a fragmented understanding of self-management. They used or suggested several self-management support strategies to help people with CLBP self-manage their condition without necessarily focusing on enhancing their self-efficacy skills. The participants also discussed several challenges to facilitate self-management support for people with chronic low back pain. Despite the lack of training on the concept, the providers discussed the potential of providing self-management support for people with the condition.

CONCLUSIONS

Self-management was a new concept to health care providers. The providers lack the competencies to provide self-management support for people with chronic low back pain. There is a need to enhance the health care providers' self-management support competencies through training.

The views of healthcare professionals on self-management of patients with advanced cancer: An interview study

OBJECTIVES

Self-management of patients with advanced cancer is challenging. Although healthcare professionals may play a crucial role in supporting these patients, scant scientific attention has been paid to their perspectives. Therefore, we examined healthcare professionals' views on self-management and self-management support in this population.

METHODS

We conducted qualitative interviews with 27 purposively sampled medical specialists (n = 6), nurse specialists (n = 6), general practitioners (n = 8) and homecare/ hospice nurses (n = 7) in the Netherlands. Transcripts were analysed using thematic analysis.

RESULTS

Healthcare professionals experienced self-management of patients with advanced cancer to be diverse, dynamic and challenging. They adopted instructive, collaborative and advisory roles in self-management support for this population. Whereas some professionals preferred or inclined towards one role, others indicated to switch roles, depending on the situation.

CONCLUSIONS

Just like patients with advanced cancer, healthcare professionals differ in their views and approaches regarding self-management and self-management support in this population. Therefore, instructive, collaborative and advisory self-management support roles will all be useful under certain circumstances.

PRACTICE IMPLICATIONS

Healthcare professionals can support self-management by being aware of their own views and communicating these clearly to their patients and colleagues. Education in self-management support should include self-reflection skills and discuss the relation between self-management and professional care.

Social network participation towards enactment of self-care in people with chronic obstructive pulmonary disease: A qualitative meta-ethnography

BACKGROUND

How people with chronic obstructive pulmonary disease (COPD) engage with supportive social networks to enhance self-care is not understood. The personal rationales for participation in socially directed support have not been addressed in the literature. To determine how people with COPD identify, engage and participate in socially supportive self-care practices, we conducted a systematic review and meta-ethnography of qualitative studies.

METHODS

A systematic literature search was conducted between June 2010 and June 2021. Of 3536 articles, 8 fulfilled the inclusion criteria. Using a meta-ethnography approach to the qualitative synthesis, new concepts were derived from the data to identify aligning themes and develop a conceptual model.

FINDINGS

Interpretations from the papers yielded concepts of (1) accountability and personal responsibility in self-care, (2) valued positive relationships with clinicians, (3) understanding of illness through shared and personal experiences and (4) acknowledging social networks in fostering self-care engagement in people with COPD. The independence-experience (Index) model of synthesized (third order) interpretations highlighted the processes of social networks and self-care practices: (a) fear or avoidance of dependency, (b) learning from experiences of adaptive self-care behaviours and (c) including valued practices in self-care. Self-care strategies are formed through illness experiences and relatable social encounters.

CONCLUSION

The model derived from the third-order interpretations is a framework to describe socially supported self-care and can be used to direct future self-care strategies and target interventions for people with COPD.

PATIENT OR PUBLIC CONTRIBUTION

The findings and model were presented to the long-term conditions patient and public involvement group. The manuscript is coauthored by a public representative.

Implementation of Self-Management Interventions in Cancer Survivors: Why Are We Not There Yet?

Despite the growing evidence base for supported self-management for the improvement of quality of life, there is a lack of widespread implementation of self-management interventions for cancer survivors. We propose five key areas that, if addressed, would optimise the development and evaluation of these interventions, namely: (1) improving intervention adaptability to different survivor populations; (2) establishing intervention acceptability (and feasibility); (3) ensuring systematic description of interventions, their content, and active ingredients; (4) conducting process evaluations; and (5) assessing cost-effectiveness. These areas are an essential prerequisite for translation of self-management interventions from research into routine cancer care.

What influences the provision and reception of oral health education? A narrative review of the literature

OBJECTIVES

Most common diseases of the mouth are preventable through behavioural changes, oral hygiene routines and regular professional care. Research suggests dental professionals may prioritize clinical experience, personal values and preferences over evidence when delivering such interventions. Research also suggests variable rates of patient behaviour change following oral health education (OHE) interactions. This review explores the literature to answer the question: what factors influence the provision and reception of OHE messages and the wider OHE process?

METHODS

A structured search of literature was carried out with databases covering a range of academic disciplines (healthcare sciences, social sciences, education). Key words/terms were searched to elicit papers published since 1998. Citation mining (relevant citations within papers) and citation tracking (papers citing relevant papers) were also used. Recurring themes within the papers were identified and coded using NVivo12 and presented in a conceptual model.

RESULTS

The studies analysed tended to employ small-scale surveys, larger-scale surveys (some with low response rates), or interview studies of varying sizes. There was also a limited number of review papers. However, several key messages were identified regarding dental professionals' and patients' views on OHE and the factors that influence its provision. Factors that were identified related to the wider social and policy context (macro), community-level factors (meso), the individual practitioner and patient (micro), factors that influenced the nature of OHE interaction and any resulting behaviour change, and how the outcomes of the process influence future OHE interactions for both parties.

CONCLUSIONS

The literature highlighted how factors influence the OHE process before, during and after the educational interaction. The resultant conceptual model acknowledges the influence of wider 'upstream' factors alongside interpersonal and individual influences which should be taken into consideration when developing OHE interventions.

