Self-management Efforts Research Articles

Psychosocial Issues in Diabetes Self-Management: Strategies for Healthcare Providers

Education and training for diabetes mellitus self-management is widely available and an essential part of many diabetes centres. Nonetheless, the majority of individuals with diabetes do not adhere to optimal self-management recommendations. It is believed that psychosocial issues play an important role in individuals' ability to undertake the extensive behavioural demands involved in managing diabetes. The goal of the present article is to provide an overview of psychosocial issues and suggest strategies for healthcare providers in supporting patients with the challenges of diabetes self-management. First, motivational enhancement strategies have the potential to augment patients' own motivation to engage in health behaviours. Second, behavior modification principles can increase patients' self-efficacy and their experiences of success. Third, managing distressing emotions, including anxiety, depression, distress specifically related to diabetes care, and fear of hypoglycemia, can facilitate motivation and ability to undertake diabetes self-management efforts. Recognizing and addressing psychosocial challenges allows healthcare providers to better support their patients in the demanding tasks of diabetes self- management.

Transformative Learning and Graduate Nurses’ Understanding of the Complexities of Diabetes Self-Management

Clinical nurses are increasingly responsible for facilitating and providing diabetes education in the acute care setting. However, research suggests that the lack of awareness about the psychosocial factors that influence diabetes self-management impairs the nurse's ability to effectively and comprehensively support the patient's self-management efforts. This mixed-methods design of the research study describes how transformative learning, in conjunction with critical reflection, enhanced graduate nurses' understanding of the psychosocial aspects of diabetes self-management and improved their ability to provide patient-centered care.

"This does my head in". Ethnographic study of self-management by people with diabetes

BackgroundSelf-management is rarely studied 'in the wild'. We sought to produce a richer understanding of how people live with diabetes and why self-management is challenging for some.MethodEthnographic study supplemented with background documents on social context. We studied a socio-economically and ethnically diverse UK population. We sampled 30 people with diabetes (15 type 1, 15 type 2) by snowballing from patient groups, community contacts and NHS clinics. Participants (aged 5-88, from a range of ethnic and socio-economic groups) were shadowed at home and in the community for 2-4 periods of several hours (total 88 visits, 230 hours); interviewed (sometimes with a family member or carer) about their self-management efforts and support needs; and taken out for a meal. Detailed field notes were made and annotated. Data analysis was informed by structuration theory, which assumes that individuals' actions and choices depend on their dispositions and capabilities, which in turn are shaped and constrained (though not entirely determined) by wider social structures.ResultsSelf-management comprised both practical and cognitive tasks (e.g. self-monitoring, menu planning, medication adjustment) and socio-emotional ones (e.g. coping with illness, managing relatives' input, negotiating access to services or resources). Self-management was hard work, and was enabled or constrained by economic, material and socio-cultural conditions within the family, workplace and community. Some people managed their diabetes skilfully and flexibly, drawing on personal capabilities, family and social networks and the healthcare system. For others, capacity to self-manage (including overcoming economic and socio-cultural constraints) was limited by co-morbidity, cognitive ability, psychological factors (e.g. under-confidence, denial) and social capital. The consequences of self-management efforts strongly influenced people's capacity and motivation to continue them.ConclusionSelf-management of diabetes is physically, intellectually, emotionally and socially demanding. Non-engagement with self-management may make sense in the context of low personal resources (e.g. health literacy, resilience) and overwhelming personal, family and social circumstances. Success of self-management as a policy solution will be affected by interacting influences at three levels: [a] at micro level by individuals' dispositions and capabilities; [b] at meso level by roles, relationships and material conditions within the family and in the workplace, school and healthcare organisation; and [c] at macro level by prevailing economic conditions, cultural norms and expectations, and the underpinning logic of the healthcare system. We propose that the research agenda on living with diabetes be extended and the political economy of self-management systematically studied.

Social support for self-management behaviors among people with epilepsy: A content analysis of the WebEase program

Social support is an important component in managing epilepsy; however little is known about support provided to people with epilepsy. This study examined whom people with epilepsy identify as supportive, and how those individuals support people with epilepsy's self-management efforts. Data come from the WebEase project, an effective online epilepsy self-management program. People with epilepsy who participated in the pilot (n=35) and efficacy trials (n=118) were included. A content analysis was conducted on responses to open-ended questions related to support. The majority of participants provided information about their supporters. The number of support providers ranged from 0 to 6, with about 12% indicating no support. Parents and significant others were most commonly listed as supporters. Support providers mainly offer emotional and instrumental support, reminders and aid for taking medication, and support for self-management strategies. These results could be useful for interventions aimed at bolstering support in order to improve self-management.

