Self-management Plan Research Articles

Impact of panic disorder upon self-management educational goals in chronic obstructive pulmonary disease?

The rationale for introducing self-management plans for the whole chronic obstructive pulmonary disease (COPD) population is uncertain. This study's aim was to investigate whether people with panic disorder (PD), compared to non-panic-disordered (NPD), derived additional educational or psychological benefits from having a self-management plan. The 24-week prospective study followed 76 participants hospitalized with an exacerbation of COPD. Participants completed mental health questionnaires including psychological measures of self-management plan impact. Subsequently, a nurse provided education for using a self-management plan. All participants were Plan naïve irrespective of their PD status. Self-management knowledge was assessed before introducing the Plan (baseline), 1 week post discharge and at 24 weeks. At baseline 28 (37%) of participants met the criteria for PD and this group had higher scores (better knowledge) for an impending (p < 0.05) and severe exacerbation (p < 0.05) and capacity to act during a severe exacerbation (p < 0.01). No interaction effect was found between PD and NPD scores over time, indicating that the PD's knowledge did not improve or deteriorate over time relative to the NPD. Evidence was mixed regarding the Plan's psychological impact. Self-management confidence improved in both groups. Amongst the PD group, perceived control of self-management tasks increased but so did body vigilance and distress about having COPD. There is mixed evidence regarding educational and psychological benefits of COPD self-management plans for people with PD. No additional educational advantages were found for the PD group. Plans may increase confidence and control over self-management but may also increase body vigilance and distress about having COPD.

Determining Clinical and Psychological Benefits and Barriers with Continuous Glucose Monitoring Therapy

Preventing the complications of diabetes requires tight control and minimizing blood glucose fluctuation. Pursuing these goals increases the risk of severe hypoglycemia. The authors hoped to identify if using continuous glucose monitoring (CGM) decreased the incidence of severe hypoglycemia, resulted in less fear of hypoglycemia, and improved patient empowerment and what impact CCM had on quality of life (QOL) issues. Questionnaires were used to gather demographic data, to measure educational experiences with CGM, QOL issues concerning fear of hypoglycemia and severe hypoglycemia, confidence to make changes to insulin regimens before and after using CGM, and the incidence of severe hypoglycemia before and while using CGM, and to assess the impact of CGM on QOL. The data and answers reported suggest significantly less fear of hypoglycemia and severe hypoglycemia and increased patient empowerment with CGM. Further shown is a reduced incidence of acute complications as evidenced by significantly decreased incidence of severe hypoglycemia. CGM appears to have a significant, positive impact on the stress associated with having and managing diabetes. Using CGM as part of the diabetes self-management plan offers the potential to significantly improve user outcomes as measured by QOL, reduction of fear, and patient empowerment. Using CGM can allow patients to achieve tighter control of their blood glucose values with reduced fear of hypoglycemia, reduced incidence of severe hypoglycemia, and a decreased sense of burden from having diabetes.

Caractéristiques des hospitalisations pour exacerbation d’asthme en pédiatrie

In France, half of hospital admissions for asthma concern children and the rates of hospitalization, decreasing in adults, are stable in children. Most admissions for asthma exacerbation are avoidable with appropriate disease management. The objective of this study was to describe the characteristics of children admitted for asthma. The study was carried out in 14 pediatric units over 1 year. Children aged 3 years and over who were hospitalized for an asthma exacerbation were included. Data from 727 hospitalizations were collected. In 48% of the hospitalizations, children were 3-5 years old. Asthma was undiagnosed at the time of the admission in 27%. Among children with diagnosed asthma, 57% had already been admitted to the hospital for asthma exacerbation, 37% had been admitted to the hospital or emergency department during the last year, and the control of asthma in the previous month was unacceptable in 46%; 11% had received an oral and written self-management action plan. This study underlines the need to strengthen the efforts to encourage improvement of the therapeutic education of asthmatic children in order to decrease the risk of hospitalization for exacerbation of asthma.