The Seamless Communication on a Rural Island in Japan: A Qualitative Study from the Perspective of Healthcare Professionals

On remote islands, interprofessional collaboration is essential to support older adults who live at home, despite the limited number of healthcare professionals (HCPs). Therefore, it is important for HCPs to collect and share information about older adults with health problems. This study aimed to clarify how rural HCPs collaborate using limited resources to support older adults in remote islands. We conducted semi-structured interviews with 10 healthcare providers for older adults on Zamami Island of Okinawa, Japan. We performed a qualitative analysis using the steps for coding and theorization method. Four themes were extracted: “Collection and communication of information between residents”, “Communication of information from non-HCPs to HCPs”, “Sharing of information between HCPs”, and “HCPs taking action to initiate their approach”. Islanders take care of each other and know each other’s health status, while HCPs gather their health information. When necessary, HCPs on the island gain essential information regarding older adult patients from islanders not only through work, but also through personal interactions. Afterward, HCPs approach older adults who need health care. The human connections on this remote island serve as social capital and enable flexibility in both gathering information and seamless communication among islanders who also serve as informal resources that contribute support for older adults.

Participants' experiences of and perceived value regarding different support types for long-term condition self-management programmes

OBJECTIVES

Health professional-led group programmes are a common form of long-term condition self-management support. Much research has focused on clinical outcomes of group participation, yet there is limited research on how group participants perceive and experience the support they receive. We aim to identify the different types of support that participants receive from both facilitators and other participants, and how they value this support.

METHODS

Semi-structured interviews were conducted with 20 participants taking part in a self-management group programme for a long-term condition (obesity, type 2 diabetes or chronic obstructive pulmonary disease). Data pertaining to support types were deductively identified through a social support framework prior to interpretive thematic analysis.

RESULTS

Participants identified information and emotional support from both facilitators and other participants as complementary yet distinct. Facilitators' support came from professional training and other participants' support reflected the contextual, lived experience. Professional interactions were prioritised, constraining opportunities for participant-participant support to be received and exchanged.

DISCUSSION

We identified a key gap in how self-management support is enacted in groups. Engaging participants to share experiential knowledge will make group support more relevant and mutually beneficial to participants living with a long-term condition.

Employer perspectives concerning the self-management support needs of workers with long-term health conditions

Purpose

Long-term health conditions are a significant occupational and global burden and can undermine people's ability to work. Workplace support for self-management of long-term conditions has the potential to minimise adverse work effects, by enhancing health and work outcomes. No data exist about employers' views concerning supporting workers with long-term conditions to self-manage.

Design/methodology/approach

The exploration of employers' views involved recruiting 15 participants with responsibilities for workplace health, well-being and safety responsibilities, who participated in a semi-structured interview about self-management and support. Data were analysed using a qualitative six-stage thematic analysis technique.

Findings

Self-management support is not purposely provided to workers with long-term conditions. Support in any form rests on workers disclosing a condition and on their relationship with their line-manager. While employers have considerable control over people's ability to self-manage, they consider that workers are responsible for self-management at work. Stigma, work demands and line-manager behaviours are potential obstacles to workers' self-management and support.

Practical implications

Workplace discussions about self-managing long-term conditions at work should be encouraged and opened up, to improve health and work outcomes and aligned with return-to-work and rehabilitation approaches. A wider biopsychosocial culture could help ensure workplaces are regarded as settings in which long-term conditions can be self-managed.

Originality/value

This study highlights that employer self-management support is not provided to workers with long-term conditions in a purposeful way. Workplace support depends on an employer knowing what needs to be supported which, in turn, depends on aspects of disclosure, stigma, work demands and line management.

Physiotherapists' views on their role in self-management approaches: A qualitative systematic review

Background: Self-management has been an increasingly important aspect of helping people manage their long-term conditions. The aim of this qualitative review was to synthesize the views of physiotherapists concerning their delivery of a self-management approach.Method: A systematic search was conducted on six electronic bibliographic databases to identify relevant primary studies. Studies were assessed for quality and data extracted. Qualitative data were analyzed using thematic synthesis. A total of 1189 studies were identified and screened. Eleven studies met the inclusion criteria.Results: Findings suggest that for self-management approaches to work, physio-therapists believe that patients need to actively participate. Boundaries on who is the expert were blurred at times with some physiotherapists struggling to relinquish control. High-quality patient-therapist relationships are required to build trust in order to support patients in the self-management of their long-term conditions. It is also important to consider the competing paradigms in which a service is delivered as this may facilitate or hinder self-management. Seeing patients as people is integral to supporting self-management approaches.Conclusion: Physiotherapists are well placed to support self-management but there is still a need for a cultural and paradigmatic shift in the physiotherapy profession and in some environments, this shift as yet is to be realized.

Patients' and healthcare professionals' beliefs, perceptions and needs towards chronic kidney disease self-management in China: a qualitative study

OBJECTIVES

To support the adaptation and translation of an evidence-based chronic kidney disease (CKD) self-management intervention to the Chinese context, we examined the beliefs, perceptions and needs of Chinese patients with CKD and healthcare professionals (HCPs) towards CKD self-management.

DESIGN

A basic interpretive, cross-sectional qualitative study comprising semistructured interviews and observations.

SETTING

One major tertiary referral hospital in Henan province, China.

PARTICIPANTS

11 adults with a diagnosis of CKD with CKD stages G1-G5 and 10 HCPs who worked in the Department of Nephrology.

RESULTS

Four themes emerged: (1) CKD illness perceptions, (2) understanding of and motivation towards CKD self-management, (3) current CKD practice and (4) barriers, (anticipated) facilitators and needs towards CKD self-management. Most patients and HCPs solely mentioned medical management of CKD, and self-management was largely unknown or misinterpreted as adherence to medical treatment. Also, the majority of patients only mentioned performing disease-specific acts of control and not, for instance, behaviour for coping with emotional problems. A paternalistic patient-HCP relationship was often present. Finally, the barriers, facilitators and needs towards CKD self-management were frequently related to knowledge and environmental context and resources.

CONCLUSIONS

The limited understanding of CKD self-management, as observed, underlines the need for educational efforts on the use and benefits of self-management before intervention implementation. Also, specific characteristics and needs within the Chinese context need to guide the development or tailoring of CKD self-management interventions. Emphasis should be placed on role management and emotional coping skills, while self-management components should be tailored by addressing the existing paternalistic patient-HCP relationship. The use of electronic health innovations can be an essential facilitator for implementation.

