Self-management Program Research Articles

Effectiveness of an institution-based adapted physical activity programme versus a home-based self-management programme for chronic poststroke adults: protocol for a randomised controlled study

IntroductionPhysical activity (PA) protects the cardiovascular system and reduces the risk of stroke recurrence. However, most stroke survivors have significantly lower daily PA levels than those recommended. Adapted PA programmes...

A protocol for a multidisciplinary early intervention during chemotherapy to improve dietary management behavior in breast cancer patients: a two-arm, single-center randomized controlled trial

BackgroundAdverse reactions are prone to occur in the early stage of chemotherapy and can negatively affect the dietary intake and nutritional status of breast cancer (BC) patients. Consequently, they need to participate in health self-management and lifestyle promotion programs. Early multidisciplinary interventions aim to enhance dietary management behavior and quality of life in chemotherapy-treated BC patients.MethodsThis single-blinded, single-center, randomized controlled trial will include 88 females who have not yet started the early or middle stage of the chemotherapy cycle. A random number table will be used randomly assign females to the intervention group or usual group at a 1:1 ratio. The intervention elements are based on the theoretical guidance of the Integrated Theory of Health Behavior Change (ITHBC). A multidisciplinary team (MDT) comprising oncologists, dietitians, nurses, traditional Chinese medicine (TCM) practitioners, and psychologists will provide the intervention. Intervention sessions will be conducted once a week for 8 weeks, beginning in the early or middle stage of the chemotherapy cycle and continuing through admission and a home-based interval chemotherapy period. The intervention includes face-to-face discussions, online meetings, WeChat messaging, and telephone calls. The themes target adverse reactions, dietary information and habits, self-care self-efficacy, treatment self-regulation, dietary supplement and TCM use, social support, weight management, and outcome expectations. The primary outcome is dietary management behavior measured by the Dietary Management Behavior Questionnaire (DMBQ). Secondary outcomes are self-care self-efficacy assessed by the Strategies Used by People to Promote Health (SUPPH); quality of life measured by the Functional Assessment of Cancer Therapy-Breast (FACT-B); and body mass index (BMI) measured by an electronic meter. All participants will be assessed at baseline and immediately, 1 month, 3 months, 6 months, and 12 months after the intervention.DiscussionEarly dietary intervention is needed, as diet is one of the most common health self-management behaviors influenced by chemotherapy. Early multidisciplinary interventions may provide a foundation for dietary self-management and improve nutritional status in the survival period.Trial registrationThis intervention protocol was registered with the Chinese Clinical Trials Registry (ChiCTR2300076503, October 10, 2023).

Effectiveness of self-management program for gastric cancer patients: A randomized controlled trial comparing gain vs. loss message framing

ObjectiveThis study aims to evaluate the effectiveness of a self-management program using gain/loss-framed messages in patients with gastric cancer. MethodsIn this randomized controlled trial, 69 patients with gastric cancer who underwent gastrectomy at a university hospital were assigned to the gain- or loss-framed message group. The self-management program consisted of: 1) face-to-face education, 2) gain/loss-framed text messages, and 3) self-monitoring of health behaviors. Health outcomes (i.e., nutritional status, physical activity, exercise intensity, and distress), and health behaviors (i.e., dietary habits, physical activity performance, and distress management) were measured, and a generalized estimating equation was used for the analysis. ResultsNutritional status and dietary habits in the loss framed message group were statistically higher after the intervention compared to the counterpart (β = −1.72, p = .049; β = 0.36, p = .033, respectively). There was no time-group interaction effect on physical activity, exercise intensity, physical activity performance, distress or distress management. ConclusionsA self-management program employing loss-framed messages was effective in promoting nutrition-related self-management among patients with gastric cancer. Practice implicationsMessage-framing is an effective communication technique that can be easily used in clinical settings, and a loss-message-framing strategy may enhance nutrition-related self-management in patients with gastric cancer.

Improving Health and Reducing Chronic Disease Disparities with Latinx Communities: Evaluating the Role of Documented Community-Based Intervention Participation.