Effectiveness of Asthma Education with and Without a Self-Management Plan in Hospitalized Children

Background. Formal education in primary care can reduce asthma exacerbations. However, there are few studies in hospitalized children, with none originating in Latin America. Methods. A prospective randomized study was designed to evaluate whether a full education with self-management plan (ESM) was more effective than an education without self-management plan (E) in reducing asthma hospitalization. Children (5 to 15 years of age) who were hospitalized for an asthma attack were divided in two groups. Children in the E group received general instructions based on a booklet. Those in the ESM group received the same booklet plus a self-management guide and a puzzle game that reinforces the lessons learned in the booklet. Patients were interviewed every 3 months, by telephone, for one year. Interviewers recording the number of hospitalizations, exacerbations, and emergency visits for asthma and oral steroid burst uses. Results. From 88 children who met the inclusion criteria, 77 (86%) completed one year of follow-up (41 from E and 36 from ESM group). Overall, after one year, the hospitalization decreased by 66% and the inhaled corticosteroids therapy increased from 36% to 79%. At the end of the study, there was no difference in exacerbations, emergency visits, oral steroid burst uses, or hospitalizations between the two groups. Conclusions. Asthma education with or without a self-management plan during asthma hospitalization were effective in reducing exacerbations, emergency visits, oral steroid burst uses, and future rehospitalizations. This evidence supports the importance of providing a complete asthma education plan in any patient who is admitted for asthma exacerbation.

Innovation Networks

UPGRADING PRIMARY CARE IS KEY TO REALIZING THE promise of health care reform to improve access and quality while reducing costs. Promising models, such as the patient-centered medical home and new measurement systems for detecting better population outcomes, require primary care clinicians to develop innovative ways of organizing care. Because new and improved approaches are not easily transplanted directly into practice, transforming primary health care will be virtually impossible without a system for innovating, testing, and providing what works. Primary health care innovation networks can accelerate primary care transformation by harnessing the collective intelligence and motivation of the medical community. Collaborative networks of primary care practices can enhance the capability of individual practices, as well as the capacity of local primary care systems, to improve health outcomes. One example is the Cincinnati Children’s PhysicianHospital Organization, which is a network of 40 independently owned and operated practices that have developed a shared infrastructure led by a board of practice leaders. The Cincinnati Children’s Physician-Hospital Organization provides centralized technical support for quality improvement and a shared registry for population management. Novel payfor-performance approaches were implemented that focused on improving population-level outcomes for children with asthma that created incentives for improvement within and across practices. These efforts contributed to substantial improvement in care delivery for 13 000 asthmatic children, including use of written self-management plans, controller medications, and influenza vaccinations. Although large organized health care systems like Cincinnati Children’s Physician-Hospital Organization, the US Department of Veterans Affairs, and Kaiser Permanente have the resources and power to accomplish such changes, more than two-thirds of care in the United States is delivered by practices that are not part of such systems. Providing policy and practice supports for these primary care practices poses an enormous challenge. Most research on primary care improvement has focused on practice-level improvement and has involved relatively small numbers of practices. Advances necessary to transform primary care will require a better understanding of how to align improvements across practice, community, health plan, and regional levels of the health care system. Engineering such improvement and understanding of what strategies are likely to work across diverse local contexts will require participation of large numbers of practices and communities. Research needs to go beyond simply describing and analyzing the barriers to providing better care, and do much better at finding creative solutions, experimenting to determine what works, and understanding what it takes to spread and scale new effective care strategies. Ways to promote active involvement of clinicians in innovating and adapting new ideas are needed by harnessing the collective intelligence and motivation of individual clinicians, organizations, and communities to transform care.

Quadrupling the Dose of Inhaled Corticosteroid to Prevent Asthma Exacerbations

Asthma exacerbations are unpredictable, disruptive, and frightening, and are therefore important to prevent. We investigated whether a policy of quadrupling the dose of inhaled corticosteroid when asthma control starts to deteriorate reduces asthma exacerbations requiring treatment with oral corticosteroids. A total of 403 people with asthma were given a self-management plan and randomized to take an active or placebo corticosteroid inhaler in addition to their usual asthma treatment when their PEF fell by 15% on 2 consecutive days or by 30% on 1 day. The study inhalers provided a quadrupling or no change in corticosteroid dose. Eighteen of 197 (9%) and 29 of 203 (14%) participants had an exacerbation of asthma requiring treatment with oral corticosteroids in the active and placebo groups, respectively, giving a risk ratio of 0.64 (95% confidence interval, 0.37-1.11, P = 0.11). Of the 94 participants who started the study inhaler far fewer required treatment with oral corticosteroids in the active compared with the placebo group: 12 of 56 (21%) in the active group and 19 of 38 (50%) in the placebo group, giving a risk ratio of 0.43 (95% confidence interval, 0.24-0.78, P = 0.004). Although our primary outcome did not reach statistical significance, quadrupling the dose of inhaled corticosteroid when asthma control starts to deteriorate appears to reduce acute exacerbations of asthma and deserves further investigation. Clinical trial registered with www.controlled-trials.com (ISRCTN 46018181).

