What impact do chronic disease self-management support interventions have on health inequity gaps related to socioeconomic status: a systematic review

Preferences, Needs, and Values of Patients With Chronic Obstructive Pulmonary Disease Attending a Telehealth Service: Qualitative Interview Study

BACKGROUND

Digitally assisted health care services and technologies are gaining popularity. They assist patients in managing their conditions, thereby reducing the burden on health care staff. Digital health care enables individuals to receive care that is more tailored to their needs and preferences. When implemented properly, it can promote equity by considering each person's opportunities and limitations in the context of health care needs, preferences, values, and capabilities.

OBJECTIVE

This study aims to understand the needs, values, and preferences of individuals with chronic obstructive pulmonary disease (COPD) who are provided with a 24/7 digital health care service. Furthermore, we aim to understand the dynamics of the communities to which they belong and how these communities intersect. This will provide us with the essential knowledge to establish new methods of providing education, including the development of educational activities for health professionals to engage, train, and empower people living with COPD.

METHODS

The study included 7 informants diagnosed with COPD who received 24/7 digital health care service support from a regional project in Region Zealand, Denmark. The informants were visited 4 times during 2 months, including a "Hello" visit, a day with a semistructured interview, and 2 days with field observations. The informants participated in a semistructured interview, following participant observation and an ethnographic approach. The interview content was analyzed using an inductive methodology to categorize the empirical data.

RESULTS

Using the inductive approach, we identified 3 main categories related to the informants' needs, values, and preferences: (1) Health, (2) Value Creation, and (3) Resources. These 3 main categories were based on 9 subcategories: (1) health and barriers, (2) self-monitoring, (3) medication, (4) behavior, (5) motivation, (6) hobbies, (7) social networks, (8) health professionals, and (9) technology. These findings revealed that the informants placed value on maintaining their daily activities and preserving their sense of identity before the onset of COPD. Furthermore, they expressed a desire not to be defined by their COPD, as conversations about COPD often shifted away from the topic.

CONCLUSIONS

Digital health solutions and the health care professionals who offer them should prioritize the individuals they serve, considering their needs, values, and preferences rather than solely focusing on the medical condition. This approach ensures the highest level of daily living and empowerment for those living with long-term health conditions. The communities surrounding individuals must engage in constant interaction and collaboration. They should work together to incorporate people's needs, values, and preferences into future digital health services, thereby promoting empowerment and self-management. New educational programs aimed at developing the digital health service competencies of registered nurses should facilitate collaboration between the 2 communities. This collaboration is essential for supporting patients with long-term health conditions in their daily activities.

Participation in a digital self-management intervention for osteoarthritis and socioeconomic inequalities in patient-related outcomes

OBJECTIVE

To investigate changes in socioeconomic inequalities in patient-related outcomes and pain medication use, following participation in a digital self-management intervention for osteoarthritis (OA) in Sweden.

METHOD

Participants with hip/knee OA enrolled in the digital intervention were included. Self-reported outcomes collected were the numerical rating scale (NRS) pain, activity impairment, general health, Knee/Hip injury and Osteoarthritis Outcome Score (KOOS-12, HOOS-12) Pain, Function, and Quality of Life subscales, 5-level EuroQol 5 Dimensions (EQ-5D-5L), Patient Acceptable Symptom State (PASS) for function, walking difficulties, fear of movement, wish for surgery, pain medication use, physical function measured by the 30s chair-stand test, and level of physical activity. Educational attainment was used as a socioeconomic measure and the concentration index was used to assess the magnitude of inequalities at baseline and 3 month follow-up.

RESULTS

The study included 21,688 participants (mean ± sd age 64.1 ± 9.1 years, 74.4% females). All outcomes except for PASS demonstrated inequalities in favour of highly educated participants at both time-points, with highly educated participants reporting better outcomes. At 3 month follow-up, the magnitude of inequality widened for activity impairment, but narrowed for NRS pain, EQ-5D-5L, KOOS-12/HOOS-12 Pain and Function, physical function, and wish for surgery. There were no statistically conclusive changes in the magnitude of inequalities for the remaining outcomes.

CONCLUSIONS

There were inequalities in patient-related outcomes in favour of those with higher education among participants of a digital self-management intervention for OA, although the magnitude of these pre-existing inequalities generally narrowed after the 3 month intervention.

Barriers and facilitators of self-management of diabetes amongst people experiencing socioeconomic deprivation: A systematic review and qualitative synthesis

BACKGROUND

The number of people living with diabetes is rising worldwide and a higher prevalence of diabetes has been linked to those experiencing socioeconomic deprivation. Self-management strategies are vital and known to reduce the risks of long-term complications amongst people living with diabetes. Lack of knowledge about self-care activity required to manage diabetes is a key barrier to successful self-management. Self-management interventions can be less effective in socioeconomically deprived populations which can increase the risk of exacerbating health inequalities. The purpose of this review is to identify and synthesise qualitative evidence on the barriers and facilitators of self-management of diabetes amongst people who are socioeconomically disadvantaged.

METHODS

MEDLINE, EMBASE, AMED, PsycINFO and CINAHL Plus were searched for qualitative studies concerning self-management of multiple long-term conditions amongst socioeconomically disadvantaged populations. Relevant papers which focused on diabetes were identified. Data were coded and thematically synthesised using NVivo.

FINDINGS

From the search results, 79 qualitative studies were identified after full-text screening and 26 studies were included in the final thematic analysis. Two overarching analytical themes were identified alongside a set of subthemes: (1) Socioeconomic barriers to diabetes self-management; healthcare costs, financial costs of healthy eating, cultural influences, living in areas of deprivation, competing priorities and time constraints, health literacy, (2) facilitators of diabetes self-management; lifestyle and having goals, support from healthcare providers, informal support.

DISCUSSION

Self-management of diabetes is challenging for people experiencing socioeconomic deprivation due to barriers associated with living in areas of deprivation and financial barriers surrounding healthcare, medication and healthy food. Support from healthcare providers can facilitate self-management, and it is important that people with diabetes have access to interventions that are designed to be inclusive from a cultural perspective as well as affordable.

PATIENT OR PUBLIC CONTRIBUTION

A patient advisory group contributed to the research questions and interpretation of the qualitative findings by reflecting on the themes developed.

Sociodemographic and clinical variables associated with negative illness perception in patients newly diagnosed with rheumatoid arthritis, axial spondyloarthritis, or psoriatic arthritis-a survey based cross-sectional study

When newly diagnosed with inflammatory arthritis (IA), acquiring self-management skills is beneficial, to enhance quality of life. The personal beliefs and mental representations patients hold about their illness, known as illness perception, significantly influence the development of these skills. Recognizing characteristics that affect illness perception is key to identifying patients requiring additional support for the development of self-management skills. This study aimed at identifying the sociodemographic and clinical characteristics associated with a negative illness perception. This cross-sectional study was based on survey data from patients diagnosed for ≤ 2 years. The Brief Illness Perception Questionnaire (B-IPQ) was used to measure illness perception. After psychometric testing, we divided the B-IPQ into two domains: (1) a control domain and (2) a consequence domain. We performed logistic regression analyses with multiple imputations. A total of 1,360 patients (61% females) were included. Among them, 64%, 20%, and 16% were diagnosed with rheumatoid arthritis, psoriatic arthritis (PsA) and axial spondyloarthritis (axSpA), respectively. Younger patients with lower socioeconomic status, a diagnosis of PsA or axSpA, high disease activity (OR 3.026, CI 2.208;4.147), severe physical disability (OR 4.147. CI 2.883;6.007), severe pain (OR 3.034, CI 1.991;4.622), and severe fatigue (OR 2.612, CI 1.942;3.513) were significantly more likely to report having a negative illness perception. Younger patients with a higher symptom burden, increased disease activity, lower socioeconomic status, and a diagnosis of PsA or axSpA may require additional attention and support in rheumatology clinical practice to aid in the development of their self-management skills.

Modeling chronic disease risk across equity factors using a population-based prediction model: the Chronic Disease Population Risk Tool (CDPoRT)

BACKGROUND

Predicting chronic disease incidence at a population level can help inform overall future chronic disease burden and opportunities for prevention. This study aimed to estimate the future burden of chronic disease in Ontario, Canada, using a population-level risk prediction algorithm and model interventions for equity-deserving groups who experience barriers to services and resources due to disadvantages and discrimination.

METHODS

The validated Chronic Disease Population Risk Tool (CDPoRT) estimates the 10-year risk and incidence of major chronic diseases. CDPoRT was applied to data from the 2017/2018 Canadian Community Health Survey to predict baseline 10-year chronic disease estimates to 2027/2028 in the adult population of Ontario, Canada, and among equity-deserving groups. CDPoRT was used to model prevention scenarios of 2% and 5% risk reductions over 10 years targeting high-risk equity-deserving groups.

RESULTS

Baseline chronic disease risk was highest among those with less than secondary school education (37.5%), severe food insecurity (19.5%), low income (21.2%) and extreme workplace stress (15.0%). CDPoRT predicted 1.42 million new chronic disease cases in Ontario from 2017/2018 to 2027/2028. Reducing chronic disease risk by 5% prevented 1500 cases among those with less than secondary school education, prevented 14 900 cases among those with low household income and prevented 2800 cases among food-insecure populations. Large reductions of 57 100 cases were found by applying a 5% risk reduction in individuals with quite a bit workplace stress.

CONCLUSION

Considerable reduction in chronic disease cases was predicted across equity-defined scenarios, suggesting the need for prevention strategies that consider upstream determinants affecting chronic disease risk.