Remote area nursing: best practice or paternalism in action? The importance of consumer perspectives on primary health care nursing practice in remote communities

This paper reports on a study that aimed to understand how remote area nurses implemented primary health care principles in the Australian remote health care setting. Twenty-four Registered Nurses and Nurse Practitioners who worked in remote health services without inpatient facilities were interviewed using constructivist grounded theory methods. Findings revealed that nurses in this study aimed to practice in a way that was guided by Indigenous empowerment and social justice. However, some nurses questioned elements of their practice such as 'chasing' people for appointments or routine screening required by clinical guidelines that may not reflect the values of Indigenous peoples. Nurses expressed concern that they may be reinforcing past colonising practices and their actions may be considered paternalistic rather than empowering. Nurses in this study wanted to develop partnerships and provide nursing care that aligned with the health and wellbeing expectations of communities. However, ways of communicating the needs of communities and the development of partnerships between health providers and communities need to be developed. The present study calls for further research from the perspective of remote community members in order to develop ways of sharing knowledge about health and wellbeing between remote area nurses and communities.

The content and conduct of GP consultations for dermatology problems: a cross-sectional study

Background

Skin complaints are common in primary care, and poor outcomes in long-term conditions are often due to low adherence to treatment. Shared decision making and self-management support may help, yet there is little understanding of patient involvement or the support provided by GPs.

Aim

To describe the content of primary care consultations for skin problems, including shared decision making practice, delivery of self-management advice, and follow-up.

Design and setting

Cross-sectional study of video-recorded UK adult GP consultations and linked data.

Method

A coding tool was developed and applied to all consultations with skin problems. Shared decision making was assessed using the observer OPTION⁵ scale.

Results

A total of 45/318 consultations (14.2%) related to one or more skin problems, which were discussed alongside other problems in 71.1% (32/45) of consultations. Of the 100 different problems discussed in these consultations, 51 were dermatological. The mean amount of time spent on skin problems in the consultations was 4 minutes 16 seconds. Medication was recommended for 66.7% (34/51) of skin problems, with low shared decision making (mean OPTION⁵ score = 10.7). Self-management advice (verbal only) was given for 47.1% (24/51) of skin problems. Most skin problems (84.3%; 43/51) were not referred to secondary care; 32.6% (14/43) of the skin problems not referred were seen again in primary care within 12 weeks, of which 35.7% (5/14) follow-up appointments were not planned.

Conclusion

In this study, skin problems were usually presented alongside other complaints and resulted in a medication recommendation. Shared decision making was uncommon and self-management advice not consistently given, with re-attendance for the same problem common. GPs’ training should reflect how frequently skin problems are seen and seek to improve patient involvement in decision making and support self-management.

Nurses' perceptions of self-management and self-management support of older patients during hospitalization

Four focus group interviews were held with nurses, recruited from eight wards of two general hospitals, to explore nurses' perceptions of self-management and self-management support of older patients during hospitalization. A thematic analyze of the interview transcripts was conducted. Regarding nurses understanding of self-management two perceptions emerged namely 'being self-reliant' and 'being in control'. In terms of their understanding self-management support three perceptions emerged: encouraging patients to perform activities of daily living (ADL); stimulating patient participation; and increasing patients' awareness. We also found seven themes relating to nurses' beliefs regarding older patients' self-management and self-management support during hospitalization. Results indicate that nurses have a limited understanding of self-management and do not fully understand what is expected from them with regards to inpatients' self-management. It is feasible to argue that addressing nurses' beliefs can influence nurses intention and behavior regarding supporting older inpatients' self-management.

An extended stroke rehabilitation service for people who have had a stroke: the EXTRAS RCT

BACKGROUND

There is limited evidence about the effectiveness of rehabilitation in meeting the longer-term needs of stroke patients and their carers.

OBJECTIVE

To determine the clinical effectiveness and cost-effectiveness of an extended stroke rehabilitation service (EXTRAS).

DESIGN

A pragmatic, observer-blind, parallel-group, multicentre randomised controlled trial with embedded health economic and process evaluations. Participants were randomised (1 : 1) to receive EXTRAS or usual care.

SETTING

Nineteen NHS study centres.

PARTICIPANTS

Patients with a new stroke who received early supported discharge and their informal carers.

INTERVENTIONS

Five EXTRAS reviews provided by an early supported discharge team member between 1 and 18 months post early supported discharge, usually over the telephone. Reviewers assessed rehabilitation needs, with goal-setting and action-planning. Control treatment was usual care post early supported discharge.

MAIN OUTCOME MEASURES

The primary outcome was performance in extended activities of daily living (Nottingham Extended Activities of Daily Living Scale) at 24 months post randomisation. Secondary outcomes at 12 and 24 months included patient mood (Hospital Anxiety and Depression Scale), health status (Oxford Handicap Scale), experience of services and adverse events. For carers, secondary outcomes included carers' strain (Caregiver Strain Index) and experience of services. Cost-effectiveness was estimated using resource utilisation costs (adaptation of the Client Service Receipt Inventory) and quality-adjusted life-years.

RESULTS

A total of 573 patients (EXTRAS, n = 285; usual care, n = 288) with 194 carers (EXTRAS, n = 103; usual care, n = 91) were randomised. Mean 24-month Nottingham Extended Activities of Daily Living Scale scores were 40.0 (standard deviation 18.1) for EXTRAS (n = 219) and 37.2 (standard deviation 18.5) for usual care (n = 231), giving an adjusted mean difference of 1.8 (95% confidence interval -0.7 to 4.2). The mean intervention group Hospital Anxiety and Depression Scale scores were not significantly different at 12 and 24 months. The intervention did not improve patient health status or carer strain. EXTRAS patients and carers reported greater satisfaction with some aspects of care. The mean cost of resource utilisation was lower in the intervention group: -£311 (95% confidence interval -£3292 to £2787), with a 68% chance of EXTRAS being cost-saving. EXTRAS was associated with 0.07 (95% confidence interval 0.01 to 0.12) additional quality-adjusted life-years. At current conventional thresholds of willingness to pay for a quality-adjusted life-year, there is a 90% chance that EXTRAS is cost-effective.