Limited evidence exists on the impact of participation in community-based chronic disease self-management and prevention programs on health disparities. The purpose of this research was to determine the effects of participation in the Healthy Here Wellness Referral System on existing disparities in glycated hemoglobin (HbA1c), systolic blood pressure (BP), and diastolic BP among Hispanic/Latinx adults compared with non-Hispanic White adults. We merged administrative clinical and referral data from 2018 through 2022 for adult patients in six focus ZIP codes in New Mexico resulting in a sample of 1331 patients and used regression models to examine predictors of intervention participation as well as propensity-adjusted impacts of participation on HbA1c and BP outcomes. Non-Hispanic White patients who were referred to community-based programming but did not participate saw statistically significant increases in HbA1c. Hispanic/Latinx patients saw statistically significant decreases in HbA1c with referral alone, with no added benefit from program participation. The impact of participation differed statistically significantly (t(683) = 3.55, p < .001) between these two groups for HbA1c levels, as well as for systolic (t(958) = 2.11, p = .04) and diastolic BP outcomes (t(958) = 2.96, p = .003). Results of this study support the promise of using centralized referral systems to co-produce health improvement in community settings. Mixed findings highlight the need for further uptake of theory-informed measurement in evaluations seeking to understand heterogeneous program impacts by race and ethnicity.

Supporting Self-Management of Healthy Behaviors in Chronic Kidney Disease and Hypertension: The Supporting Self-Management of Healthy Behaviors Pilot Randomized Trial.

Support programs for self-management are under-utilized among people with chronic kidney disease (CKD). We examined the feasibility of a smartphone-based intervention to support physical activity and blood pressure monitoring, Supporting Self-Management of Healthy Behaviors (SMART-HABITS), for individuals with CKD and hypertension. SMART-HABITS was piloted in a 12-week randomized cross-over trial among people with CKD and hypertension. Participants were asked to monitor blood pressure ≥3-times/week and step counts ≥5-times/week. Participants were randomized to blood pressure communication approach-self-report through text message for six weeks vs. automatic reporting with a smartphone application (app) paired to a Bluetooth enabled blood pressure machine for the alternate six weeks. The approach to monitoring and reporting steps was the same during both phases. Primary outcomes were adoption (retention and use of SMART-HABITS dashboard), adherence (% of transmitted blood pressure and step counts), and acceptability as assessed with surveys and interviews. Secondary outcomes were reach, maintenance, CKD knowledge, digital health literacy, self-management, self-efficacy, quality of life, step counts and blood pressure values. Interviews were conducted at study end. Of the 47 randomized participants, 44 (94%) completed the Text phase and 43 (92%) completed the App phase. Median age was 63 years, 49% were female, and 45% were Black. Retention was 91%. Blood pressure adherence was 87% in the Text phase and 74% in the App phase, and step count adherence was 97%. Acceptability scores were high and interviews largely conveyed acceptance. CKD knowledge increased but remaining survey scores did not change. Mean step counts increased from the pre-study period similarly in both phases. Blood pressure did not change over time. Implementing a smartphone support tool for self-management was feasible among people with CKD and hypertension. The approach can supplement clinic-based care and potentially lead to less cardiovascular disease and CKD progression.

Relationship between Self-Efficacy of Nurses and their General Wellbeing

Background: Nurses, as key personnel in healthcare delivery, play a critical role in the provision and coordination of care, prevention of adverse events, and optimization of health service productivity and patient outcomes. Self-efficacy is the belief, and confidence individuals feel in their ability to perform a particular task or action. Increased self-efficacy is the desired outcome of a self-management program. Several articles used Albert Bandura’s concept of self-efficacy. Objectives: To assess the self-efficacy and wellbeing of nurses. To find out relationship between self-efficacy and wellbeing of nurses. To find out relationship between self-efficacy and wellbeing with socio-demographic characteristics of nurse. Methodology: A descriptive, correlational study design. The study sample composed of 380 nurses who works in Al-Najaf Al-Ashraf hospitals and primary health care center. self-report questionnaire. The instrument used in this study different scales, self-efficacy scale consists of general and social=23item, and 5-well-being scale. Some nurses’ sociodemographic information was included as a separated part. The study was carried out from November 1st, 2023 up to 1 st of April 2024. Results: The majority of study sample (67.4%) are female, (60.8%) were with age less than 27 years old. (84.5%) of nurses are from urban residency. (46.3%) of them held diploma certificate, (89.5%) of nurses do not smoke, and not suffer from physical and mental illnesses. In addition, the overall assessment of nurses' well-being is normal. Conclusion: The majority of study sample were female (67.4); all the self-efficacy domains were high, and majority of nurses well-being are normal. The study shows that non-significant relationship between self-efficacy &amp; wellbeing.