A qualitative exploration of the barriers and facilitators to self-managing multiple long-term conditions amongst people experiencing socioeconomic deprivation

BACKGROUND

Globally, it is estimated that one in three adults live with two or more long-term conditions (multiple long-term conditions, MLTCs), that require self-management. People who experience socioeconomic deprivation face significant health inequalities due to a range of interrelated characteristics that lead to a lack of resources and opportunities. Previous research with underserved populations indicate low levels of trust towards primary care providers and potential barriers for developing patient-healthcare professional relationships. The purpose of this paper is to explore the barriers and facilitators to self-managing MLTCs, amongst people who experience socioeconomic deprivation.

METHODS

Semistructured one-to-one interviews with adults (n = 28) living in London and Sheffield, United Kingdom with MLTCs who are experiencing socioeconomic deprivation. Participants were recruited through general practices, community channels and social media. Data were analysed in NVivo using reflexive thematic analysis methods.

FINDINGS

Four analytical themes were developed: (1) challenges in accessing healthcare services, financial assistance, and cultural awareness; (2) empowerment and disempowerment through technology, including digital exclusion, and use of technology; (3) impact and causes of exclusion on self-management, including social isolation, area-based and economic exclusion, and health-related stigma and (4) adapting self-management strategies, including cost-effective, and culturally/lifestyle appropriate strategies.

CONCLUSIONS

Future health interventions and services need to be developed with consideration of the combined complexities of managing MLTCs while experiencing socioeconomic deprivation. Increased awareness in practitioners and commissioners of the complexities surrounding the lives of people experiencing socioeconomic deprivation, and the need for targeted strategies to promote self-management of MLTCs are of great importa.

PATIENT OR PUBLIC CONTRIBUTION

A patient advisory group contributed to all stages of the study, including providing important feedback on study documents (topic guides and recruitment materials), as well as providing critical insights surrounding the interpretation of interview data.

Impact of socioeconomic status on chronic control and complications of type 1 diabetes mellitus in users of glucose flash systems: a follow-up study

BACKGROUND

This study investigates the association between socioeconomic status (SES) and glycemic control in individuals with type 1 diabetes (T1D) using flash glucose monitoring (FGM) devices within a public health system where these technologies are freely available and utilized according to recommended guidelines.

METHODS

A follow-up study of 1060 adults (mean age 47.4 ± 15.0 years, 49.0% women) with T1D, receiving care at three Spanish university hospitals that regularly employ the FGM system. SES was assessed using the Spanish Deprivation Index and the average annual net income per person. Glycemic data were collected over a 14-day follow-up period, including baseline glycated hemoglobin (HbA1c) levels prior to sensor placement, the last available HbA1c levels, and FGM-derived glucose metrics. Individuals with sensor usage time < 70% were excluded. Chronic micro and macrovascular complications related to diabetes were documented. Regression models, adjusted for clinical variables, were employed to determine the impact of SES on optimal sensor control (defined as time in range (TIR) ≥ 70% with time below range < 4%) and disease complications.

RESULTS

The average follow-up was of 2 years. The mean TIR and the percentage of individuals with optimal control were higher in individuals in the highest SES quartile (64.9% ± 17.8% and 27.9%, respectively) compared to those in the lowest SES quartile (57.8 ± 17.4% and 12.1%) (p < 0.001). Regression models showed a higher risk of suboptimal control (OR 2.27, p < 0.001) and ischemic heart disease and/or stroke (OR 3.59, p = 0.005) in the lowest SES quartile. No association was observed between SES and the risk of diabetic nephropathy and retinopathy. FGM system improved HbA1c levels across all SES quartiles. Although individuals in the highest SES quartile still achieved a significantly lower value at the end of the follow-up 55 mmol/mol (7.2%) compared to those in the lowest SES quartile 60 mmol/mol (7.6%) (p < 0.001), the significant disparities in this parameter between the various SES groups were significantly reduced after FGM technology use.

CONCLUSIONS

Socioeconomic status plays a significant role in glycemic control and complications in individuals with T1D, extending beyond access to technology and its proper utilization. The free utilization of FGM technology helps alleviate the impact of social inequalities on glycemic control.

Effectiveness of self-management interventions for long-term conditions in people experiencing socio-economic deprivation in high-income countries: a systematic review and meta-analysis

BACKGROUND

Long-term conditions (LTCs) are prevalent in socio-economically deprived populations. Self-management interventions can improve health outcomes, but socio-economically deprived groups have lower participation in them, with potentially lower effectiveness. This review explored whether self-management interventions delivered to people experiencing socio-economic deprivation improve outcomes.

METHODS

We searched databases up to November 2022 for randomized trials. We screened, extracted data and assessed the quality of these studies using Cochrane Risk of Bias 2 (RoB2). We narratively synthesized all studies and performed a meta-analysis on eligible articles. We assessed the certainty of evidence using GRADE for articles included in the meta-analysis.

RESULTS

The 51 studies included in this review had mixed findings. For the diabetes meta-analysis, there was a statistically significant pooled reduction in haemoglobin A1c (-0.29%). We had moderate certainty in the evidence. Thirty-eight of the study interventions had specific tailoring for socio-economically deprived populations, including adaptions for low literacy and financial incentives. Each intervention had an average of four self-management components.

CONCLUSIONS

Self-management interventions for socio-economically deprived populations show promise, though more evidence is needed. Our review suggests that the number of self-management components may not be important. With the increasing emphasis on self-management, to avoid exacerbating health inequalities, interventions should include tailoring for socio-economically deprived individuals.

Population-based evaluation of the impact of socioeconomic status on clinical outcomes in patients with heart failure in integrated care settings

INTRODUCTION AND OBJECTIVES

Low socioeconomic status (SES) is associated with poor outcomes in patients with heart failure (HF). We aimed to examine the influence of SES on health outcomes after a quality of care improvement intervention for the management of HF integrating hospital and primary care resources in a health care area of 209 255 inhabitants.

METHODS

We conducted a population-based pragmatic evaluation of the implementation of an integrated HF program by conducting a natural experiment using health care data. We included all individuals consecutively admitted to hospital with at least one ICD-9-CM code for HF as the primary diagnosis and discharged alive in Catalonia between January 1, 2015 and December 31, 2019. We compared outcomes between patients exposed to the new HF program and those in the remaining health care areas, globally and stratified by SES.

RESULTS

A total of 77 554 patients were included in the study. Death occurred in 37 469 (48.3%), clinically-related hospitalization in 41 709 (53.8%) and HF readmission in 29 755 (38.4%). On multivariate analysis, low or very low SES was associated with an increased risk of all-cause death and clinically-related hospitalization (all Ps <.05). The multivariate models showed a significant reduction in the risk of all-cause death (HR, 0.812; 95%CI, 0.723-0.912), clinically-related hospitalization (HR, 0.886; 95%CI, 0.805-0.976) and HF hospitalization (HR, 0.838; 95%CI, 0.745-0.944) in patients exposed to the new HF program compared with patients exposed to the remaining health care areas and this effect was independent of SES.

CONCLUSIONS

An intensive transitional HF management program improved clinical outcomes, both overall and across SES strata.

Current evidence for designing self-management support for underserved populations: an integrative review using the example of diabetes

AIMS

With numerous and continuing attempts at adapting diabetes self-management support programmes to better account for underserved populations, its important that the lessons being learned are understood and shared. The work we present here reviews the latest evidence and best practice in designing and embedding culturally and socially sensitive, self-management support programmes.

METHODS

We explored the literature with regard to four key design considerations of diabetes self-management support programmes: Composition - the design and content of written materials and digital tools and interfaces; Structure - the combination of individual and group sessions, their frequency, and the overall duration of programmes; Facilitators - the combination of individuals used to deliver the programme; and Context - the influence and mitigation of a range of individual, socio-cultural, and environmental factors.

RESULTS

We found useful and recent examples of design innovation within a variety of countries and models of health care delivery including Brazil, Mexico, Netherlands, Spain, United Kingdom, and United States of America. Within Composition we confirmed the importance of retaining best practice in creating readily understood written information and intuitive digital interfaces; Structure the need to offer group, individual, and remote learning options in programmes of flexible duration and frequency; Facilitators where the benefits of using culturally concordant peers and community-based providers were described; and finally in Context the need to integrate self-management support programmes within existing health systems, and tailor their various constituent elements according to the language, resources, and beliefs of individuals and their communities.

CONCLUSIONS

A number of design principles across the four design considerations were identified that together offer a promising means of creating the next generation of self-management support programme more readily accessible for underserved communities. Ultimately, we recommend that the precise configuration should be co-produced by all relevant service and patient stakeholders and its delivery embedded in local health systems.

Emergency Department Use Among Recently Homeless Adults in a Nationally Representative Sample

Introduction: In this study we examined the association of homelessness and emergency department (ED) use, considering social, medical, and mental health factors associated with both homelessness and ED use. We hypothesized that social disadvantage alone could account for most of the association between ED use and homelessness. Methods: We used nationally representative data from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC-III). Emergency department use within the prior year was categorized into no use (27,674; 76.61%); moderate use (1-4 visits: 7,972; 22.1%); and high use (5 or more visits: 475; 1.32%). We used bivariate analyses followed by multivariable-adjusted logistic regression analyses to identify demographic, social, medical, and mental health characteristics associated with ED use. Results: Among 36,121 respondents, unadjusted logistic regression showed prior-year homelessness was strongly associated with moderate and high prior-year ED use (odds ratio [OR] 2.31 and 7.34, respectively, P < 0.001). After adjusting for sociodemographic factors, the associations of homelessness with moderate/high ED use diminished (adjusted OR [AOR] 1.27 and 1.62, respectively, both P < 0.05). Adjusting for medical/mental health variables, alone, similarly diminished the association between homelessness and moderate/high ED use (AOR 1.26, P < .05 and 2.07, P < 0.001, respectively). In a final stepwise model including social and health variables, homelessness was no longer significantly associated with moderate or high ED use in the prior year. Conclusion: After adjustment for social disadvantage and health problems, we found no statistically significant association between homelessness and ED use. The implications of our findings suggest that ED service delivery must address both health issues and social factors.