An Online Approach to Providing Chronic Illness Self-Management Information

The purpose of this article was to describe an online approach to providing chronic illness self-management information to rural women with chronic illness. To self-manage chronic illness, individuals require information about their conditions. For those in rural areas who have limited access to health services, computer-based interventions are a means of providing this information. Participants were randomly assigned either to an 11-week computer intervention in which they completed nine online self-study health teaching units related to self-management, or to a control group. The health teaching units were positively rated as being helpful in managing their chronic illnesses, with scores ranging from 4.09 to 4.84 on a six-point scale. Perceptions of computer skills increased significantly for the intervention group, with no increase in the control group. Computer-based programs can be an effective approach to providing health information to rural women with chronic conditions that will assist them in their self-management efforts.

Self-management support in “real-world” settings: An empowerment-based intervention

Objective This study examined the impact of a 6-month, empowerment-based diabetes self-management support (DSMS) intervention on clinical outcomes, self-care behaviors, and quality of life (QOL) compared to a 6-month control period. Methods This control-intervention cohort study recruited 77 African-American adults with type 2 diabetes. Baseline, 6-month, and 12-month assessments measured A1C, weight, body mass index (BMI), blood pressure, lipids, self-care behaviors, and QOL. During the control period, participants received weekly educational newsletters. During the intervention period, participants attended weekly DSMS groups as frequently as they needed. Sessions were guided by participants’ self-management questions and concerns, and also emphasized experiential learning, coping, problem-solving, and goal-setting. Results The control period found significant improvements for diastolic BP ( p < 0.05), serum cholesterol ( p < 0.001), following a healthy diet ( p < 0.01), and monitoring blood glucose ( p < 0.01). The intervention period found significant additional improvements for A1C ( p < 0.001), weight ( p < 0.05), BMI ( p < 0.05), and LDL ( p < 0.001). Compared to the control period, participation in the intervention led to a significant reduction in A1C ( p < 0.01). Conclusion Findings suggest that an empowerment-based, DSMS intervention is promising for improving and/or maintaining diabetes-related health, particularly A1C. Practical implications Incorporating empowerment principles in DSMS interventions may be useful for supporting patients’ self-management efforts in “real-world” settings.

What happens after diagnosis? Understanding the experiences of patients with newly‐diagnosed bipolar disorder

Bipolar disorder is chronic condition involving episodes of both depression and elevated mood, associated with significant disability and high relapse rates. Recent estimates suggest a lifetime prevalence of 5%. Little is known about the subjective experiences of patients after receiving a diagnosis of bipolar disorder, and the impact of these experiences on patients' willingness and ability to work with their health professionals to find the most effective combination of treatments and to set up self-management plans. This paper describes a qualitative study exploring the experiences and difficulties faced by patients after they have received a diagnosis of bipolar disorder, as expressed online to expert patients trained to provide informed support. Qualitative study. Online communication within a public health service setting. Twenty-six participants with recently-diagnosed bipolar disorder communicated online with 'Informed Supporters', people who had been managing their bipolar disorder effectively for 2 years or more, as part of an online psycho-education programme. Participants cited unwanted side-effects of medication, coping with unpleasant symptoms, positive and negative reactions to the diagnosis, identifying early warning signs and triggers of the illness, the loss of a sense of self, uncertainty about their future and stigma as issues of major importance after diagnosis. Personal concerns and difficulties following diagnosis can undermine effective treatment, thwart self-management efforts and interfere with effective functioning. Such data are important for clinicians to take into account when they work in partnership with their patients to fine-tune treatments and help them set up self-management plans.

Translating Clinical Trial Data Into New Patterns of Practice

The ongoing research into the intricacies of glucoregulation and the upsurge in the number of pharmacologic therapies has broadened the treatment options for type 2 diabetes. Successful translation of pharmacologic clinical trial data into new patterns of practice begins by creating the space for a new therapy through a thorough understanding of its mechanism of action. This article will discuss important considerations for identifying patients who could benefit from incretin mimetic therapy, the role of the diabetes educator in building a cohesive team, and teaching strategies that support patients' self-management efforts.