CONCLUSIONS

EXTRAS did not improve stroke survivors' performance in extended activities of daily living but did improve their overall satisfaction with services. Given the impact on costs and quality-adjusted life-years, there is a high chance that EXTRAS could be considered cost-effective.

FUTURE WORK

Further research is required to identify whether or not community-based interventions can improve performance of extended activities of daily living, and to understand the improvements in health-related quality of life and costs seen by provision of intermittent longer-term specialist review.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN45203373.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 24. See the NIHR Journals Library website for further project information.

Training in health coaching skills for health professionals who work with people with progressive neurological conditions: A realist evaluation

Background

Supporting people to self‐manage their long‐term conditions is a UK policy priority. Health coaching is one approach health professionals can use to provide such support. There has been little research done on how to train clinicians in health coaching or how to target training to settings where it may be most effective.

Objective

To develop theories to describe how training health professionals in health coaching works, for whom and in what circumstances, with a focus on those working with people with progressive neurological conditions.

Design

Realist evaluation using mixed methods (participant observation, pre‐ and post‐training questionnaires, and telephone interviews with participants and trainers). Realist data analysis used to develop and refine theories.

Intervention

Two 1‐day face‐to‐face training sessions in health coaching with 11 weeks between first and second days.

Setting and participants

Twenty health‐care professionals who work with people with neurological conditions in the UK, two training facilitators.

Results

Four theories were developed using context‐mechanism‐outcome configurations to describe how training triggers critical reflection; builds knowledge, skills and confidence; how participants evaluate the relevance of the training; and their experiences of implementing the training. Some participants reported a major shift in practice, and others implemented the training in more limited ways.

Discussion

Fully embracing the role of coach is difficult for health professionals working in positions and settings where their clinical expertise appears most highly valued.

Conclusions

Training should address the practicality of using coaching approaches within existing roles, while organizations should consider their role in facilitating implementation.

Health care professionals' views towards self-management and self-management education for people with type 2 diabetes

OBJECTIVES

Significant problems with patients engaging with diabetes self-management education (DSME) exist. The role of healthcare professionals (HCPs) has been highlighted, with a lack of enthusiasm, inadequate information provision and poor promotion of available programmes all cited as affecting patients' decisions to attend. However, little is known about HCPs' views towards DSME. This study investigates the views of HCPs towards self-management generally and self-management in the context of DSME more specifically.

DESIGN

A qualitative study using semi-structured interviews to investigate HCPs views of type 2 diabetes self-management and DSME. Data were analysed thematically and emergent themes were mapped on to the constructs of Normalisation Process Theory (NPT).

SETTING

Two boroughs in London, UK.

PARTICIPANTS

Sampling was purposive to recruit a diverse range of professional roles including GPs, practice nurses, diabetes specialist nurses, healthcare assistants (HCAs), receptionists and commissioners of care.

RESULTS

Interviews were conducted with 22 participants. The NPT analysis demonstrated that while a self-management approach to diabetes care was viewed by HCPs as necessary and, in principle, valuable, the reality is much more complex. HCPs expressed ambivalence about pushing certain patients into self-managing, preferring to retain responsibility. There was a lack of awareness among HCPs about the content of DSME and benefits to patients. Commitment to and engagement with DSME was tempered by concerns about suitability for some patients. There was little evidence of communication between providers of group-based DSME and HCPs or of HCPs engaging in work to follow-up non-attenders.

CONCLUSIONS

HCPs have concerns about the appropriateness of DSME for all patients and discussed challenges to engaging with and performing the tasks required to embed the approach within practice. DSME, as a means of supporting self-management, was considered important in theory, but there was little evidence of HCPs seeing their role as extending beyond providing referrals.

The implications of the Canadian Stroke Best Practice Recommendations for design and allocation of rehabilitation after hospital discharge: a problematization

Introduction: Implementation of the Canadian Stroke Best Practice Recommendations has improved inpatient rehabilitation. As attention is turned to the design and allocation of rehabilitation after hospitalization, examination of their implications for post-discharge rehabilitation could help optimize service planningMethods: Critical discourse analysis modeled on Alvesson and Sandberg's method of problematization was conducted to determine how the Canadian Stroke Best Practice Recommendations envision and shape post-discharge rehabilitation, and identify any tensions and potential ways to resolve them.Results: Within the Canadian Stroke Best Practice Recommendations post-discharge rehabilitation is implicitly viewed as a continuation of inpatient rehabilitation. Rehabilitation is largely envisioned as a set of biomedical procedures aimed at normalization through correction of impairment. There is potential tension between this implicit goal and the explicit goal of providing patient and family-centered care and promoting reengagement in valued activities and roles.Conclusion: An alternate vision of post-discharge rehabilitation could help resolve this tension. Post-discharge rehabilitation could be envisioned as a self-management intervention. Rather than primarily an expert-driven process of measuring impairment and applying procedures aimed at normalization, rehabilitation would be considered facilitation of self-management with the goal of reengaging in forms of participation that comprise a satisfying life.Implications for RehabilitationImplicit assumptions within best practice guidelines powerfully influence recommendations. These ideas are difficult to examine because they seem self-evident.Implicit assumptions in the Canadian Stroke Best Practice Guidelines envision post-discharge stroke rehabilitation as an expert-driven, impairment-focused biomedical procedure.This biomedical image makes it difficult to provide care that meets the guideline's explicit goals of client- and family-centeredness.Reimagining post-discharge stroke rehabilitation as a chronic self-care management intervention aimed at developing a satisfying life after stroke could improve patient care.