Piloting a Peer Support Program for Patients Who Screen Positive for Intimate Partner Violence, Suicidal Ideation, and Depression

Peer support programs have been utilized for a variety of mental-health-related needs, including suicidality and depression. In this pilot program, we developed a peer support network to address multimorbidity involving intimate partner violence (IPV), suicidal ideation, and depression. Over one year, our Suicide Obviation Support (SOS) navigators enrolled and provided at-elbow support to 108 patients (67.6% women) who screened positive for IPV, many of whom also screened at moderate or high risk for suicidality (64.8%) and/or exhibited depression symptoms. At a 6-month follow-up, 63 participants (58.3%) were retained. Those who stayed enrolled in the program for six months were less likely to report IPV and depression symptoms and were at a lower risk for suicide than the original sample, and analyses showed that IPV, depression, and suicide risk scores declined significantly in this group. The SOS navigators provided direct support and continuity of care for these high-risk patients, which included referrals to mental health treatment and other types of support services, such as transportation and emergency housing. This program provides a model for healthcare systems that desire to implement peer support programs servicing individuals who face multiple, acute mental health care needs.

The effect of a community-based group intervention on chronic disease self-management in a vulnerable population

Introduction

Chronic non-communicable diseases (NCDs) are predominantly related to modifiable health behaviors and account for 74% of global deaths at present. Behavior modification through self-management is a strategy to prevent NCDs. Chronic Disease Self-Management Programs (CDSMPs) have demonstrated improvements in health behaviors, health status, and use of healthcare.

Objective

We evaluated the effects of a 6-week CDSMP on self-efficacy, health behaviors, mental health, health-related quality of life (HR-QoL), and health responsibilities among vulnerable populations with chronic disease in Europe.

Methods

A prospective cohort study with a 6-month pre-post single-group design was conducted in five European countries. The intervention targeted adults with chronic conditions and low socioeconomic status, as well as their caregivers. The intervention was a 6-week community-based CDSMP in a group setting. Outcomes were measured per self-report questionnaire at baseline and 6-month follow-up: self-efficacy, health behaviors, mental health, HR-QoL, and health responsibilities.

Results

Of 1,844 participants, 1,248 (67.7%) completed follow-up and attended ≥4 sessions. For the chronic condition group, the following outcome measures at follow-up significantly improved compared with baseline (all P < 0.002): self-efficacy (SEMCD-6 6.7 vs. 6.4), mental health (PHQ-8 6.3 vs. 7.0), HR-QoL (SF-12 PCS 42.3 vs. 40.2, SF-12 MCS 42.8 vs. 41.4), health utility (EQ-5D-5L 0.88 vs. 0.86), self-rated health (EQ-5D-5L 67.2 vs. 63.9), communication with healthcare providers (2.28 vs. 2.11), understanding information (3.10 vs. 3.02), number of doctor visits (3.61 vs. 4.97), accident and emergency department visits (0.25 vs. 0.48), total nights in a hospital (0.65 vs. 1.13), and perceived medical errors (19.6 vs. 28.7%). No significant changes were detected in dietary habits, physical activity, substance use, and sleep and fatigue. For caregivers without a chronic condition, only doctor visits significantly decreased (1.54 vs. 2.25, P < 0.001).

Discussion

This CDSMP was associated with improvement in self-efficacy, depression, HR-QoL, and health responsibilities over 6 months in a diverse European population with a chronic condition. However, additional interventions targeting lifestyle risk factors are needed to improve health outcomes.

Combination of health care service use and the relation to demographic and socioeconomic factors for patients with musculoskeletal disorders: a descriptive cohort study

BACKGROUND

Patients with musculoskeletal disorders (MSDs) access health care in different ways. Despite the high prevalence and significant costs, we know little about the different ways patients use health care. We aim to fill this gap by identifying which combinations of health care services patients use for new MSDs, and its relation to clinical characteristics, demographic and socioeconomic factors, long-term use and costs, and discuss what the implications of this variation are.

METHODS

The study combines Norwegian registers on health care use, diagnoses, comorbidities, demographic and socioeconomic factors. Patients (≥ 18 years) are included by their first health consultation for MSD in 2013-2015. Latent class analysis (LCA) with count data of first year consultations for General Practitioners (GPs), hospital consultants, physiotherapists and chiropractors are used to identify combinations of health care use. Long-term high-cost patients are defined as total cost year 1-5 above 95th percentile (≥ 3 744€).

RESULTS

We identified seven latent classes: 1: GP, low use; 2: GP, high use; 3: GP and hospital; 4: GP and physiotherapy, low use; 5: GP, hospital and physiotherapy, high use; 6: Chiropractor, low use; 7: GP and chiropractor, high use. Median first year health care contacts varied between classes from 1-30 and costs from 20€-838€. Eighty-seven percent belonged to class 1, 4 or 6, characterised by few consultations and treatment in primary care. Classes with high first year use were characterised by higher age, lower education and more comorbidities and were overrepresented among the long-term high-cost users.

CONCLUSION

There was a large variation in first year health care service use, and we identified seven latent classes based on frequency of consultations. A small proportion of patients accounted for a high proportion of total resource use. This can indicate the potential for more efficient resource use. However, the effect of demographic and socioeconomic variables for determining combinations of service use can be interpreted as the health care system transforming unobserved patient needs into variations in use. These findings contribute to the understanding of clinical pathways and can help in the planning of future care, reduction in disparities and improvement in health outcomes for patients with MSDs.

Efficacy of a multidimensional self-management intervention on low-education women with metabolic syndrome: a cluster randomized controlled trial

Low-education women, a substantially older population, are subject to increased risks of metabolic syndrome and consequent cardiometabolic diseases; early detection and effective management were urgently needed. Ninety-nine women with metabolic syndrome, age 61 and education ≤ 6 years, from four community units were randomly assigned to either a self-management intervention (n = 51) or a control arm (n = 48). The intervention consisted of five dimensions, physical activity and diet modifications (daily exercise classes and two nutrition courses), goal setting, coaching and peer support, problem-solving, and self-monitoring. The control arm received an education leaflet. Assessments were performed at baseline, six months, and 18 months. Compared with the control, the intervention participants improved the overall rate of meeting the recommended servings for six health foods, including vegetables, dairy products, and nuts (except whole grains, fruits, and protein); the rate of meeting regular leisure-time physical activity; and criteria biomarkers-waist circumference, fasting blood glucose, high-density lipoprotein cholesterol (except blood pressure and triglycerides); as well as body weight and body mass index; consequently decreased the number of risk factors and rate of metabolic syndrome. In conclusion, the multidimensional self-management intervention improved physical activity, healthy eating, and metabolic syndrome risks among low-education women with metabolic syndrome.

Supporting reproductive health among birthing persons with chronic conditions in the United States: A qualitative multilevel study using systems thinking to inform action

OBJECTIVE (STUDY QUESTION)

To use systems thinking with diverse system actors to (a) characterize current problems at the intersection of chronic conditions (CCs) and reproductive health (RH) care and their determinants, (b) determine necessary system actors for change, and (c) document cross-system actions that can improve identified problems in the United States.

DATA SOURCES/STUDY SETTING

Data were collected from six groups of system actors via online focus groups.

STUDY DESIGN

This is a qualitative multilevel study using the iceberg systems thinking framework.

DATA COLLECTION/EXTRACTION METHODS

Data were collected by note-taking and recording six focus groups; analysis incorporated perspective triangulation using the systems thinking iceberg and system mapping to visualize interconnected system challenges, actors, and action ideas.

PRINCIPAL FINDINGS

Participants described eight necessary system actors: health care institutions, medical leaders, medical providers, patient advocates and foundations, patients and families, payors, policy makers, and research funders. Forty pain points were identified, spread across each of the four levels of the systems thinking iceberg: undesirable outcomes (6), concerning trends (9), system structure flaws (15), and problematic mental models (10). In response to these pain points, a set of 46 action ideas was generated by participants and mapped into nine action themes: (1) adjust QI metrics, incentives, and reimbursement, (2) bolster RH medical education and training, (3) break down medical silos, (4) enrich patient education, (5) expand the health care team, (6) improve holistic health care, (7) modify research and programmatic funding to prioritize RH and CC, (8) spur innovation for patient visits, and (9) support professional champions and leaders.

CONCLUSIONS

By embracing system complexity, creating visual maps, and pushing participants to identify actionable strategies for improvement, this study generates a set of specific actions that can be used to address pain points across the multiple system levels that make improving reproductive care for people with CCs so challenging.

Area-level Socioeconomic Disadvantage and Cancer Survival in Metropolitan Detroit

BACKGROUND

Racial segregation is linked to poorer neighborhood quality and adverse health conditions among minorities, including worse cancer outcomes. We evaluated relationships between race, neighborhood social disadvantage, and cancer survival.

METHODS

We calculated overall and cancer-specific survival for 11,367 non-Hispanic Black (NHB) and 29,481 non-Hispanic White (NHW) individuals with breast, colorectal, lung, or prostate cancer using data from the Metropolitan Detroit Cancer Surveillance System. The area deprivation index (ADI) was used to measure social disadvantage at the census block group level, where higher ADI is associated with poorer neighborhood factors. Associations between ADI and survival were estimated using Cox proportional hazards mixed-effects models accounting for geographic grouping and adjusting for demographic and clinical factors.