AUTOGESTÃO: ESTADO OU PROCESSO? (RE)REFLETINDO AS EXPERIÊNCIAS NO VALE DO SÃO FRANCISCO

The purpose of this essay is to stimulate reflection on the concept and practice of selfmanagement through the experiences analysis or self-management efforts. For this test, two types of experiences which took place in the Sao Francisco Valley were the bases for such a purpose (The Sao Francisco Valley is the region bordering the Sao Francisco River in Minas Gerais, state in the southeast, Bahia and Pernambuco, both in the northeast, in Brazil). One refers to the implementation of agricultural cooperatives in the irrigated areas of the region by CODEVASF(the Development Company of the Valleys of San Francisco and Parnaiba). An experience full of things that made difficult the self-managed process. The other relates to the creation of rural settlement Mandacaru, in which case you may notice elements of the process of self-management. What one learn from this reanalysis ,is that self-management must be seen as a way in alternatives to labor relations searching arising from a exploratory system and not a goal to be attained. It must be seen as a process of great social value to the individuals involved. Key-Words: Self-management. Cooperativism. Association.

Patients with Complex Chronic Diseases: perspectives on supporting self-management.

A Complex Chronic Disease (CCD) is a condition involving multiple morbidities that requires the attention of multiple health care providers or facilities and possibly community (home)-based care. A patient with CCD presents to the health care system with unique needs, disabilities, or functional limitations. The literature on how to best support self-management efforts in those with CCD is lacking. With this paper, the authors present the case of an individual with diabetes and end-stage renal disease who is having difficulty with self-management. The case is discussed in terms of intervention effectiveness in the areas of prevention, addiction, and self-management of single diseases. Implications for research are discussed.

Randomized controlled trials of positive affect and self-affirmation to facilitate healthy behaviors in patients with cardiopulmonary diseases: Rationale, trial design, and methods

Secondary prevention of adverse outcomes in patients with cardiopulmonary disease requires that patients become actively engaged in self-management efforts such as participation in physical activity or medication adherence. However, despite assiduous efforts to find strategies that help cardiovascular patients to adopt and maintain such behaviors, many studies of interventions designed to improve physical activity and adherence to medication have shown disappointing results. To this end, the Translational Behavioral Science Research Consortium was created by the National Heart, Lung, and Blood Institute to identify promising, but underutilized findings from basic behavioral science that might have potential application for translation to clinical populations where behavioral change has been refractory to standard intervention approaches. This paper describes the rationale and methods of a novel research project designed to test the efficacy of a behavioral intervention that combines constructs from two behavioral science theories ( positive affect and self-affirmation) in order to help patients with coronary artery disease, asthma, and hypertension successfully change behaviors. The project consists of an intervention framed upon positive affect and self-affirmation and tested in three concurrent randomized controlled trials among three distinct populations. Each trial had a qualitative phase that served as a formative stage to inform the intervention; a pilot phase during which the feasibility of the intervention was tested and refined; and a randomized controlled phase conducted to investigate the effects of the interventions in these three patient groups.