The social networks of New Zealand patients with multimorbidity and the work of those nominated as their 'significant supporters': An exploratory study

Social networks are informal relationships often with social ties and voluntary or mandatory obligations that can positively support a patient with multimorbidity. This exploratory study sought insights into the social networks of New Zealand people with multimorbidity and also the work of those nominated as providing significant support. Ten participants were recruited from general practice as part of an education programme in which health professional students discussed living with multimorbidity and completed a social network template together with patients. Each patient nominated an individual from their social network whom they considered provided significant support. A researcher interviewed each supporter about their experience of providing support, and their view of the patient's social network. Significant supporters included three classified as 'lay' supporters (sister, wife and daughter) and seven classified as 'professional' supporters (exercise physiologist, general practitioners, nurse, medical specialists). The activities described by supporters was classified according to Vassilev et al.'s expansion of Corbin and Strauss's 1985 classification of work in chronic illness, including the categories of "illness," "everyday" and "emotional" work. Irrespective of whether supporters were lay or professional, they gave examples of each category. While this is expected of lay supporters, it is not expected of professional supporters who are typically viewed as undertaking illness work. Lay supporters described a complex array of activities sometimes impacting on their own personal well-being, making them more akin to meeting the formal definition of being a carer, while professional supports gave objective yet professionally invested descriptions. The work of lay and professional supporters is complementary in the provision of support for those with multimorbidity. Consideration should be given to the role of lay supporters and to their own needs if they are to be able to sustain their support work with patients.

The Taxonomy of Everyday Self-management Strategies (TEDSS): A framework derived from the literature and refined using empirical data

OBJECTIVE

To extend our understanding of self-management by using original data and a recent concept analysis to propose a unifying framework for self-management strategies.

METHODS

Longitudinal interview data with 117 people with neurological conditions were used to test a preliminary framework derived from the literature. Statements from the interviews were sorted according to the predefined categories of the preliminary framework to investigate the fit between the framework and the qualitative data. Data on frequencies of strategies complemented the qualitative analysis.

RESULTS

The Taxonomy of Every Day Self-management Strategies (TEDSS) Framework includes five Goal-oriented Domains (Internal, Social Interaction, Activities, Health Behaviour and Disease Controlling), and two additional Support-oriented Domains (Process and Resource). The Support-oriented Domain strategies (such as information seeking and health navigation) are not, in and of themselves, goal focused. Instead, they underlie and support the Goal-oriented Domain strategies. Together, the seven domains create a comprehensive and unified framework for understanding how people with neurological conditions self-manage all aspects of everyday life.

CONCLUSIONS

The resulting TEDSS Framework provides a taxonomy that has potential to resolve conceptual confusion within the field of self-management science.

PRACTICE IMPLICATIONS

The TEDSS Framework may help to guide health service delivery and research.

Positioning the six-month review in the recovery process post-stroke: The ideology of personal responsibility

Stroke is the UK's fourth highest cause of death and an estimated 300,000 people in England are living with related disability. This paper explores the six-month review (6MR), a policy initiative that aimed to ameliorate unmet need. A multiple case study approach underpinned by critical realism was used to elicit the views of patients, carers, providers and commissioners across three sites using interviews, observations and documentation. Forty-six patients (age range 28-91 years), 30 carers and 28 professionals were interviewed between December 2015 and October 2016. Twenty-nine reviews were observed. Data was analysed thematically across sites. 6MRs carried out by stroke nurse specialists (SNSs) were found to be more medically orientated than those completed by a Stroke Association (SA) co-ordinator who focused on social issues. Reviewers regarded reviews primarily as an opportunity to address unmet need and signpost to further services. Patients responded in three different ways: proactive and engaged, reflected an active orientation to recovery and self-management; proactive and self-managing on their own terms, encompassed patients who were striving for independence but took their own approach sometimes at odds with that of clinicians; and passive orientation, whereby patients did not engage in rehabilitation or self-management. Patients identified different priorities to those of reviewers, particularly those with other long-term conditions and this appeared to contribute to the dissatisfaction that some expressed. In conclusion, there was little evidence that the 6MR played a key role in recovery. Locally defined outcomes for the 6MR reflecting national policy were not substantiated by the findings. Our findings suggest that the 6MR should review therapy goals and facilitate patient-led goals. Reviewers should be allowed the freedom to individualise the process rather than adhering to a rigid framework dictated by national policy and local protocols.

Patient work from a context and time use perspective: a mixed-methods study protocol

INTRODUCTION

Self-management is widely promoted but less attention is focused on the work required from patients. To date, many individuals struggle to practise self-management. 'Patient work', a concept that examines the 'work' involved in self-management, is an approach to understanding the tasks, effort, time and context from patient perspective. The purpose of our study is to use a novel approach combining non-obstructive observations via digital devices with in-depth qualitative data about health behaviours and motivations, to capture the full range of patient work experienced by people with type 2 diabetes and chronic comorbidities. It aims to yield comprehensive insights about 'what works' in self-management, potentially extending to populations with other chronic health conditions.

METHODS AND ANALYSIS

This mixed-methods observational study involves a (1) prestudy interview and questionnaires, (2) a 24-hour period during which participants wear a camera and complete a time-use diary, and a (3) poststudy interview and study feedback. Adult participants living with type 2 diabetes with at least one chronic comorbidity will be recruited using purposive sampling to obtain a balanced gender ratio and of participants using insulin and those using only oral medication. Interviews will be analysed using thematic analysis. Data captured by digital devices, diaries and questionnaires will be used to analyse the duration, time, context and patterns of health-related behaviours.

ETHICS AND DISSEMINATION

The study was approved by the Macquarie University Human Research Ethics Committee for Medical Sciences (reference number 5201700718). Participants will carry a wallet-sized card that explains the purpose of the study to third parties, and can remove the camera at any stage. Before the poststudy interview begins, participants will view the camera images in private and can delete any images. Should any images be used in future publications or presentations, identifying features such as human faces and names will be obscured.

Exploring challenges at 6 months after stroke: what is important to patients for self-management?