RESULTS

Increasing ADI quintile was associated with increased overall mortality for all four cancer sites in multivariable-adjusted models. Stratified by race, these associations remained among breast (NHW: HR = 1.16, P < 0.0001; NHB: HR = 1.20, P < 0.0001), colorectal (NHW: HR = 1.11, P < 0.0001; NHB: HR = 1.09, P = 0.00378), prostate (NHW: HR = 1.18, P < 0.0001; NHB: HR = 1.18, P < 0.0001), and lung cancers (NHW: HR = 1.06, P < 0.0001; NHB: HR = 1.07, P = 0.00177). Cancer-specific mortality estimates were similar to overall mortality. Adjustment for ADI substantially attenuated the effects of race on mortality for breast [overall proportion attenuated (OPA) = 47%, P < 0.0001; cancer-specific proportion attenuated (CSPA) = 37%, P < 0.0001] prostate cancer (OPA = 51%, P < 0.0001; CSPA = 56%, P < 0.0001), and colorectal cancer (OPA = 69%, P = 0.032; CSPA = 36%, P = 0.018).

CONCLUSIONS

Area-level socioeconomic disadvantage is related to cancer mortality in a racially diverse population, impacting racial differences in cancer mortality.

IMPACT

Understanding the role of neighborhood quality in cancer survivorship could improve community-based intervention practices.

Newly diagnosed with inflammatory arthritis (NISMA)-development of a complex self-management intervention

BACKGROUND

Patients newly diagnosed with inflammatory arthritis (IA) request regular consultations and support from health professionals to manage physiological, emotional, and social challenges. Evidence suggests that providing a tailored multi-component self-management program may benefit disease management. However, there is a lack of evidence of effective interventions with multiple components targeting the needs of this group. Therefore, the aim of this study was to develop a self-management intervention targeting newly diagnosed patients with IA, following the Medical Research Council (MRC) framework for developing complex interventions.

METHODS

The development of the complex self-management intervention covered three steps. First, the evidence base was identified through literature reviews, in which we described a preliminary nurse-led intervention. Secondly, we chose Social Cognitive Theory as the underlying theory along with Acceptance and Commitment Theory to support our communication strategy. Thirdly, the preliminary intervention was discussed and further developed in workshops to ensure that the intervention was in accordance with patients' needs and feasible in clinical practice.

RESULTS

The developed intervention comprises a 9-month nurse-led intervention (four individual and two group sessions). A physiotherapist and an occupational therapist will attend the group sessions along with the nurse. All sessions should target IA-specific self-management with a particular focus on medical, role, and emotional management.

CONCLUSION

Through the workshops, we involved all levels of the organization to optimize the intervention, but also to create ownership and commitment, and to identify barriers and shortcomings of the preliminary intervention. As a result, from the existing evidence, we believe that we have identified effective mechanisms to increase self-management in people newly diagnosed with IA. Further, we believe that the involvement of various stakeholders has contributed significantly to developing a relevant and feasible intervention. The intervention is a nurse-led complex self-management intervention embedded in a multidisciplinary team (named NISMA). The intervention is currently being tested in a feasibility study.

Do Patients With Intersectional Disadvantage Have Poorer Outcomes From Osteoarthritis Management Programs? A Tapered Balancing Study of Patient Outcomes From the Good Life With Osteoarthritis in Denmark Program

OBJECTIVE

To investigate whether adults with potential multiple social disadvantage have poorer outcomes following attendance in an osteoarthritis (OA) management program (OAMP), and if so, what might determine this result.

METHODS

Among consecutive knee OA attendees of the Good Life With Osteoarthritis in Denmark (GLA:D) OAMP in Denmark we defined a group with potential "intersectional disadvantage" based on self-reported educational attainment, country of birth, and citizenship. Outcomes of this group were compared with GLA:D participants who were native Danish citizens with higher educational attainment. Outcomes were pain intensity, Knee Injury and Osteoarthritis Outcome Score (KOOS) quality of life subscale score, and the EuroQol 5-domain instrument in 5 levels (EQ-5D-5L) score at 3 and 12 months. After data preprocessing, we used entropy balancing to sequentially control for differences between the groups in baseline covariates. Mean between-group differences in outcomes were estimated by weighted linear regression.

RESULTS

Of 18,448 eligible participants, 250 (1.4%) were nonnative/foreign citizens with lower education. After balancing for differences in baseline score and in administrative and demographic characteristics, they had poorer outcomes than higher-educated native Danish citizens on pain intensity and EQ-5D-5L score at both follow-up points (e.g., between-group mean differences in pain visual analog scale [0-100] at 3 and 12 months: 3.4 [95% confidence interval (95% CI) -0.5, 7.3] and 6.2 [95% CI 1.7, 10.7], respectively). Differences in KOOS quality of life subscale score, were smaller or absent. Balancing for differences on baseline score, comorbidity, self-efficacy, and depression had the greatest effect on reducing observed outcome inequalities.

CONCLUSION

Outcome inequalities widened following OAMP attendance, particularly at longer-term follow-up, but the magnitude of differences was generally modest and inconsistent across outcome measures. Tailoring content to reduce outcome inequalities may be indicated, but improving access appears the greater priority.

Self-management of multiple long-term conditions: A systematic review of the barriers and facilitators amongst people experiencing socioeconomic deprivation

BACKGROUND

Multiple long-term conditions are rising across all groups but people experiencing socioeconomic deprivation are found to have a higher prevalence. Self-management strategies are a vital part of healthcare for people with long-term conditions and effective strategies are associated with improved health outcomes in a variety of health conditions. The management of multiple long-term conditions are, however, less effective in people experiencing socioeconomic deprivation, leaving them more at risk of health inequalities. The purpose of this review is to identify and synthesise qualitative evidence on the barriers and facilitators of self-management on long-term conditions in those experiencing socioeconomic deprivation.

METHODS

MEDLINE, EMBASE, AMED, PsycINFO and CINAHL Plus were searched for qualitative studies concerning self-management of multiple long-term conditions among socioeconomically disadvantaged populations. Data were coded and thematically synthesised using NVivo.

FINDINGS

From the search results, 79 relevant qualitative studies were identified after the full text screening and 11 studies were included in the final thematic synthesis. Three overarching analytical themes were identified alongside a set of sub-themes: (1) Challenges of having multiple long-term conditions; prioritisation of conditions, impact of multiple long-term conditions on mental health and wellbeing, polypharmacy, (2) Socioeconomic barriers to self-management; financial, health literacy, compounding impact of multiple long-term conditions and socioeconomic deprivation, (3) Facilitators of self-management in people experiencing socioeconomic deprivation; maintaining independence, 'meaningful' activities, support networks.

DISCUSSION

Self-management of multiple long-term conditions is challenging for people experiencing socioeconomic deprivation due to barriers around financial constraints and health literacy, which can lead to poor mental health and wellbeing. To support targeted interventions, greater awareness is needed among health professionals of the barriers/challenges of self-management among these populations.

Diabetes self-management: a qualitative study on challenges and solutions from the perspective of South African patients and health care providers

BACKGROUND

Health education and self-management are among key strategies for managing diabetes and hypertension to reduce morbidity and mortality. Inappropriate self-management support can potentially worsen chronic diseases outcomes if relevant barriers are not identified and self-management solutions are not contextualised. Few studies deliberately solicit suggestions for enhancing self-management from patients and their providers.

OBJECTIVE

This qualitative study aimed to unravel experiences, identify self-management barriers, and solicit solutions for enhancing self-management from patients and their healthcare providers.

METHODS

Eight in-depth interviews were conducted with healthcare providers. These were followed by four focus group discussions among patients with type-2- diabetes and or hypertension receiving chronic disease care from two health facilities in a peri-urban township in Cape Town, South Africa. The Self-Management framework described by Lorig and Holman, based on work done by Corbin and Strauss was used to analyse the data.

RESULTS

Patients experienced challenges across all three self-management tasks of behavioural/medical management, role management, and emotional management. Main challenges included poor patient self-control towards lifestyle modification, sub-optimal patient-provider and family partnerships, and post-diagnosis grief-reactions by patients. Barriers experienced were stigma, socio-economic and cultural influences, provider-patient communication gaps, disconnect between facility-based services and patients' lived experiences, and inadequate community care services. Patients suggested empowering community-based solutions to strengthen their disease self-management, including dedicated multidisciplinary diabetes services, counselling services; strengthened family support; patient buddies; patient-led community projects, and advocacy. Providers suggested contextualised communication using audio-visual technologies and patient-centred provider consultations.

CONCLUSIONS

Community-based dedicated multidisciplinary chronic disease healthcare teams, chronic disease counselling services, patient-driven projects and advocacy are needed to improve patient self-management.

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.

A parent-led, patient-centered medical home model instruction for interprofessional undergraduate and graduate learning opportunities

INTRODUCTION

Despite national efforts to establish patient-centered medical homes (PCMH), 57.3% of children with special health care needs are receiving care that does not meet medical home criteria. Project DOCC, a national curriculum designed by parents of children with disabilities or chronic disease, has shown documented strengths in medical resident learner education of children with special health care needs from the parent perspectives for over a decade. Because of the importance of PCMH and the need to provide compassionate care, our team adapted the curriculum to incorporate team-based learning in the rural setting.

MATERIALS AND METHODS

Reading materials were distributed to learners prior to an in-person workshop at which time, learners reviewed a video and discussed PCMH materials to identify elements of the PCMH. Learners then engaged with parent mentors across three breakout sessions. A final group reflection was completed to review and discuss efforts providers would take to establish and maintain the PCMH in their own practice. Baseline and post-workshop PCMH perceptions and parent mentor reflections were collected and compared using t-test comparisons.

