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Self-Management
and Behavioral Change Support
Reducing complications
and symptoms from most chronic diseases requires changes in lifestyle
and the development of self-management competencies by the patient
and family. For example, for the large majority of back pain patients,
outcomes may be more dependent on effective self-care than on
diagnostic or therapeutic interventions (Von
Korff, 1994). Essentially all successful protocols or chronic
illness programs provide some program to address these issues.
More importantly, staff must be able and willing to implement
regular assessment of patient needs, including those relating
to symptoms. Care must be a shared responsibility between patients
and providers.
Generally, successful
self-management programs provide these elements to help patients
become better managers of their care:
- Collaborative
problem definition (Glasgow
and Anderson, 1999; Inui
and Carter, 1985; Giloth,
1990): Both patients and providers contribute their
perspectives and priorities in defining issues to be addressed
by clinical and educational interventions.
- Targeting,
goal setting, and planning
(Glasgow,
1995): Approaches that target the issues of greatest
importance to both patients and providers, set realistic goals,
and develop a personalized improvement plan are more likely
to be successful.
- A
continuum of self-management training and support services:
For most chronic illnesses, this includes instruction in disease
management, behavioral change support, exercise options, and
interventions that target the psychosocial impact of chronic
illness (Glasgow
and Toobert., 2000; Davis
et al., 1994).
- Active
and sustained follow-up:
Evidence suggests that routine follow-up initiated by the provider
leads to better outcomes (Wasson
et al., 1992; Stuck
et al., 1995).
Evidence of the effectiveness
of self-management and exercise interventions on improving symptoms
in arthritis is impressive (Lorig
et al., 1999; Lorig
and Holman, 1989; Barlow
et al., 1999; Ettinger
et al., 1997; Burton
et al., 1999; Lonn
et al., 1999; Lindroth
et al., 1997; Kovar
et al., 1992). Table 1 below presents examples of studies
that focus on the positive effects of self-management support
on symptom control and other key patient indicators. In most cases,
self-management interventions directed at improving health status
and reducing disability and pain are effective. For example, Ettinger
and colleagues (1997)
demonstrated 10% lower (better) disability scores, 16% better
ambulation, and 11% lower (better) pain scores in an aerobic exercise
group versus standard education group.
| Table
6.1 Sample Self-management Programs and Interventions
in Arthritis
|
|---|
| Title/Description
| Study
design & duration
| Intervention
| Patients
| Summary
|
|---|
| Long-term
outcomes of an arthritis self-management program (Barlow
et al., 1998) | Non-randomized,
pre-post, 12 months | Arthritis
Self Management Program | n=112
OA(44%)
RA(46%)
other(10%)
| Pts.
reported increased self-efficacy; improved symptom management,
communication, and decreased pain; and anxiety from
baseline. No increasing trend in disability for tx.
group. |
| Evaluation
of computer assisted education on patients' appropriate
use of medication (Edworthy et al., 1999) | Randomized
double-blind, 8 weeks | Computer
assisted education on appropriate and in appropriate
use of medications for OA vs. generic information about
OA | n=252
OA
of knee and hip
| More
patients in experimental group demonstrated appropriate
utilization of medication for OA. Trend was observed
toward less stiffness and disability among experimental
group. |
| Evaluation
of a supervised fitness walking program on functional
status, pain, and use of medication (Kovar et al., 1992) | Randomized
8 weeks | Fitness
walking program and patient education vs. standard care | n=102
OA
of knee
| Walking
distance and functional status increased and pain decreased
among walking program participants. Walking group used
less medication, but not significant. |
| Evaluation
of an arthritis education program (Lindroth et al.,
1997) | Non-randomized,
12 months | "Educational-behavioral"
based program vs. control | n=200
OA
(65/200)
RA (135/200)
| Intervention
group reported improved knowledge, increased work simplification
and reduced problems. There was a trend toward lower
disability in the tx. group but no difference in perception
of pain. |
| Effects
of self-care education on inner-city patients with knee
OA (Mazzuca et al., 1997) | Non-randomized,
single-blind, 12 months | Self-care
education about OA vs. attention-control | n=221
OA
of knee
| Education
group reported significantly less disability and resting
pain. Decreased pain was maintianed at one-year assessment. |
|
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