Interpersonal processes and vasculitis management

Patients with antineutrophil cytoplasmic antibody–associated systemic vasculitis (AASV) have recently benefited from treatment advances that prolong life. AASV refers to a range of rare disorders characterized by small blood vessel inflammation and the production of antibodies against specific components within the neutrophils (e.g., Wegener’s granulomatosis, microscopic polyangiitis, and Churg-Strauss syndrome) (1). The inflammatory process can adversely affect organs, including the skin, lungs, and kidneys. AASV is marked by periods of remission and relapse, making its course highly uncertain. When critical organs are compromised, patients experience severe symptoms, including death. Treatment with corticosteroids and immunosuppressive drugs has proven beneficial, and has increased the likelihood of patient survival and sustained remission. Patients with AASV and their family members are now concerned with enhancing quality of life in addition to prolonging quantity of life (2). One central issue is chronic illness management (CIM), or efforts that patients and family members undertake to control AASV and minimize its negative impact on health status and functioning. AASV and its consequences are managed through activities, which may include strict adherence to medication regimens, visits to health professionals, nutrition changes, mild exercise, fatigue management, symptom monitoring, emotion management, and in some cases dialysis. Understanding the determinants of patients’ CIM is important because these behaviors affect illness progression (3,4) and could inform interventions. Here we focus on the interpersonal context of the lives of patients with AASV. There is considerable evidence demonstrating that support provided by persons who are close to these patients is associated with improved health behavior (5) and psychosocial functioning (6); however, interventions designed to increase support have been disappointing (7). Emerging literature on dyadic coping in the context of chronic illness (8) and rheumatic disease (9–11) integrates concepts from the field of relationship science into health-related research on social support. This literature offers a potentially useful process-oriented approach for examining support in couples facing chronic illness. The purpose of our article is to introduce a conceptual model of dyadic CIM that draws on recent theoretical and empirical work in relationship science and dyadic coping. This article is not meant to be a comprehensive review of social support and dyadic coping in rheumatic illness, but aims to introduce concepts from this emerging area and apply them to CIM in the context of AASV. We therefore do not report data, but instead use examples from our previous studies, and a current longitudinal study of CIM in couples coping with AASV, to illustrate the importance of the couple relationship to CIM. Three factors motivate our choice for focusing on marital partners in the context of CIM. First, prevailing CIM perspectives acknowledge that the interpersonal context may affect patient self-management efforts and, thus, patient outcomes (12). Second, research across diverse populations shows that marriage is strongly related to many beneficial health outcomes (13,14) and that spouses influence health-related perceptions and behaviors of partners (15– 17). These associations are well documented in couples coping with rheumatic diseases (9,17–21). Studies show that spouses can be effectively engaged in rheumatic illness coping interventions (10,22,23). Third, couples likely find AASV challenging to manage because of unpredictable periods of flares and remissions, treatment with medications that may have serious side effects, and the need for strict adherence to a variety of health behaviors (24). Supported by the National Institute of Arthritis and Musculoskeletal and Skin Diseases (grant P60-AR-49465-03), the National Cancer Institute (grant R21-CA-108744), and Wegener’s Granulomatosis Association. Megan A. Lewis, PhD, Carolyn T. Kalinowski, MPH, Tracy M. Barrett, PhD, Robert F. DeVellis, PhD: Thurston Arthritis Research Center, University of North Carolina at Chapel Hill; Katherine R. Sterba, PhD: School of Public Health, University of Texas at Houston. Address correspondence to Megan A. Lewis, PhD, Department of Health Behavior and Health Education, Campus Box 7440, University of North Carolina, Chapel Hill, NC 275997440. E-mail: megan.lewis@unc.edu. Submitted for publication August 25, 2005; accepted in revised form January 19, 2006. Arthritis & Rheumatism (Arthritis Care & Research) Vol. 55, No. 4, August 15, 2006, pp 670–675 DOI 10.1002/art.22092 © 2006, American College of Rheumatology

Consideration for legacies about diabetes and self-care for the family with a multigenerational occurrence of type 2 diabetes.

Type 2 diabetes mellitus is a familial disorder that is fast becoming epidemic in the USA. It is possible that nurses will care for entire families with diabetes in the near future. In multiple studies, family functioning, a family systems variable, has been correlated with self-management and glycemic outcomes. Most persons with diabetes live with family members who might facilitate or inhibit self-management tasks or skills. Multiple afflictions of family members with diabetes can further complicate matters relating to diabetes self-management. Diabetes collectively affects over 16 million people in the USA, incurring healthcare costs in excess of 92 billion dollars annually. Individuals engage in self-management behavior for diabetes care in the context of their family's environment. It is imperative that nurses consider factors that might inhibit or facilitate self-management efforts by individuals with type 2 diabetes mellitus. Assessment of family determinants of adaptation to diabetes with appropriate interventions can improve clinical outcomes, subsequently preventing complications.

Do children with asthma and their parents agree on household ETS exposure? Implications for asthma management

The adverse consequences of passive smoking have spurred efforts to reduce environmental tobacco smoke (ETS) exposure among children, particularly in the home. For children with asthma, teaching them to avoid tobacco smoke at home is an important element of patient self-management. This strategy assumes that children can accurately assess household smoking behaviors and the level of their own exposure in the home. This study compared child and parental assessments of household smoking behaviors in an urban, low-income and largely ethnic minority sample of asthmatic children and their parents. While there was general parent–child agreement on the smoking status of household members, there was less agreement on duration of household smoking and the child’s exposure to ETS. Objective validation measures (cotinine, nicotine) suggest that parents were better able than their children to assess hours of indoor smoking. Children’s assessment of the extent of exposure to ETS may be problematic, with important implications for asthma patient self-management efforts.