RESULTS

Learner knowledge, perceptions, and comfort significantly increased after the workshop. Parent mentor comments also highlighted an increased understanding for the provider. Discussion: The adapted PCMH curriculum significantly impacted learner outcomes using a feasible approach that fit nicely within health professional curricula and limited resources of the rural setting. Parents enjoyed the opportunity to serve as mentors and valued the instruction format.

Environmental Regulation and Chronic Conditions: Evidence from China's Air Pollution Prevention and Control Action Plan

In January 2013, a dense haze covered 1.4 million kilometers of China and affected more than 800 million people. Air pollution in China had become a serious threat to the daily lives of people. The State Council of China enacted the "Air Pollution Prevention and Control Action Plan" (APPCAP) in 2013 to lower the particulate matter (PM) level. Between 2013 and 2017, each administrative division established its own environmental preservation strategy in accordance with the APPCAP. We examined the effects of the nationwide air pollution control policy, APPCAP, on chronic health conditions among adults using a nationally representative survey, CFPS, conducted in 2012, 2014, and 2016. We applied a difference-in-differences model, using the time gap when each administrative division implemented the APPCAP. We found that the APPCAP significantly reduced doctor-diagnosed chronic conditions of the respiratory and circulatory systems in the last six months. In respiratory diseases and circulatory system diseases, the treatment effect of the APPCAP was a 34.6% and 11.5% reduction in the sample mean, respectively. The poorest socioeconomic groups and the elderly benefited the most. The stronger the goal, the more positive the effects were on health; the longer the policy intervention, the better the health outcomes were.

Effects of sociodemographic and health factors on the self-management of non-communicable diseases among Chilean adults during the Covid-19 pandemic

Individuals with non-communicable diseases (NCDs) are potentially at increased vulnerability during the Covid-19 pandemic and require additional help to reduce risk. Self-management is one effective strategy and this study investigated the effect of sociodemographic and health factors on the self-management of some non-communicable diseases, namely hypertension, type 2 diabetes mellitus and dyslipidemia, among Chilean adults during the Covid-19 pandemic. A cross-sectional telephone survey was carried out on 910 participants with NCDs, from Santiago, Chile. An adapted and validated version of the "Partners in Health" scale was used to measure self-management. Exploratory Factor analysis yielded five dimensions of this scale: Disease Knowledge, Healthcare Team Relationship, General Self-Management and Daily Routines, Drug Access and Intake, and Monitoring and Decision-Making. The average of these dimensions was calculated to create a new variable Self-Management Mean, which was used as a dependent variable together with the five separate dimensions. Independent variables included age, gender, years of schooling, number of diseases, the percentage of Multidimensional Poverty Index in the commune of residence, and self-rated health status. Beta regressions and ANOVA for the Beta regression residuals were utilized for analyses. Beta regression model explained 8.1% of the variance in Self-Management Mean. Age, years of schooling, number of diseases and self-rated health status were statistically associated with Self-Management Mean and dimensions related to daily routines and health decision making, such as Disease Knowledge, General Self-Management and Daily Routines, and Monitoring and Decision-Making. Gender and the percentage of Multidimensional Poverty Index in the commune of residence were insignificant. Strategies for self-management of NCDs during a crisis should consider age, years of schooling, number of diseases, and self-rated health status in their design.

Use of photo diary and focus group to explore needs for digital disease management program among community older adults with chronic disease

As technology advanced, new e-health solutions are evolved to empower people to manage their care at home. This study explored the needs for disease management in activity tracking using photo diary through older adults' subjective perspective. It further aimed to suggest which lifestyle measures, symptoms and behaviours would be meaningful to include in such a digital diseases care management program for technology design. Both photo diary and focus group discussion were used, 11 older adults with multiple metabolism-related chronic diseases (Mean age, 72.5 ± 6.14 years) were recruited and asked to carry out the photo diary to trace their living situation and needs using a tablet camera. A focus group discussion was applied to identify the needs of chronic disease management, based on the results of living context tracing. Five themes, regular physical activity, smart management of healthy behaviors, healthy diet, regular daily routine and social connection, were identified by content analysis from photo diary and the focus group discussion. The results indicated that the photo diary program can raise awareness and promotes positive behavior changes. It is believed that the E-approach can be applied to the effectively enhance older adults' self-management by monitoring their health status and their daily routine activities.

Self-care Behaviours and Technology utilised during COVID-19: Systematic Review

Background

Self-care behaviors are essential for people living with chronic conditions; however, the outbreak of the COVID-19 pandemic has imposed additional complications on their daily routines. Few studies have analyzed how self-care behaviors have changed during COVID-19 and the role of digital technology, especially among people with chronic conditions.

Objective

This study aims to review how self-care behaviors have changed for people with chronic conditions during the COVID-19 pandemic, and what technology they have adopted to manage their conditions during that period.

Methods

A systematic review was conducted using narrative synthesis. Data were extracted from PubMed, MEDLINE, EMBASE, PsycINFO, CINAHL, and Google Scholar, including articles from December 2019 onward. Eligible studies focused on adults diagnosed with chronic conditions undertaking any self-care tasks in line with the middle-range theory of self-care of chronic illness (ie, self-care maintenance, monitoring, and management). The methodological quality of the included articles was assessed with the McMaster Critical Review Forms for Quantitative or Qualitative Studies.

Results

In total, 36 primary research articles were included. Changes to self-care behaviors during COVID-19 among people with chronic conditions were organized according to the middle-range theory of self-care of chronic illness focusing on self-care maintenance (ie, medication adherence, physical activity, and diet control), self-care monitoring (ie, monitoring signs and symptoms), and self-care management (ie, consultations with health care providers). Positive self-care behaviors observed include the following: individuals trying to maintain good glycemic control during COVID-19 increased their medication adherence in 27% (10/36) of studies; and diet control improved in 50% (18/36) of studies. Negative self-care behaviors observed include the following: decline in physical activities and increased sedentariness were observed in 65% (23/36) of studies; poor diet control was observed in 57% (21/36) of studies; and self-monitoring of health status dropped in 43% (15/36) of studies. The use of technology to support self-care of chronic conditions during COVID-19 was reported in 72% (26/36) of studies. The actual use of telehealth in place of physical consultations during COVID-19 was observed in 50% (18/36) of studies, and other digital technologies (eg, social media apps, smartphone apps, web-based platforms, and web browsing) were used in 50% (18/36) of studies. Telehealth was discussed and recommended as the default technology in delivering future health care services during COVID-19 and beyond in 77% (28/36) of studies.

Conclusions

This review highlighted the necessity to rethink how models of self-care should continue to address the demands of chronic conditions while being responsive to the imminent threats of infectious diseases. Perhaps the silver lining of COVID-19 is that adoption of digital technology (especially telehealth) among a vast cross-section of people with chronic conditions is possible. Future research should investigate effective ways to incorporate evidence-based digital health tools into these new models of self-care that address the challenges of chronic and infectious conditions.

How the Term 'Self-Management' is Used in HIV Research in Low- and Middle-Income Countries: A Scoping Review

This scoping review assessed how the term 'self-management' (SM) is used in peer-reviewed literature describing HIV populations in low- and middle-income countries (LMIC). This review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews. OVID Medline, Embase, CAB Abstracts, and EBSCO CINAHL, Scopus, and Cochrane Library were searched up to September 2021 for articles with SM in titles, key words, or abstracts. Two team members independently screened the titles and abstracts, followed by the full-text. A data extraction tool assisted with collecting findings. A total of 103 articles were included. Since 2015, there has been a 74% increase in articles that use SM in relation to HIV in LMIC. Fifty-three articles used the term in the context of chronic disease management and described it as a complex process involving active participation from patients alongside providers. Many of the remaining 50 articles used SM as a strategy for handling one's care by oneself, with or without the help of community or family members. This demonstrates the varied conceptualizations and uses of the term in LMIC, with implications for the management of HIV in these settings. Future research should examine the applicability of SM frameworks developed in high-income settings for LMIC.

Recruitment and engagement in disease self-management programs: Special concerns for rural residents reporting depression and/or anxiety

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Poorer health outcomes are correlated with depression/anxiety in a rural population.

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Electronic modes of recruitment engage those reporting depression/anxiety into CDSME.

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CDSME increases patient activation regardless of history of depression/anxiety.

Chronic disease self-management education (CDSME) programs benefit individuals with chronic diseases, including mental health conditions, by improving health-related outcomes and increasing engagement with the health care system. Recruiting individuals with a history of mental health conditions to participate in CDSME is challenging, particularly in rural, underserved areas. Hence, it is important to understand factors associated with the presence of mental health conditions, and impacts of CDSME on patient engagement. This project identifies individual and program-level characteristics, as well as recruitment characteristics, associated with reporting a history of depression and/or anxiety. It also assesses factors related to program engagement and the relationship between completing CDSME and patient activation. Data were collected during CDSME workshops offered in 2019 in a rural region of New York. Of the 421 enrollees who completed survey instruments, 162 reported a history of depression and/or anxiety. Univariate analyses indicated that those reporting a history of depression and/or anxiety were younger, female, in poorer health, had more comorbidities, were Medicaid beneficiaries, and had lower patient activation scores. They also heard about and signed up for the workshop through the internet at higher rates than those not reporting a history of depression and/or anxiety. Multivariable logistic regression modeling indicated age, self-rated health, and number of comorbidities were independent predictors of reporting a history of depression and/or anxiety. Among CDSME completers, patient activation significantly improved regardless of history of depression and/or anxiety. Engaging individuals with mental health conditions in CDSME requires a multimodal recruitment strategy incorporating electronic marketing and registration.