Background/Aims:

Self-management models have recently been applied to stroke, but the most effective components are yet to be determined. To inform the ongoing refinement of stroke self-management programmes, this study explored challenges at 6 months after stroke.

Methods:

A total of 53 stroke survivors and 26 significant others were interviewed 6 months after stroke. Results were analysed qualitatively using thematic analysis.

Findings:

Stroke was experienced as a shocking and frightening event regardless of severity, and participants struggled to manage the consequences of their stroke. The stroke experience occurred within the context of more than one chronic condition and with competing demands of everyday life. Participants struggled to formulate a model of causation for their stroke, yet this appeared a necessary basis for action.

Conclusions:

The findings suggest that health care targeted at enhancing self-management, including self-management programmes, may benefit from encompassing a specific focus on participants' beliefs as an important foundation for recovery after stroke.

Meeting patients where they are: improving outcomes in early chronic kidney disease with tailored self-management support (the CKD-SMS study)

BACKGROUND

To achieve optimal health outcomes, people with chronic kidney disease must make changes in their everyday lives to self-manage their condition. This can be challenging, and there is a need for self-management support interventions which assist people to become successful self-managers. While interventions have been developed, the literature in this area is sparse and limited by lack of both individualisation and sound theoretical basis. The aim of this study was to implement and evaluate the Chronic Kidney Disease-Self-Management Support intervention: a theory-based, person-centred self-management intervention for people with chronic kidney disease stages 1-4.

METHODS

A single-sample, pre-post study of an individualised, 12-week intervention based upon principles of social-cognitive theory and person-centred care was conducted with patients attending outpatient renal clinics in Queensland, Australia (N = 66). Data were collected at T0 (pre-intervention) and T1 (post-intervention). Primary outcomes were self-efficacy and self-management behaviour.

RESULTS

There were significant, small-to-medium improvements in primary outcomes (self-efficacy: mean difference + 0.8, 95% CI 0.3-1.2, d = 0.4; self-management behaviour: mean difference + 6.2, 95% CI 4.5-7.9, d = 0.8). There were further significant improvements in secondary outcomes (blood pressure, disease-specific knowledge, physical activity, fruit and vegetable consumption, alcohol consumption, health-related quality of life, psychological distress, and communication with healthcare providers), with effect sizes ranging from negligible to large (all ps < .05).

CONCLUSIONS

Social-cognitive theory shows promise as a framework for providing effective person-centred self-management support to patients within this population, and longer-term evaluation is needed.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12618000066280 . Retrospectively registered 17/01/2018.

mHealth Tools for the Self-Management of Patients With Multimorbidity in Primary Care Settings: Pilot Study to Explore User Experience

Background

Given the complex and evolving needs of individuals with multimorbidity, the adoption of mHealth tools to support self-management efforts is increasingly being explored, particularly in primary care settings. The electronic patient-reported outcomes (ePRO) tool was codeveloped with patients and providers in an interdisciplinary primary care team in Toronto, Canada, to help facilitate self-management in community-dwelling adults with multiple chronic conditions.

Objective

The objective of study is to explore the experience and expectations of patients with multimorbidity and their providers around the use of the ePRO tool in supporting self-management efforts.

Methods

We conducted a 4-week pilot study of the ePRO tool. Patients’ and providers’ experiences and expectations were explored through focus groups that were conducted at the end of the study. In addition, thematic analyses were used to assess the shared and contrasting perspectives of patients and providers on the role of the ePRO tool in facilitating self-management. Coded data were then mapped onto the Individual and Family Self-Management Theory using the framework method.

Results

In this pilot study, 12 patients and 6 providers participated. Both patients and providers emphasized the need for a more explicit recognition of self-management context, including greater customizability of content to better adapt to the complexity and fluidity of self-management in this particular patient population. Patients and providers highlighted gaps in the extent to which the tool enables self-management processes, including how limited progress toward self-management goals and the absence of direct provider engagement through the ePRO tool inhibited patients from meeting their self-management goals. Providers highlighted proximal outcomes based on their experience of the tool and specifically, they indicated that the tool offered valuable insights into the broader patient context, which helps to inform the self-management approach and activities they recommend to patients, whereas patients recognized the tool’s potential in helping to improve access to different providers in a team-based primary care setting.

Conclusions

This study identifies a more explicit recognition of the contextual factors that influence patients’ ability to self-manage and greater adaptability to accommodate patient complexity and provider workflow as next steps in refining the ePRO tool to better support self-management efforts in primary care ahead of its application in a full-scale randomized pragmatic trial.

The international knowledge base for new care models relevant to primary care-led integrated models: a realist synthesis

Background

The Multispecialty Community Provider (MCP) model was introduced to the NHS as a primary care-led, community-based integrated care model to provide better quality, experience and value for local populations.

Objectives

The three main objectives were to (1) articulate the underlying programme theories for the MCP model of care; (2) identify sources of theoretical, empirical and practice evidence to test the programme theories; and (3) explain how mechanisms used in different contexts contribute to outcomes and process variables.

Design

There were three main phases: (1) identification of programme theories from logic models of MCP vanguards, prioritising key theories for investigation; (2) appraisal, extraction and analysis of evidence against a best-fit framework; and (3) realist reviews of prioritised theory components and maps of remaining theory components.

Main outcome measures

The quadruple aim outcomes addressed population health, cost-effectiveness, patient experience and staff experience.

Data sources

Searches of electronic databases with forward- and backward-citation tracking, identifying research-based evidence and practice-derived evidence.

Review methods

A realist synthesis was used to identify, test and refine the following programme theory components: (1) community-based, co-ordinated care is more accessible; (2) place-based contracting and payment systems incentivise shared accountability; and (3) fostering relational behaviours builds resilience within communities.

Results

Delivery of a MCP model requires professional and service user engagement, which is dependent on building trust and empowerment. These are generated if values and incentives for new ways of working are aligned and there are opportunities for training and development. Together, these can facilitate accountability at the individual, community and system levels. The evidence base relating to these theory components was, for the most part, limited by initiatives that are relatively new or not formally evaluated. Support for the programme theory components varies, with moderate support for enhanced primary care and community involvement in care, and relatively weak support for new contracting models.