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.

Managing oneself: An essential skill for managing others

ObjectivesTo discuss the importance of self-management for student pharmacists, pharmacists, and pharmacy managers and present a series of steps that students and new pharmacists can use in managing themselves. Data sourcesAn English language—only literature search was conducted of the PubMed and International Pharmaceutical Abstracts databases from 1980 to 2007 using the keywords managing and career, managing oneself, and career management. Information from the search was supplemented with selected articles and books from the management and self-improvement literature. Study selectionCited sources were chosen based on their relevance to the article's objectives. Data extractionBy the author. Data synthesisCommon steps associated with managing oneself and one's career consist of taking responsibility for your life, knowing yourself, deciding what you want to do and be, establishing goals to achieve the life you want to live, and taking action. A major goal of any self-management plan for managers is to develop soft interpersonal skills that help individuals manage themselves and influence the world around them. ConclusionEffective self-management is necessary for success in managing others. The steps are relatively simple but take a lifetime to master.

Outpatient management of asthma in children age 5–11 years: Guidelines for practice

To increase awareness among nurse practitioners (NPs) regarding diagnostic and treatment guidelines for asthma for the 5-11 year age group recently updated by the National Asthma Education Prevention Program-Expert Panel 3 (NAEPP-EPR3). NAEPP-EPR3 guidelines for the diagnosis and management of asthma released from the National Heart, Lung, and Blood Institute in August 2007, selected clinical trials, meta-analyses, and clinical reviews. Recent research has revealed that children suffering from asthma in the United States are underdiagnosed and their asthma is poorly controlled. Compelling evidence supports that children classified as having persistent asthma following NAEPP-EPR3 guidelines benefit from daily inhaled corticosteroid therapy, yet many are misclassified and undertreated. With application of current guidelines from NAEPP-EPR3, NPs can more effectively assess, diagnose, treat, and foster a collaborative self-management plan for children age 5-11 years. These interventions will result in an improved quality of life and decreased health risks for this young population.

Evaluating the efficacy of an empowerment-based self-management consultant intervention: results of a two-year randomized controlled trial

OBJECTIVES: This study was conducted to determine if an empowerment-based Diabetes Self-Management Consultant (DSMC) was more effective than a group receiving Mailed metabolic Assessments Only (MAO) in improving diabetes-related quality of life and blood glucose control. MATERIALS AND METHODS: A two-year clinical trial, in which 310 patients with type 2 diabetes were randomized to the DSMC intervention or the MAO group. The DSMC met with the patient to review the baseline assessments, then met with this review was patient and the patient's physician. Subsequently patients received monthly telephone calls from the DSMC who used the empowerment approach to help patients identify self-management problems, consider options, set goals and make adjustments to their diabetes self-management plans. RESULTS: The Diabetes Self-Management Consultant (DSMC) intervention resulted in improvements in diabetes related quality of life (PAID) p= .008, the Empowerment Scale p= .024, A1C p= .016, Perceived understanding of diabetes p= .001 and satisfaction with diabetes care p= .019 as compared to the MAO group. DISCUSSION/CONCLUSION: The DSMC the intervention resulted in a broad array of modest diabetes related improvements. A promising area for future research would be to test the efficacy of combining an empowerment-based DSMC intervention with case management using algorithm-based medication adjustments for higher risk patients.

Impact of Geriatric Assessment and Self-Management Support on Community-Dwelling Older Adults with Chronic Illnesses

Purpose: The purpose of this study was to assess the effectiveness of interdisciplinary geriatric home-based assessment and self-management support services to community-dwelling older adults. Design: A quasi-experimental, pre-post test design tested two types of service delivery models. The first protocol included geriatric assessment services, with a brief self-management care plan intervention. The second protocol added a telephone support intervention. Results: All participants showed significant progress in improved self–efficacy, self-rated health, functional status and physical mobility (specifically lower extremity muscle strength), mental health (specifically reduced depression) and in reduced fall hazards in their physical home environment. The telephone support intervention protocol did not provide additional value to the first protocol. Implications: This study demonstrates the value of non-medical intervention strategies for community dwelling older adults with chronic illnesses.