Do recommended interventions widen or narrow inequalities in musculoskeletal health? An equity-focussed systematic review of differential effectiveness

Background

It is unclear whether seven interventions recommended by Public Health England for preventing and managing common musculoskeletal conditions reduce or widen health inequalities in adults with musculoskeletal conditions.

Methods

We used citation searches of Web of Science (date of ‘parent publication’ for each intervention to April 2021) to identify original research articles reporting subgroup or moderator analyses of intervention effects by social stratifiers defined using the PROGRESS-Plus frameworks. Randomized controlled trials, controlled before-after studies, interrupted time series, systematic reviews presenting subgroup/stratified analyses or meta-regressions, individual participant data meta-analyses and modelling studies were eligible. Two reviewers independently assessed the credibility of effect moderation claims using Instrument to assess the Credibility of Effect Moderation Analyses. A narrative approach to synthesis was used (PROSPERO registration number: CRD42019140018).

Results

Of 1480 potentially relevant studies, seven eligible analyses of single trials and five meta-analyses were included. Among these, we found eight claims of potential differential effectiveness according to social characteristics, but none that were judged to have high credibility.

Conclusions

In the absence of highly credible evidence of differential effectiveness in different social groups, and given ongoing national implementation, equity concerns may be best served by investing in monitoring and action aimed at ensuring fair access to these interventions.

Systematic review of perception of barriers and facilitators to chronic disease self-management among older adults: Implications for evidence-based practice

BACKGROUND

An aging population has contributed to an increased prevalence in chronic disease. To empower patients, healthcare systems are shifting toward chronic disease self-management. However, no review on how older adults self-manage chronic disease and the barriers and facilitators they experience has been published.

AIMS

To explore barriers and facilitators perceived by older adults during the process of self-managing chronic disease.

METHODS

A systematic review of qualitative literature was performed using the Joanna Briggs Institute methodology. The literature search was conducted using Ovid databases (MEDLINE, CINAHL with full text, and PsycINFO) for the period of 1988-2020. All records were screened using predetermined eligibility criteria. The critical appraisal instrument QARI (Qualitative Assessment and Review Instrument) was employed to assess the quality of the included studies. Data from the included papers were extracted using the QARI data extraction tool. Extracted data were then synthesized to produce final sets of themes and sub-themes relating to the review question.

RESULTS

A total of 267 abstracts were screened, and 13 studies reporting barriers and facilitators perceived by older adults during the process of managing chronic diseases were included in the review. Physical and cognitive decline, low-health literacy, culture, and relationships with healthcare professionals were described as barriers. Facilitators were described as resources that supported disease self-management and included family, social networks, healthcare professionals, and religious beliefs.

LINKING EVIDENCE TO ACTION

This study highlights the importance of understanding the patients' perspectives of the barriers and enablers of self-management of chronic illness for health professionals across settings. Understanding barriers and facilitators to chronic disease self-management will support health professionals to identify strength-based approaches to self-management that meet the needs of individual older adults.

Improvements in physical activity and some dietary behaviors in a community health worker-led diabetes self-management intervention for adults with low incomes: results from a randomized controlled trial

People with low incomes have a disproportionate prevalence of diabetes and its complications and experience many barriers to self-management, which community health workers (CHWs) may help address. We sought to examine the effects of an in-home CHW-led intervention for adults with diabetes and incomes <250% of the federal poverty line on self-management behaviors and test mediators and moderators. From 2010 to 2013, we randomized participants from three Washington State health systems with type 2 diabetes and hemoglobin A1c (HbA1c) ≥ 8% to the CHW intervention (N = 145) or usual care control (N = 142) arms. We examined effects on 12-month self-management: physical activity, dietary behaviors, medication taking, blood glucose monitoring, foot care, and tobacco use. For behaviors with significant intervention-control group differences, we tested mediation by self-efficacy and social support. We also investigated whether intervention-associated changes in behaviors varied by race/ethnicity, gender, and baseline values of HbA1c, diabetes distress, depression, and food insecurity (moderators). Compared to controls, intervention participants engaged in more physical activity and reported better dietary behaviors for some measures (general diet, frequency of skipping meals, and frequency of eating out) at 12-months, but there was no evidence of mediation by self-efficacy or social support. Evidence of moderation was limited: improvements in the frequency of skipping meals were restricted to participants with baseline HbA1c < 10%. Study findings suggest CHWs could be integrated into diabetes care to effectively support lifestyle changes around physical activity and some eating behaviors among adults with low incomes. More research is needed to understand mechanisms of change.

Ineffective health management: A systematic review and meta-analysis of related factors

PURPOSE

A standardized language system can support the elaboration of clinical guidelines by matching information from similar patterns of response to people. To identify the factors that are related to a higher likelihood of an ineffective health management nursing diagnosis.

METHODS

We conduct a systematic review and meta-analysis. An electronic search was conducted in MEDLINE databases via PubMed, Web of Science, SciELO, CINAHL, SCOPUS, and Embase between October and November 2020. Descriptive data were extracted from each article. The odds ratios for each etiological factor related to ineffective health management were directly extracted from the articles or calculated from the data described in the articles. The analysis of the measurements of exposure and the magnitude of the effect was performed using the statistical software R, and a forest plot was constructed for each etiological factor.

FINDINGS

Ten studies were included, and 15 related factors were recovered from the primary studies. The factors that significantly increased the likelihood of an ineffective health management nursing diagnosis were insufficient knowledge of the therapeutic regimen, perceived barriers, powerlessness, economic disadvantage, and difficulty managing complex treatment regimens. No effect was verified with the following factors: decision conflict, family pattern of healthcare, and inadequate number of cues to action.

CONCLUSION

Factors related to a higher likelihood of ineffective health management may be the focus of early and targeted nursing interventions, contributing to an improved quality of care.

CLINICAL RELEVANCE

Understanding exposure to these factors can improve diagnostic reasoning at different population levels.

Living with a chronic disease: insights from patients with a low socioeconomic status

Background

Little is known about how patients with low socioeconomic status (SES) experience their chronic disease, and how it impacts health-related quality of life (HRQoL). Compared to their more affluent counterparts, worse outcomes have been reported. A better understanding of the domains of HRQoL that are relevant to these specific populations is therefore needed. We explored the experiences of living with a chronic disease in low SES persons.

Methods

A qualitative interview study was performed in Flanders, Belgium. Semi-structured interviews were conducted in chronically ill patients, selected through purposive sampling. Interviews were audio-recorded and transcribed verbatim. Analysis followed an inductive and iterative approach.

Results

Fifteen patients were interviewed. Six major themes were identified: a heavy bag to carry, loss of autonomous life, inner and outer loneliness, emotional imbalance, unmet need for support, and coping strategies. Patients experienced their illness as an additional problem on top of all other problems (i.e. financial/social problems, traumatic life events). In general, the disease burden and non-disease burden were mutually reinforcing, resulting in greater dependency, greater risk of social isolation, greater psychological distress, and greater risk of impaired HRQoL.

Conclusions

This study is the first to provide detailed insight into the experiences of living with a chronic disease in low SES persons. A conceptual model is proposed that can be used in daily clinical practice to raise awareness among clinicians and health care providers that the patient’s needs go beyond the disease itself. Future research is needed to validate and test the model.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-021-01578-7.

The impact of poverty and deprivation at the end of life: a critical review

This critical review interrogates what we know about how poverty and deprivation impact people at the end of life and what more we need to uncover. While we know that people in economically resource-rich countries who experience poverty and deprivation over the life course are likely to die younger, with increased co-morbidities, palliative care researchers are beginning to establish a full picture of the disproportionate impact of poverty on how, when and where we die. This is something the Covid-19 pandemic has further illustrated. Our article uses a critical social science lens to investigate an eclectic range of literature addressing health inequities and is focused on poverty and deprivation at the end of life. Our aim was to see if we could shed new light on the myriad ways in which experiences of poverty shape the end of people's lives. We start by exploring the definitions and language of poverty while acknowledging the multiple intersecting identities that produce privilege. We then discuss poverty and deprivation as a context for the nature of palliative care need and overall end-of-life circumstances. In particular, we explore: total pain; choice at the end of life; access to palliative care; and family caregiving. Overall, we argue that in addressing the effects of poverty and deprivation on end-of-life experiences, there is a need to recognise not just socio-economic injustice but also cultural and symbolic injustice. Too often, a deficit-based approach is adopted which both 'Others' those living with poverty and renders invisible the strategies and resilience they develop to support themselves, their families and communities. We conclude with some recommendations for future research, highlighting in particular the need to amplify the voices of people with lived experience of poverty regarding palliative and end-of-life care.

Patient Activation, Depressive Symptoms, and Self-Rated Health: Care Management Intervention Effects among High-Need, Medically Complex Adults

The purpose of this randomized controlled trial (n = 268) at a Federally Qualified Health Center was to evaluate the outcomes of a care management intervention versus an attention control telephone intervention on changes in patient activation, depressive symptoms and self-rated health among a population of high-need, medically complex adults. Both groups had similar, statistically significant improvements in patient activation and self-rated health. Both groups had significant reductions in depressive symptoms over time; however, the group who received the care management intervention had greater reductions in depressive symptoms. Participants in both study groups who had more depressive symptoms had lower activation at baseline and throughout the 12 month study. Findings suggest that patients in the high-need, medically complex population can realize improvements in patient activation, depressive symptoms, and health status perceptions even with a brief telephone intervention. The importance of treating depressive symptoms in patients with complex health conditions is highlighted.