Changing office practice and health care systems to facilitate diabetes self-management.

Diabetes is a self-managed disease for which patients provide 99% of their own care. For patients to succeed as diabetes self-managers, they need office practices and health care systems that can prepare and support them in their diabetes self-management efforts over the long term. In order to provide effective diabetes education and ongoing support, office practices and health care systems will have to fundamentally redefine the roles of health professionals and patients with diabetes, and redesign practices and systems to allow for effective long-term self-management education and support. Although it is difficult for both people and systems to change, change is essential if we are going to provide self-management support for the majority of patients suffering from this serious chronic disease.

Research Beyond Diabetes: What Is Translatable?

This Diabetes Spectrum From Research to Practice section addresses translation as a theme. The articles focus on how intervention approaches may be applied in diabetes. The research areas address weight loss, community-based strategies for environmental change, adherence to treatment recommendations, and reducing high-risk behaviors such as smoking. The term “translation” is becoming widely used in research to address the transfer of information from one context to another. In the research continuum, knowledge acquired in bench research is applied to clinical research, and information from clinical research is in turn applied to community or applied research. Likewise, basic research in the behavioral sciences can provide information and techniques developed to address one health issue or situation that can be applicable or translatable to another health situation. Translation requires thinking broadly about how information in one area can be applied to another. Thinking narrowly about diabetes can limit potential applications of findings from other disease conditions. Early in the treatment of diabetes, the diabetic diet approach did address common concomitant conditions such as obesity, hypertension, and dyslipidemia. But diabetes was often viewed as an abnormality of carbohydrate metabolism rather than a complex metabolic syndrome that results in lipid and blood pressure abnormalities as well. Today, the emphasis of care has shifted from efforts to help patients survive acute problems to more complex self-management efforts aimed at preventing long-term diabetes complications. A similar shift has occurred with advances in the treatment and increased longevity of the HIV-infected population. Indeed, diabetes is of increasing concern for patients who are treated with protease inhibitors.1 In an era of …

Can children teach their parents about asthma?

The Open Airways for Schools (OAS) program has been shown to improve the self-management skills and health outcomes of students with asthma in Grades 3 to 5. This report examines the impact of OAS on students' parents. Because pilot studies showed that parental attendance at school-based sessions was low, the authors held six sessions at school for children and gave children homework assignments to complete with parents at home to teach parents about asthma and build support for children's self-management efforts. Analysis of 1-year follow-up data showed that children's participation in OAS was a significant predictor of parental self-management skills (p <.03) and that OAS children's communication was more strongly associated than controls' with parents' self-management (p = .05). The findings show that health education activities brought home from school by children can positively influence parents' self-management of a complex chronic disease such as asthma.

Understanding the adoption of arthritis self-management: stages of change profiles among arthritis patients

Clinical observations and recent studies suggest that arthritis patients vary considerably in their involvement in self-management efforts. In the literature on health promotion, there is growing recognition that patients may be at different stages of change with respect to the adoption of self-management strategies. The major goal of the present study was to examine whether cluster analysis could be used to identify homogeneous subgroups of patients having persistent arthritis pain based on their responses to a stages of change questionnaire. Participants in this study (103 patients having rheumatoid arthritis and 74 patients having osteoarthritis) completed a stages-of-change measure specific to adoption of a self-management approach to their arthritis. A cluster analysis identified five distinct subgroups of arthritis patients: (1) precontemplation – 44% of the sample; (2) contemplation – 11% of the sample; (3) preparation – 22% of the sample; (4) unprepared action – 6% of the sample; and (5) prepared maintenance – 17% of the sample. These subgroups are generally consistent with what might be expected based on the transtheoretical model of stages of change by Prochaska and DiClemente (Prochaska JO, DiClemente CC. Towards a comprehensive, transtheoretical model of change: states of change and addictive behaviors. In: Miller WR, Heather N, editors. Applied clinical psychology, 2nd ed. Treating addictive behaviors, New York: Plenum Press, 1998. pp. 3–24.), and may have important clinical implications. For example, it is possible that the arthritis subgroups identified may predict arthritis patients’ participation in and responsiveness to pain-coping skills training, exercise interventions, or other formal self-management training programs. Also, one may be able enhance the outcomes of self-management interventions for arthritis by tailoring treatment to the patient's particular stage.