Self-Management Plans for Asthma Control and Predictors of Patient Compliance

Objective. To evaluate the impact of peak flow or symptom-based self–management plans on asthma control and patients' quality of life and to determine the main psychosocial factors that affect compliance with these plans. Methods. The study sample consisted of 63 patients with persistent asthma outpatients. Data collection included demographics, pulmonary functions, symptom scores, and asthma control parameters recorded over the previous 2 consecutive years. A standard asthma self-management education program including personal action plans was given to the patients who were randomly divided into peak flow meter (PFM) (n = 31) or symptom-based (n = 32) action plan groups. Patients were then assessed prospectively for various study outcomes including symptoms, drug compliance, psychiatric co-morbidities, quality of life, and asthma control over the next 12 months. Psychiatric co-morbidities were assessed using Rotter's Internal and External Locus of Control Scale (RIELCS), Beck Depression Inventory (BDI), Structured Clinical Interview for DSM-IV (SCID-I), Spielberger State-Trait-Anxiety Inventory (STAI), and Short Form-36 (SF-36). Results. Of the 63 patients (79% female; mean age 43), 85% of them had moderately or severely persistent asthma. Baseline demographics, clinical parameters, psychiatric diagnosis, and quality of life were not different between groups. Personal asthma plans increased optimal asthma control significantly. Emergency visits, antibiotic treatments, systemic corticosteroid treatments, and unscheduled visits were fewer than the previous year. Control parameters were better in the PFM group. After the self-management education, the quality of life dimensions, i.e., vitality, total mental and general scores of both groups increased. Frequency of psychiatric co-morbidities decreased from 61.9% to 49.2%. However, state anxiety levels were increased in both groups. These increases were statistically significant in the PFM group. Compliance with the action plans was better in the PFM group. Higher BDI scores were associated with worse compliance. No statistically significant association was found between demographic parameters and the compliance. Although the compliance had decreased in both groups after 6 months, this decrease was greater in the symptom group. Higher RIELCS and mental health scores were associated with better compliance. Conclusion. Introduction of self-management plans improved illness control and quality of life in asthma patients. Use of the PFM and the presence of higher RIELCS and lower BDI scores can be used to predict compliance with the action plans.

Promoting and supporting self-management for adults living in the community with physical chronic illness: A systematic review of the effectiveness and meaningfulness of the patient-practitioner encounter.

Background There has been a reported rise in the number of people with chronic illness (also referred to as long-term disease) in the Western world. One hundred million people in the United States have at least one chronic condition and in the United Kingdom (UK) as many as 17.5 million adults may be living with chronic disease. New models of care have been developed which recognise the complexities of managing care where there is overlap between the wider community, the health care system and provider organisations, for example, the Chronic Care Model and the Expert Patient Programme. These new models herald a shift away from the idea of chronically ill patients as passive recipients of care towards active engagement, in partnership with health professionals, in managing their own care. Partnership, ideally, involves collaborative care and self-management education. This may support self-care alongside medical, preventative and health maintenance interventions. In this context the nature of the patient-practitioner consultation in promoting self-care takes on a new importance. Objective The overall objective of the review was to determine the best available evidence regarding the promotion and support of self-care management for adults living in the community with chronic illness during the patient-practitioner encounter. Specifically the review sought to determine: What is the effectiveness of the patientpractitioner encounter in promoting and supporting self-care management of people with chronic illness? What are the individual and organisational factors which help or hinder recognition, promotion and support of chronic disease self-care management strategies? What are the similarities and differences between how ‘effectiveness’ is defined in this context by patients and different practitioners? Inclusion Criteria Types of participants The review focussed on self-caring adults aged nineteen years and older living in the community, with a physical chronic illness, and not currently being treated as an in-patient. For example, people with diabetes, asthma, arthritis, coronary disease, lung disease, heart failure, epilepsy, kidney disease and inflammatory bowel disease. Since patients meet various professionals in a variety of community settings regarding their care, a practitioner in this review included doctors (physicians and General Practitioners), nurses, nurse specialists, dieticians, podiatrists and community health workers. Types of outcome measures A variety of outcomes measures was used to evaluate effective self-care management. These included physiological measurements such as: HbA1c, blood pressure, body weight, lipids; lifestyle measurements, for example physical activity; and self-care determinants such as knowledge, attitude; and self-care behaviours regarding, for example, diet and physical exercise, and medication. The outcome measures used to explore the meaningfulness of the patient-practitioner encounter, concerned patients’, physicians’ and nurses’ views and perceptions of selfcare management and support. Types of studies The review considered all types of quantitative and qualitative evidence regarding the patient-practitioner encounter where self-care in chronic illness was the focus. The quantitative studies reviewed included systematic reviews, randomised controlled trials (RCTs), quasi-experimental studies, and survey studies. Qualitative studies reviewed included interview designs, vignette technique, qualitative evaluation, grounded theory, and exploratory descriptive design. Search Strategy The search sought to find both published and unpublished studies between 1990 and 2005. The year 1990 was deemed appropriate since it precedes the development of the Chronic Care Model in which self-management support for people living with chronic illness is heralded as an important part of care-management. An initial search of CINAHL and MEDLINE databases was undertaken to identify appropriate search terms regarding self-care and chronic illness. A search strategy was then developed using all identified MeSH headings and key words and the following databases were searched: - Ovid CINAHL; Ovid MEDLINE (R); Ovid EMBASE; Ovid EBM Reviews (CDSR, ACP Journal Club, DARE, CCTR); ASSIA; SIGLE; TRUNCATED AT 600 WORDS.