Good Sleep Quality Improves the Relationship Between Pain and Depression Among Individuals With Chronic Pain

Individuals with chronic pain often experience co-existing sleep problems and depression-related states. Chronic pain, sleep problems, and depression interrelate, and have been shown to exacerbate one another, which negatively impacts quality of life. This study explored the relationships between pain severity, pain interference, sleep quality, and depression among individuals with chronic pain. Secondly, we tested whether sleep quality may moderate the relationship between pain and depression. A cross-sectional survey was completed by 1,059 adults with non-malignant chronic pain conditions (M age 43 years, 88% identified as women) and collected measures related to pain severity, pain interference, sleep quality, and depression. Multiple regression analyses found that pain severity, pain interference, and sleep quality are all significantly associated with depression. Secondly, moderated regression analyses revealed that sleep quality moderates the relationship between pain interference and depression among individuals with chronic pain such that good sleep quality attenuates the effect of pain interference on depression, and poor sleep quality amplifies the effect of pain interference on depression. These findings suggest that sleep quality may be a relevant therapeutic target for individuals with chronic pain and co-existing depression.

Management of Cancer and Health After the Clinic Visit: A Call to Action for Self-Management in Cancer Care

Individuals with cancer and their families assume responsibility for management of cancer as an acute and chronic disease. Yet, cancer lags other chronic diseases in its provision of proactive self-management support in routine, everyday care leaving this population vulnerable to worse health status, long-term disability, and poorer survival. Enabling cancer patients to manage the medical and emotional consequences and lifestyle and work changes due to cancer and treatment is essential to optimizing health and recovery across the continuum of cancer. In this paper, the Global Partners on Self-Management in Cancer puts forth six priority areas for action: Action 1: Prepare patients and survivors for active involvement in care; Action 2: Shift the care culture to support patients as partners in cocreating health and embed self-management support in everyday health-care provider practices and in care pathways; Action 3: Prepare the workforce in the knowledge and skills necessary to enable patients in effective self-management and reach consensus on core curricula; Action 4: Establish and reach consensus on a patient-reported outcome system for measuring the effects of self-management support and performance accountability; Action 5: Advance the evidence and stimulate research on self-management and self-management support in cancer populations; Action 6: Expand reach and access to self-management support programs across care sectors and tailored to diversity of need and stimulation of research to advance knowledge. It is time for a revolution to better integrate self-management support as part of high-quality, person-centered support and precision medicine in cancer care to optimize health outcomes, accelerate recovery, and possibly improve survival.

Sustained long-term benefits of patient support program participation in immune-mediated diseases: improved medication-taking behavior and lower risk of a hospital visit

BACKGROUND: Patient support programs (PSPs) improve medication-taking behavior in the first 12 months of treatment for patients with immune-mediated diseases, but it is unknown if these benefits are sustained. As immune-mediated diseases continue to increase in prevalence and economic burden, understanding the potential value of PSPs in helping patients adhere to their long-term treatment plan and avoid costly hospital visits is crucial. Launched nationally in 2015, HUMIRA Complete (a PSP for adalimumab patients) provides an opportunity to study long-term effects of PSP participation, including the impact on medication-taking behavior and hospital visits. OBJECTIVE: To evaluate the sustained relationship between PSP participation, long-term medication-taking behavior, and hospital visits. METHODS: A longitudinal, retrospective matched-cohort study was conducted of patients initiating adalimumab between January 2015 and February 2016 with or without enrolling in the PSP, using patient-level data from the HUMIRA Complete PSP linked with Symphony Health claims. The sample included adult, commercially insured patients diagnosed with an indicated disease who were biologic-naive and had data available for ≥ 6 months before and ≥ 12 months after initiating adalimumab. Adherence (proportion of days covered) and hospital visits were assessed at 12, 24, and 36 months for patients with sufficient follow-up data. Multivariable generalized models estimated differences between cohorts, controlling for baseline characteristics and hospital visits. Duration of persistence and time to a hospital visit were compared using Kaplan-Meier analyses. Hazard ratios were estimated using multivariable Cox proportional hazards models. RESULTS: The matched cohort included 2,268 patients (1,134 per cohort), and patient attrition was similar across cohorts. The PSP cohort consistently demonstrated higher adalimumab adherence than the non-PSP cohort at 12 (64.8% vs. 50.1%, P < 0.0001; 29% greater), 24 (49.4% vs. 38.4%; P < 0.0001; 29% greater), and 36 (39.4% vs. 35.1%; P = 0.02; 12% greater) months. PSP participation was associated with a 30% lower hazard of discontinuation (P < 0.0001), and median duration of persistence was 4.8 months longer for the PSP cohort (13.2 vs. 8.4 months; P < 0.0001). The PSP cohort had lower rates of hospital visits at 12 (30% vs. 37%; P < 0.001; 19% lower), 24 (44% vs. 53%; P = 0.01; 17% lower), and 36 (55% vs. 65%; P < 0.01; 16% lower) months, and PSP participation was associated with a 25% lower hazard of a hospital visit (P < 0.0001). Median time to a hospital visit was 10.8 months longer for the PSP cohort (32.7 vs. 21.9 months; P < 0.0001). Findings were consistent across therapeutic areas: hazard of a hospital visit was 28%, 27%, and 37% lower for rheumatology, gastroenterology, and dermatology patients participating in the PSP (all P < 0.05). CONCLUSIONS: Patients with immune-mediated diseases receiving adalimumab and utilizing this PSP had improved long-term medication-taking behavior and lower risk of hospital visits, demonstrating the potential of PSPs to improve patient outcomes and lower the burden to the health care system. DISCLOSURES: Design, study conduct, and financial support for the study were provided by AbbVie Inc., which participated in the interpretation of data, review, and approval of the manuscript. Fendrick has received personal fees from Merck, AstraZeneca, Trizetto, Amgen, Lilly, AbbVie, Johnson & Johnson, and Sanofi; grants from the National Pharmaceutical Council, PhRMA, the Gary and Mary West Health Foundation, the states of New York and Michigan, the Laura and John Arnold Foundation, the Robert Wood Johnson Foundation, and the Agency for Healthcare Research and Quality; and equity in Zansors, Sempre Health, Wellth, and V-BID Health. Brixner has received consulting fees from AbbVie, Novartis, Xcenda, Elevar Therapeutics, Sanofi, UCB Pharma, and the Millcreek Outcomes Group. Rubin has received consulting fees from AbbVie, Abgenomics, Allergan Inc., Amgen, Celgene Corporation, Forward Pharma, Genentech/Roche, Janssen Pharmaceuticals, Merck & Co., Miraca Life Sciences, Mitsubishi Tanabe Pharma Development America, Napo Pharmaceuticals, Pfizer, Salix Pharmaceuticals Inc., Samsung Bioepis, Sandoz Pharmaceuticals, Shire, Takeda, and Target Pharmaceuticals; and research support from AbbVie, Genentech/Roche, Janssen Pharmaceuticals, Prometheus Laboratories, Shire, Takeda, and UCB Pharma. Mease has received grant/research support from AbbVie, Amgen, BMS, Celgene, Janssen, Lilly, Merck, Novartis, Pfizer, SUN Pharma, and UCB; consulting fees from AbbVie, Amgen, BMS, Boehringer Ingelheim, Celgene, Galapagos, Genentech, Gilead, GlaxoSmithKline, Janssen, Lilly, Novartis, Pfizer, SUN Pharma, and UCB; and has served on the speakers bureau for AbbVie, Amgen, Celgene, Janssen, Lilly, Novartis, Pfizer, and UCB. Liu has no financial conflict of interest. Davis is an employee of Medicus Economics, which received payment from AbbVie to participate in this research. Mittal is an employee and stockholder of AbbVie. This study used a cohort of patients previously described in Brixner D, Rubin DT, Mease P, et al. Patient support program increased medication adherence with lower total health care costs despite increased drug spending. J Manag Care Spec Pharm. 2019 Jul;25(7):770-79 (doi: 10.18553/jmcp.2019.18443). As such, the sample selection and select baseline characteristics and 12-month outcomes have been published previously; however, the hospital visit outcomes and the longer-term medication-taking behavior outcomes have not been previously published or presented.

What matters when exploring fidelity when using health IT to reduce disparities?

BACKGROUND

Implementation of evidence-based interventions often involves strategies to engage diverse populations while also attempting to maintain external validity. When using health IT tools to deliver patient-centered health messages, systems-level requirements are often at odds with 'on-the ground' tailoring approaches for patient-centered care or ensuring equity among linguistically diverse populations.

METHODS

We conducted a fidelity and acceptability-focused evaluation of the STAR MAMA Program, a 5-month bilingual (English and Spanish) intervention for reducing diabetes risk factors among 181 post-partum women with recent gestational diabetes. The study's purpose was to explore fidelity to pre-determined 'core' (e.g. systems integration) and 'modifiable' equity components (e.g. health coaching responsiveness, and variation by language) using an adapted implementation fidelity framework. Participant-level surveys, systems-level databases of message delivery, call completion, and coaching notes were included.

RESULTS

96.6% of participants are Latina and 80.9% were born outside the US. Among those receiving the STAR MAMA intervention; 55 received the calls in Spanish (61%) and 35 English (39%). 90% (n = 81) completed ≥ one week. Initially, systems errors were common, and increased triggers for health coach call-backs. Although Spanish speakers had more triggers over the intervention period, the difference was not statistically significant. Of the calls triggering a health coach follow-up, attempts were made for 85.4% (n = 152) of the English call triggers and for 80.0% (n = 279) of the Spanish call triggers (NS). Of attempted calls, health coaching calls were complete for 55.6% (n = 85) of English-language call triggers and for 56.6% of Spanish-language call triggers (NS). Some differences in acceptability were noted by language, with Spanish-speakers reporting higher satisfaction with prevention content (p = < 0.01) and English-speakers reporting health coaches were less considerate of their time (p = 0.03).