"The Other Thousand Hours": A Spinal Cord Injury Self-Management Program Qualitative Analysis.

People with spinal cord injury experience secondary health conditions (SHCs) at a high rate which impacts life expectancy and functional performance. Self-management (SM) is an evidence-based approach to reduce the negative effects of SHCs, but prior SM programs have not been successful for the spinal cord injury (SCI) population. We sought to describe the experiences of participants completing a group-based telehealth program that is tailored to the SCI population: The Spinal Cord Injury Self-Management (SCISM) Program. We conducted interviews using Interpretive Phenomenological Analysis to examine participants' experiences. Twenty-two participants completed the interviews. Four themes ("A Sense of Community," "Being Held Accountable," "I'm Still Learning," and "Being Proactive Instead of Reactive") emerged. People with SCI require continued support throughout the chronic stage of SCI particularly at the community level to address mental health as well as the learning and application of SM skills through tailored interventions that foster community and accountability.

Implementing PDSA Cycles to Expand Reach of Self-Management Education in the Post-COVID Era

ABSTRACT Background COVID-19 reduced participation in our region’s evidence-based chronic disease self-management program (SMP), despite having expanded offerings to include diverse delivery modes (e.g. virtual, mailed toolkit, phone-based group support). Purpose The purpose was to test various approaches of disseminating the mailed toolkit (an independent study version of the SMP) to expand reach of the program. Methods We ran three process improvement (PDSA) cycles. We used electronic health record data, a participant survey, and implementer feedback to guide our decision-making process throughout the iterations. Results Toolkits reached populations that had not previously been exposed to SMPs: individuals with type 2 diabetes who did not attend diabetes education in the past year; individuals being discharged from acute care with an admitting diagnosis related to a chronic disease; and individuals referred by their provider to the program. Discussion Toolkit utilization will remain low for those who are not ready to make a behavior change. Running PDSA cycles provided the necessary information for our team to make decisions about future dissemination of the mailed toolkits. Translation to Health Education Practice Engaging in PDSA cycles can be a helpful tool for health educators when considering how to expand reach or engage new populations of interest.

The feasibility of a social media-based foot self-management education and support program for adults with diabetes: A partially randomized preference trial

AimTo assess the feasibility of Diabetic Foot Care Group (DFCG), a social media-based self-management education and support intervention, for people with diabetes (PWD) empowerment in diabetes-related foot ulceration prevention. MethodsA partially randomized preference trial was conducted among 32 PWD. DFCG was implemented through Facebook. Participants in the intervention group joined the DFCG in addition to their usual care, while the control group received usual care. Data were collected online using questionnaires on participants' DFCG acceptance, engagement and preliminary efficacy on nine diabetes foot care-related outcomes at baseline, one, and three months post-intervention. ResultsThe participants' study intervention acceptability and engagement rates were 84.2% and 55.2%, respectively. DFCG efficacy rate compared to usual care was 88.9% to 22.2%. Three diabetes foot care-related outcomes increased significantly in the intervention group three-month post-intervention: foot self-care adherence (p = 0.001, ηp2 = 0.35), preventive foot self-care practice (p = 0.002, ηp2 = 0.33), and physical health status (p < 0.02, ηp2 = 0.23). ConclusionDFCG is feasible and could effectively improve diabetes foot care-related outcomes. InnovationSocial media is an innovative approach healthcare professionals could utilize to virtually support PWD in ongoing learning and engagement in optimal foot self-care activities. Trial registrationClinicalTrials.gov, Identifier: NCT04395521

The effects of diabetes self-management programs on clinical and patient reported outcomes in older adults: a systematic review and meta-analysis.