Quality and availability of consumer information on heart failure in Australia

BackgroundProvision of consumer information and patient education are considered an essential part of chronic disease management programmes developed for patients with heart failure. This study aimed to review the quality and availability of consumer information materials for people with heart failure in Australia.MethodsThe availability of consumer information was assessed through a questionnaire-based survey of the major organisations in Australia known, or thought, to be producing or using consumer materials on heart failure, including hospitals. The questionnaire was designed to explore issues around the use, production and dissemination of consumer materials. Only groups that had produced consumer information on heart failure were asked to complete the totality of the questionnaire.The quality of information booklets was assessed by using a standardised checklist.ResultsOf 101 organisations which were sent a questionnaire, 33 had produced 61 consumer resources on heart failure including 21 information booklets, 3 videos, 5 reminder fridge magnets, 7 websites, 15 self-management diaries and 10 self-management plans. Questionnaires were completed for 40 separate information resources. Most had been produced by hospitals or health services. Two information booklets had been translated into other languages. There were major gaps in the availability of these resources as more than half of the resources were developed in 2 of the 8 Australian states and territories, New South Wales and Victoria.Quality assessment of 19 information booklets showed that most had good presentation and language. Overall eight high quality booklets were identified. There were gaps in terms of topics covered, provision of references, quantitative information about treatment outcomes and quality and level of scientific evidence to support medical recommendations. In only one case was there evidence that consumers had been involved in the production of the booklets.ConclusionKey findings arising from the study included the need to develop a nationally coordinated approach for increasing the dissemination of information resources on heart failure. While the more recent publication of a booklet by the National Heart Foundation may have improved the situation, dissemination of written information materials may remain sub-optimal, especially among patients who are not enrolled in chronic heart failure management programmes.

Tale of Two Courthouses: A Critique of the Underlying Assumptions in Chronic Disease Self-Management for Aboriginal People

This article reviews the assumptions that underpin the commonly implemented Chronic Disease Self-Management models. Namely that there are a clear set of instructions for patients to comply with, that all health care providers agree with; and that the health care provider and the patient agree with the chronic disease self-management plan that was developed as part of a consultation. These assumptions are evaluated for their validity in the remote health care context, particularly for Aboriginal people. These assumptions have been found to lack validity in this context, therefore an alternative model to enhance chronic disease care is proposed.

Communicating with older diabetes patients: Self-management and social comparison

Objective The health status and life experiences of older diabetes patients may be highly heterogeneous, thus making their perspectives particularly relevant for developing individualized self-management plans for this population. Our earlier research showed older diabetes patients’ healthcare goals and self-management behaviors are frequently shaped through social comparisons with peers/family members. The present paper explores this role of social comparison in their self-management practices and develops a conceptual model depicting the process. Methods Data were collected using open-ended, semi-structured interviews to elicit 28 older, type 2 diabetes patients’ healthcare goals and self-management practices. Qualitative techniques were used to extract salient themes. Results Social comparison plays a salient role in routinizing older patients’ self-management practices. Almost all patients assess their self-management by making “downward” comparisons with individuals doing worse than them; “upward” comparisons are rarely invoked. Occasionally patients’ social comparisons lead them to adopt “normalizing” behaviors resulting in deviations from medically recommended self-care. Conclusion The findings formed the basis for developing a conceptual model delineating the role of social comparison in self-management that can be beneficial for providers in tailoring educational interventions for self-management. Practice implications Fostering these comparisons can help providers enhance communication on initiating and sustaining self-management practices.