CONCLUSIONS

By exploring fidelity by language-specific factors, we identified important differences in some but not all equity indicators, with early systems errors quicky remedied and high overall engagement and acceptability. Practice implications include: (1) establishing criteria for languge-equity in interventions, (2) planning for systems level errors so as to reduce their impact between language groups and over time; and (3) examining the impact of engagement with language-concordant interventions on outcomes, including acceptability. Trial Registration National Clinical Trials registration number: CT02240420 Registered September 15, 2014. ClinicalTrials.gov.

Prevalence, types, and combinations of multiple problems among recipients of work disability benefits

PURPOSE

For persons on disability benefits who are facing multiple problems, active labour market policies seem less successful. Besides health problems, these people perceive personal, social, and environmental problems. Since very little is known about these "non-medical" problems our aim was to explore the prevalence of clients experiencing multiple problems, the types and number of perceived problems, combinations of perceived problems, and associated characteristics in a group of work disability benefit recipients.

METHODS

We performed a cross-sectional study, using self-reported data on perceived problems and socio-demographics, and register data from the Dutch Social Security Institute on diagnosed diseases and employment status. A convenient group of labour experts recruited eligible clients on work disability benefit.

RESULTS

Of the 207 persons on work disability benefit, 87% perceived having multiple problems. Most reported problems were related to physical (76%) or mental (76%) health. Health problems most frequently occurred together with a mismatch in education, financial problems, or care for family members. Clients with lower education experienced significantly more problems than clients with an intermediate or high educational level.

CONCLUSIONS

Clients with multiple problems face severe and intertwined problems in different domains of life, and need tailored multi-actor work disability management.Implications for rehabilitationClients with multiple problems face severe and intertwined problems in different domains of life; therefore, interventions tailored to deal with needs related to specific problems might be more effective than traditional programs.Interventions should match experienced barriers, and involve multi-actor work disability management with all the challenges of mutual cooperation.For persons with multiple problems a focus on pure medical barriers is too narrow, because personal, social, and environmental factors might also obstruct participation in work.

Attendance, activation and health profiles of participants, a prospective study on a regional cardiometabolic disease self-management program in Laval, Canada

Background

Chronic diseases are responsible for over 70% of all deaths globally. While some self-management programs have been shown to be efficacious in preventing or altering trajectories for some chronic conditions, scaling-up and sustaining such programs beyond tightly-controlled study conditions remain a major challenge. CISSS-Laval partnered with the Cardiovascular Health Awareness Program team to co-develop Cible-santé/prévention and evaluate the first cohort of participants enrolled in the program, in order to better understand the program’s implementation and scope. The objective of the current study was to describe the profile of attendees and the level of engagement of participants in a new, region-wide cardiometabolic disease self-management program offered in Laval, Canada.

Methods

This was a prospective study with no comparison group. Potential participants were identified and referred to the program from April to December 2015 by their primary care health professional practicing in one of the city’s interdisciplinary primary care clinics. They had their blood pressure, waist circumference and body mass index measured by trained volunteers, and completed a questionnaire on health habits, level of activation and the risk of developing prediabetes and type 2 diabetes over the next 10 years.

Results

A descriptive analysis of the first cohort of 141 Cible-Santé/prévention participants showed very low attendance. Furthermore, only 1 in 10 of enrolled participants completed the full program. The program typically attracted adults with some risk factors associated with their conditions (high waist circumference, obesity), but with an already high level of knowledge, skills and confidence to participate in self-management activities.

Conclusion

This study provides a portrait of new participants to a self-management cardiometabolic disease program, which highlights the potential of supporting patients ready to make changes but also exposes the difficulty of attracting a larger number and diversity of participants and in encouraging completion of the program.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-10558-6.

Acute impact of a national lockdown during the COVID-19 pandemic on wellbeing outcomes among individuals with chronic pain

Changes to wellbeing in a community-based sample of 638 adults with non-malignant chronic pain were assessed during a period of mandated lockdown measures in the UK to control the COVID-19 outbreak. Participants completed an online survey pre-lockdown and were followed up during lockdown. Multivariate analysis demonstrated that decreased ability to self-manage pain, restricted access to healthcare and increased dependence on others were associated with negative wellbeing outcomes related to sleep, anxiety and depression. Essential but non-urgent services are required during periods of lockdown to maintain independence and self-management in order to preserve wellbeing in this population.

Renegotiating dimensions of the self: A systematic review and qualitative evidence synthesis of the lived experience of self-managing rheumatoid arthritis

Background

As chronic illnesses, such as rheumatoid arthritis (RA), place an increased burden on health‐care systems, the ability of individuals to self‐manage these diseases is crucial.

Objective

To identify and synthesize the lived experience of self‐management described by adults living with RA.

Design

A systematic search of five electronic databases (MEDLINE, CINAHL, EMBASE, PsycINFO and ASSIA) was undertaken to identify relevant studies. Data were extracted and quality‐assessed using CASP guidelines. A meta‐synthesis was conducted based on Thomas and Harden's thematic synthesis approach.

Results

The search identified 8423 publications. After removing duplicates, 6527 records remained of which 32 studies met the inclusion criteria. Quality of studies was moderate to high, yet a considerable lack of reflection on researcher bias was evident. Our analysis identified 28 dimensions of self‐management RA across six domains: (a) cognitive‐emotional, (b) behavioural, (c) social, (d) environmental, (e) physical and (f) technological. Cognitive‐emotional experiences dominated the analysis. Renegotiating ‘the self’ (self‐concept, self‐esteem, self‐efficacy) was a key focus of self‐management among individuals with RA.

Conclusion

Our findings highlight the focus of ‘the self’ as a central concern in the self‐management of RA. Standardized self‐management programmes may primarily focus on disease management and daily functioning. However, we suggest that personal biographies and circumstances should move to the fore of self‐management support.

Registration

PROSPERO International Prospective Register of Systematic Reviews 2018: CRD42018100450.

Patient or Public Contribution

Patient and public involvement was not explicit in this review. However, three authors provided a patient perspective on the self‐management of arthritis and autoimmune disease.

Segmentation of health-care consumers: psychological determinants of subjective health and other person-related variables

Background

There is an observable, growing trend toward tailoring support programs – in addition to medical treatment – more closely to individuals to help improve patients’ health status. The segmentation model developed by Bloem & Stalpers [Nyenrode Research Papers Series 12:1–22, 2012] may serve as a solid basis for such an approach. The model is focused on individuals’ ‘health experience’ and is therefore a ‘cross-disease’ model. The model is based on the main psychological determinants of subjective health: acceptance and perceived control. The model identifies four segments of health-care consumers, based on high or low values on these determinants. The goal of the present study is twofold: the identification of criteria for differentiating between segments, and profiling of the segments in terms of socio-demographic and socio-economic variables.

Methods

The data (acceptance, perceived control, socio-economic, and socio-demographic variables) for this study were obtained by using an online survey (a questionnaire design), that was given (random sample N = 2500) to a large panel of Dutch citizens. The final sample consisted of 2465 participants – age distribution and education level distribution in the sample were similar to those in the Dutch population; there was an overrepresentation of females. To analyze the data factor analyses, reliability tests, descriptive statistics and t-tests were used.

Results

Cut-off scores, criteria to differentiate between the segments, were defined as the medians of the distributions of control and acceptance. Based on the outcomes, unique profiles have been formed for the four segments: 1. ‘Importance of self-management’ – relatively young, high social class, support programs: high-quality information. 2. ‘Importance of personal control’ – relatively old, living in rural areas, high in homeownership; supportive programs: developing personal control skills. 3. ‘Importance of acceptance’ – relatively young male; supportive programs: help by physicians and nurses. 4. ‘Importance of perspective and direction’ – female, low social class, receiving informal care; support programs: counseling and personal care.

Conclusions

The profiles describe four segments of individuals/patients that are clearly distinct from each other, each with its own description. The enriched descriptions provide a better basis for the allocation and developing of supportive programs and interventions across individuals.

Changes in health inequalities for patients with diabetes among middle-aged and elderly in China from 2011 to 2015

BACKGROUND

The purpose of this paper is to measure income-related health inequality among middle-aged and elderly patients with diabetes in China from 2011 to 2015 and to investigate factors that might be related to this inequality.

METHODS

The data for this study were obtained from the China Health and Retirement Longitudinal Study that was carried out in 2011, 2013 and 2015. In total, 48,519 Chinese middle-aged and elderly population were included (15,457 in 2011, 16,576 in 2013 and 16,486 in 2015). A principal component analysis was performed to measure asset-based economic status. The concentration index was used to measure income-related inequality in patients with diabetes. Additionally, by used generalized linear model, we decomposed the concentration index to identify factors that explained wealth-related inequality in patients with diabetes.

RESULTS

The prevalence of self-reported diabetes among middle-aged and elderly Chinese was 5.61, 7.49 and 8.99% in 2011, 2013 and 2015, respectively. The concentration indices and 95% confidence intervals for diabetes were 0.1359 (0.0525-0.0597), 0.1207 (0.0709-0.0789), 0.1021 (0.0855-0.0942) in 2011, 2013, and 2015, respectively, which are indicative of inequality that favors the rich. The decomposition of the concentration index showed that residence (39.38%), BMI (31.16%), education (7.28%), and region (6.09%) had positive contributions to the measured inequality in diabetes in China in 2015. Age (- 29.93%) had a negative contribution to inequality.

CONCLUSION

The findings confirm a health inequality in diabetes that favor the rich. Furthermore, the inequality declined from 2011 to 2015. We suggest that policy and intervention strategies should be developed to alleviate this health inequality, such as narrow the gap between urban and rural areas by improving the urban-rural medical insurance scheme, implementing strategies to enhance hygiene health education, control obesity rate.