Strengths and limitations

The project benefited from a close relationship with national and local MCP leads, reflecting the value of the proximity of the research team to decision-makers. Our use of logic models to identify theories of change could present a relatively static position for what is a dynamic programme of change.

Conclusions

Multispecialty Community Providers can be described as complex adaptive systems (CASs) and, as such, connectivity, feedback loops, system learning and adaptation of CASs play a critical role in their design. Implementation can be further reinforced by paying attention to contextual factors that influence behaviour change, in order to support more integrated working.

Future work

A set of evidence-derived ‘key ingredients’ has been compiled to inform the design and delivery of future iterations of population health-based models of care. Suggested priorities for future research include the impact of enhanced primary care on the workforce, the effects of longer-term contracts on sustainability and capacity, the conditions needed for successful continuous improvement and learning, the role of carers in patient empowerment and how community participation might contribute to community resilience.

Study registration

This study is registered as PROSPERO CRD42016039552.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Usefulness of Image Theater Workshops for Exploring Dilemmas in Diabetes Self-Management Among Adolescents

Diabetes treatment involves a demanding self-management regime that is particularly challenging to adolescents. There is a need for qualitative research into the specific contexts in which adolescents attempt to balance self-management demands with the needs and desires of adolescent life. This study investigates the usefulness of image theater, a participatory form of theater using the body as an expressive tool, to articulate these dilemmas in daily life contexts. We performed a qualitative analysis of two image theater workshops with 12- to 18-year-old adolescents living with diabetes. Our results show three areas of application: (a) unraveling the contextual complexity of lived experience, (b) the articulation of implicit understandings and underlying motives, and (c) the playful exploration of new behavior. We conclude that image theater is a promising method, especially with respect to the opportunities of a more contextual and action-oriented understanding of the trade-offs made in self-management provide for diabetes education and counseling.

'Taking back the reins' - A qualitative study of the meaning and experience of self-management in bipolar disorder

BACKGROUND

Self-management (SM) is increasingly emphasised as a key aspect of bipolar disorder (BD) treatment. However, little is known about the subjective experience of SM, which might have both positive and negative impacts. The present study aimed to advance this literature through qualitative investigation of the experiences of people with BD who participated in an SM intervention targeting quality of life (QoL).

METHODS

Forty-three individuals with BD engaged with an SM intervention and were later questioned about personal experiences of engagement with the intervention, including attempts to enact self-management strategies. Thematic analysis was used to identify important aspects of the experience of SM in BD.

RESULTS

Four themes describing people's experiences of SM were identified: 1) SM for BD is empowering, 2) individual responsibility to self-manage BD, 3) SM strategies lack power to control BD, and 4) the relationship of SM to the healthcare system.

LIMITATIONS

Potential limitations to generalisability may occur from self-selection bias in favour of SM and the QoL-focused nature of the present intervention.

CONCLUSIONS

The findings of this research generate novel insights into ways in which individuals with BD engage with SM interventions. For most people with BD, SM invokes a sense of empowerment and responsibility, although some feel symptoms remain beyond their control. A sense of partnership between consumers and clinicians may emerge from attention to SM, but traditional medical approaches were perceived as neglecting this aspect of care. Considerations from consumer perspectives are presented to assist clinicians and researchers utilising SM interventions in BD.

Evaluating the prevalence and opportunity for technology use in chronic kidney disease patients: a cross-sectional study

BACKGROUND

Chronic kidney disease (CKD) is increasing worldwide and early education to improve adherence to self-management is a key strategy to slow CKD progression. The use of the internet and mobile phone technologies (mHealth) to support patients is considered an effective tool in many other chronic disease populations. While a number of mHealth platforms for CKD exist, few studies have investigated if and how this population use technology to engage in self-management.

METHODS

Using a cross-sectional design across five health districts in Queensland (Australia), a 38-item self-report survey was distributed to adults with CKD attending outpatient clinics or dialysis units to measure current use and type of engagement with mHealth, perceived barriers to use, and opportunities to support CKD self-management. Odds ratio (OR) were calculated to identify associations between demographic characteristic and mHealth use.

RESULTS

Of the 708 participants surveyed, the majority had computer access (89.2%) and owned a mobile phone (83.5%). The most likely users of the internet were those aged ≤ 60 years (OR: 7.35, 95% confidence interval [CI]: 4.25-12.75, p < 0.001), employed (OR: 7.67, 95% CI: 2.58-22.78, p < 0.001), from non-indigenous background (OR: 6.98, 95% CI: 3.50-13.93, p < 0.001), or having completed higher levels of education (OR: 3.69, CI: 2.38-5.73, p < 0.001). Those using a mobile phone for complex communication were also younger (OR: 6.01, 95% CI: 3.55-10.19, p < 0.001), more educated (OR: 1.99, 95% CI: 1.29-3.18, p < 0.01), or from non-indigenous background (OR: 3.22, 95% CI: 1.58-6.55, p < 0.001). Overall, less than 25% were aware of websites to obtain information about renal healthcare. The mHealth technologies most preferred for communication with their renal healthcare teams were by telephone (56.5%), internet (50%), email (48.3%) and text messages (46%).

CONCLUSION

In the CKD cohort, younger patients are more likely than older patients to use mHealth intensively and interactively although all patients' technology literacy ought to be thoroughly assessed by renal teams before implementing in practice. Further research testing mHealth interventions to improve self-management in a range of patient cohorts is warranted.

"I'm still me - I'm still here!" Understanding the person's sense of self in the provision of self-management support for people with progressive neurological long-term conditions

PURPOSE

There is increasing interest in tailoring self-management support, but little detail is available on the relevance and impact of such approaches for people with progressive neurological conditions. The aim of this study was to draw on individuals' experiences to inform the practice of self-management support for these groups.