Anaphylaxis management plans for the acute and long-term management of anaphylaxis: A systematic review

Anaphylaxis management plans (AMPs) are increasingly advocated to improve outcomes and reduce the risk of recurrence in persons with anaphylaxis. A recent systematic review investigating their effectiveness failed to identify any randomized controlled trial evidence to guide clinical decision making. We sought to identify and describe available AMPs, assess their acceptability and likely effectiveness, and understand potential facilitators and barriers to their use. We performed a systematic review of published, unpublished, and ongoing epidemiologic and qualitative studies, searching 13 international databases and contacting an international panel of anaphylaxis experts. Studies were critically appraised using established international criteria and thematically synthesized. Nineteen of 789 potentially eligible studies identified satisfied our inclusion criteria. A number of AMPs exist, and other than agreement on the central importance of early administration of self-administered epinephrine, there is a range of perspectives on what should be included. AMPs are acceptable to patients/caregivers and might considerably reduce the risk of recurrence. This latter finding needs to be interpreted with caution given the substantial risk of bias in the limited number of intervention studies conducted. Access to specialists, problems with follow-up, and indemnity considerations relating to emergency administration of epinephrine in schools are important structural barriers to their wider use. There are currently no universally accepted AMPs. The available evidence to support use of self-management plans is encouraging but is, in comparison with other long-term conditions, such as asthma, extremely weak. The effectiveness and cost-effectiveness of AMPs need to be formally evaluated.

Características demográficas dos idosos vinculados ao sistema suplementar de saúde no Brasil

To assess health coverage of elderly people receiving supplementary health care and these users' sociodemographic characteristics. Descriptive study of elderly population living in Brazil and in the states of São Paulo and Rio de Janeiro in 2006. Data was collected from the National Supplementary Care Beneficiary Information System and the National Household Sample Survey. The following variables were studied: gender, age, distribution by federal unit, category of health insurance, type of contract and plan segmentation. Higher coverage of the general population was seen in the age groups 70-79 years (26.7% and 80 years and more (30.2%). Of those aged 80 years and more, 33% had private health plans among women and 25.9% among men. Nearly 80% of health insurance beneficiaries were living in southeastern and southern Brazil, of which 55% were in Rio-São Paulo axis. Health maintenance organizations covered a higher proportion of younger compared to elderly population (39% and 34.5%, respectively) and self-management care plans covered a significantly higher proportion of elderly compared to younger population in Brazil (22.8% and 13.8%, respectively). Elderly health care coverage was significantly high and age groups over 70 years showed the highest coverage rates among the Brazilian population, especially among women.

Role of Physical Activity in Diabetes Management and Prevention

During recent years, evidence supporting the vital role of physical activity in the prevention and treatment of diabetes has been accumulating. Physical activity is recognized to produce multiple general and diabetes-specific health benefits. Yet despite the multitude of benefits, many people are physically inactive. As the prevalence of overweight and obesity, prediabetes, and type 2 diabetes has continued to rise at an alarming rate, physical inactivity has become an urgent public health concern. The purpose of this article is to review the physical activity/exercise research in diabetes and summarize the current exercise recommendations. This information can be used by clinicians to make safe and effective recommendations for integrating physical activity/exercise into self-management plans for individuals with diabetes or at risk for its development.

Two for One: A Self-Management Plan Coupled with a Prescription Sheet for Children with Asthma

Despite strong recommendations in the asthma guidelines, the use of written self-management plans remains low among asthmatic patients. To develop a written self-management plan, based on scientific evidence and expert opinions, in a format intended to facilitate its dispensing by health care professionals, and to test the perception of its relevance and clarity by asthmatic children, adolescents and adults. Inspired by previously tested self-management plans, surveys of asthma educators, expert opinions and the 2004 Canadian Asthma Guidelines, the authors simultaneously developed French and English versions of a written self-management plan that coupled with a prescription. The self-management plan was tested in parents and their asthmatic children (aged one to 17 years), and it was revised until 85% clarity and perceived relevance was achieved. Ninety-seven children and their parents were interviewed. Twenty per cent had a self-management plan. On the final revision, nearly all items were clear and perceived relevant by 85% or more of the interviewees. Two self-management plans were designed for clinics and acute care settings, respectively. The plans are divided into three control zones identified by symptoms with optional peak flow values and symbolized by traffic light colours. They are designed in triplicate format with a prescription slip, a medical chart copy and a patient copy. The written self-management plans, based on available scientific evidence and expert opinions, are clear and perceived to be relevant by children, adolescents and their parents. By incorporating the prescription and chart copies, they were designed to facilitate dispensing by physicians in both clinics and acute care settings.