With diabetes self-management continuing to become more complex for older adults, self-management programs have been shown to support this population in meeting their multifaceted medical needs. Building on our previous systematic review and meta-analysis, we aimed to update the literature on the effectiveness of diabetes self-management programs and investigate the impact of specific self-management interventions on clinical and patient-reported outcomes. We updated our literature search in the following databases: Medline, EMBASE, PsychINFO, CINAHL and Cochrane Database of Randomized Controlled Trials from November 2013 to July 2023 for studies that may fit our inclusion criteria. Two independent reviewers screened and extracted data from the included group of studies. A total of 17 studies with 21 comparison arms met the inclusion criteria, totalling 5976 older adults (3510 individuals randomized to self-management programming and 2466 to usual care). The pooled effectiveness of diabetes self-management programs in older adults on glycemic control (hemoglobin A1C) was a reduction of -0.32 (95% CI -0.44, -0.19). Specifically, the most effective approach on glycemic control (A1C) was the use of feedback (-0.52%; 95% CI -0.68, -0.36). Overall, self-management programs improved behaviour change outcomes, with feedback interventions being most effective (standardized mean difference [SMD] 0.91; 95% CI 0.39, 1.43). The effect of self-management programs on body mass index, weight and lipids were statistically and clinically significant. The evidence for diabetes self-management programs for older adults demonstrates a small but clinically meaningful reduction in A1C, improvement in patient-reported outcomes (behaviour, self-efficacy, knowledge), and other clinical outcomes (BMI, weight and lipids). The specific strategy used in diabetes self-management programs for older adults should be considered to achieve optimal results on outcomes.

Observational pilot study on the influence of an app-based self-management program on the quality of life of women with endometriosis

PurposeEndometriosis can significantly impair the quality of life of those affected. Multimodal self-help measures are recommended but often difficult to access. Smartphone apps have been shown to improve the quality of life for other conditions with chronic pain. The aim of this study was to examine whether there is evidence of beneficial effects of the smartphone app “Endo-App®” and whether a multicenter randomized controlled trial should be planned to substantiate these effects.MethodsIn a sample of N = 106 women affected by endometriosis the present study determined the influence of the use of Endo-App® on their quality of life. Among others, the validated questionnaire Endometriosis Health Profile from Oxford University was used for this purpose.ResultsThe use of Endo-App® lead to a highly significant improvement in quality of life already after 2 weeks. A statistically significant change was found for nine out of ten measured variables of quality of life. A series of further analyses validated that the measured positive effects were not due to other confounding factors.ConclusionIn summary, the results indicate that the quality of life of women with endometriosis improved by the digital self-management tool Endo-App®. More studies are needed to further explore the influence of the app on quality of life and as confirmatory evidence of beneficial effects. For this purpose, a randomized controlled trial should be conducted over a longer period of time.Trial registrationThis trial is registered at clinicaltrials.gov under the registration number NCT05528601 on August 18, 2022. It was retrospectively registered.

Patients and informal caregivers in the lead: a qualitative study on the experiences of patients, informal caregivers, and healthcare professionals with involvement in treatment, e-health and self-management programs