METHOD

Community rehabilitation service users were purposively recruited and took part in in-depth qualitative interviews. Interviews were audio-recorded and transcribed. Data analysis was iterative and interpretative, taking a phenomenological approach. Strategies to enhance rigor were auditability, peer review, and researcher reflexivity.

RESULTS

The sample consisted of 10 adults (age 20-79 years) who were living with a range of progressive neurological conditions. Individuals demonstrated resourcefulness in developing practice-based self-management strategies. Beyond practical strategies, interviewees' experiences were signified by reflecting on and upholding a sense of identity and a desire for purpose against the background of losses and gains over time. Linking with this overarching theme of "Sense of self" were aspects of "My body and mind", "Time", "Space", "Relationships", and "What I do".

CONCLUSIONS

Self-management approaches for individuals with progressive neurological conditions will benefit from incorporating ways of recognizing, articulating, and supporting the person's sense of identity and purpose. Implications for rehabilitation Self-management approaches for people with progressive neurological conditions need to take account of individuals' wishes to contribute, connect with others, and be valued as a person. Person-centred self-management support can be realized through a broader approach than solely managing disease progression. The experiences and words of people with progressive neurological conditions can be used to inform meaningful evaluation of self-management support to drive service delivery by measuring what really matters. Rehabilitation practitioners need to adapt their conceptualisations of goal setting to account for how people with progressive neurological conditions themselves interpret "progress" and "improvement". Person-centred conversation that values who the person is can be an effective starting point for self-management interventions in people with progressive neurological conditions.

Supporting patients self-managing respiratory health: a qualitative study on the impact of the Breathe Easy voluntary group network

Self-management strategies are designed to improve lung and respiratory health through structured self-management plans with regular practitioner reviews. Strategies have not, however, focused upon how patient support groups and advocacy networks can help with the management of these conditions; therefore, it is unknown what impact they may have on patient self-management. A qualitative study was designed to help understand what impact the British Lung Foundation's Breathe Easy (BE) groups have on patients managing their lung and respiratory conditions. A semistructured telephone interview schedule was developed to study the network. Topics covered included: perceptions about the BE groups; current referrals systems and integration pathways; benefits of attending the BE groups; and integration of the BE groups into the respiratory pathway. Key themes explored included: shared patient experience and peer support; patient self-management and self-education; attendance of healthcare professionals; and the impact of integrating BE groups into the respiratory pathway. BE networks were shown to support self-care initiatives for people attending the groups, and members expressed a social and educational benefit. BE networks were working with the local National Health Service to become an integral part of the respiratory pathway, yet there was evidence of resistance from the health service in incorporating the networks.

Le retour au travail d’immigrants ayant subi une lésion professionnelle : les embûches de la rencontre interculturelle et la précarité du lien d’emploi

Cet article rapporte une partie des résultats d'une étude exploratoire sur le processus de réadaptation et de retour au travail en contexte de relations interculturelles. Cette étude avait deux objectifs : identifier les stratégies mises de l'avant par les différents acteurs pour faciliter le processus de réadaptation et de retour au travail des travailleurs immigrants et décrire les contraintes, les obstacles et les aides au processus selon la perspective des différents acteurs. Des entrevues semi-dirigées ont ainsi été menées auprès de 47 répondants : cliniciens, agents d'indemnisation et conseillers en réadaptation de la CNESST, employeurs et travailleurs immigrants victimes d'une lésion reconnue et indemnisée. Au-delà des barrières linguistiques et culturelles, deux facteurs nuisent au retour en emploi des travailleurs immigrants : d'une part, la précarité du lien d'emploi freine leurs efforts et mine leur volonté de consolider leur état de santé et, d'autre part, la menace ou la perte réelle du lien d'emploi amène une rupture symbolique dans leur processus d'intégration. Cette rupture est importante pour ceux qui sont surqualifiés pour leur poste, surtout si leur emploi est un passage obligé pour acquérir une expérience de travail au Canada et viser ensuite un emploi à la hauteur de leurs compétences. Le processus de réadaptation peut soit se transformer en un « parcours déshonorant », soit fournir une occasion d'améliorer sa situation sur un marché du travail discriminant. Adapter les programmes à la réalité de ces travailleurs immigrants est possible, mais pose un dilemme moral et éthique : comment motiver les travailleurs à se rétablir tout en explorant un autre créneau d'emploi si leur lien d'emploi risque d'être rompu, alors que les règles relatives au droit de retour au travail prévoient la réintégration de l'emploi prélésionnel ou tout autre poste jugé équivalent?

A qualitative follow-up study of diabetes patients' appraisal of an integrated diabetes service in primary care

As the prevalence of type 2 diabetes continues to escalate, health system reform is seeking better patient outcomes through new models of care that aim to provide the most appropriate care when needed. Patients' experiences of service innovations can shed light on the successes and challenges of implementing change. This paper explores patients' views of a new model of integrated care for patients with type 2 diabetes. A mixed-methods, randomised control trial evaluated a beacon clinic model of care for complex type 2 diabetes led by specialist general practitioners (GPs) in primary care settings in Brisbane, Australia. In this qualitative sub-study conducted between May 2014 and January 2015, 25 consenting participants were re-interviewed after 12 months using semi-structured questions, to explore their experiences of the new model of care. Interview transcripts were analysed thematically. In the first theme, Organised for patient-centred care, patients appraised the structural elements of the clinic. For most, it was an enabling experience which included convenience, flexibility and prompt communication back to the referring GPs. The preferences of a minority were partly realised, as they tried to understand the clinical purpose in comparison with traditional care. The second theme, Positioned as partners in care, revealed the pivotal role of patient-clinician relationships in patients' engagement with advice and self-care. Most found clinicians' collaborative approach engaging and motivating. A small minority with contextual concerns were disappointed with the focus on diabetes and struggled to engage fully with the model. Most participants valued this model of care, which reflects a capacity to manage the variable and complex needs of most patients referred for care. However, multi-level strategies are also needed to enhance patients' engagement with care and the sustainability of integrated diabetes care.