BackgroundA significant proportion of patients and informal caregivers favor an active role in decisions concerning their health. Simultaneously, governments aim to shift treatment from a professional care setting to a community setting, in light of an ageing population, a decreasing number of health workers and allocation of scarce resources. This transition of care solicits patients’ and informal caregivers’ ability to self-manage. Therefore, the Maastricht University Medical Centre + has established the Academy for Patients and Informal caregivers. The aim is to proactively and professionally support patients and their informal caregivers to enhance their self-management. For that, the Academy offers activities in three categories: (1) instruction of nursing techniques, (2) training of e-health competencies and (3) the provision of self-management programs. Both patients with an episodic care need, as well as patients and informal caregivers with chronic illness, are eligible to participate in the Academy’s activities. However, little is known about the experience of these interventions from the perspective of patients, informal caregivers and healthcare professionals.MethodsWe conducted semi-structured interviews with 15 patients, 8 informal caregivers and 19 health care professionals who either participated in, referred to or received patients from the Academy. Topics revolved around self-management and the Quadruple aim, covering topics such as patient experiences, healthcare costs, health and well-being of the population and improving work life for health professionals. Data were analyzed using thematic analysis.ResultsPatients and caregivers experienced an increase in the ability to manage health needs independently, leading to increased mental well-being and self-efficacy. They felt recognized as partners in care, although managing illness needs came with its own burdens. Health care professionals indicated that they felt assured of the quality, uniformity and availability of activities due to its central organization, with instruction nurses finding greater meaning in their work. On the level of health care systems, participants in this study mentioned a decrease in use of formal healthcare, whilst enabling a more equitable division of care.ConclusionStakeholders’ experiences with the Academy for Patients and Informal caregivers indicate that participation contributes to development of self-management, whilst also improving working conditions, reducing the appeal to formal care and advancing equity in healthcare. The burden for patients and informal caregivers is to be considered in future developments.

Evaluation of the Expert Patient PANLAR self-management program in rheumatoid arthritis. A pilot study in Argentina, Colombia and Panamá

Education is a cornerstone of the comprehensive management of patients living with rheumatic and musculoskeletal diseases (RMSDs). It allows them to optimize their self-care for health maintenance. The objective of this study was to assess the effectiveness of the PANLAR Patient Expert (PE) program in optimizing self-care skills for physical activity, healthy eating, communication with professionals, therapeutic adherence and decision making.

Effectiveness of self-management programmes for heart failure with reduced ejection fraction: a systematic review protocol

IntroductionChronic disease self-management (CDSM) is a vital component of congestive heart failure (CHF) programmes. Recent CHF guidelines have downgraded CDSM programmes citing a lack of gold-standard evidence. This protocol describes...

Smartphone applications supporting self-management programme for adults with Chronic Obstructive Pulmonary Disease: A Scoping Review.

Chronic Obstructive Pulmonary Disease (COPD) significantly impacts on both the quality and quantity of life for patients due to frequent exacerbations requiring hospital admissions resulting in increased morbidity and mortality. A self-management programme purpose is to increase one's knowledge, confidence, and skills to self-manage their chronic illness such as COPD. The objective of this review will therefore answer the following research question: What is the current literature pertaining to the use of a smartphone app in supporting a comprehensive self-management programme among COPD patients? A preliminary search was conducted in, Medline, Embase and CINAHL databases to ascertain index terms and keywords. Following this a rigorous search was carried out on Medline, Embase, CINAHL, Web of Science and ASSIA. The findings from this search are presented in tabular form using the PRSIMA flow diagram. In this review, fifteen studies met the inclusion criteria. Across all studies participants engaged with the app and developed self-management skills and knowledge to manage their chronic illness. However, engagement with the app without third party involvement declined over time. Technical issues did not cause harm to participants but in some cases contributed to reduced engagement. Smartphone self-management apps empowered a cohort of COPD participants to engage in managing their chronic illness which proved useful in detecting exacerbations earlier resulting in reducing the need for hospitalisations over a three-to-six-month period. By reducing hospitalisations incurred a cost savings for health care and an improved quality and quantity of life for these participants. It is evident from the literature that smartphone self-management apps may positively influence participants self-management decisions in terms of knowledge, increase physical activity, self-efficacy that may result in reduced hospitalisation and improved quality of life. It is clear that technical issues and sustained engagement over longer periods of time remains a challenge.

Effectiveness of the Mobile e-Health Individual and Family Self-management Program for Primiparous Pregnant Adolescents: A Quasi-experimental Study

Effectiveness of the Mobile e-Health Individual and Family Self-management Program for Primiparous Pregnant Adolescents: A Quasi-experimental Study

Barriers and facilitators to engaging with a digital self-management programme for painful distal upper limb musculoskeletal disorders: A qualitative exploratory study.

People living with a painful distal upper limb musculoskeletal disorder (DUL-MSD) often experience pain, difficulty in doing everyday tasks and a reduced quality of life. Currently, there are challenges in the treatment of DUL-MSDs, highlighting the need to develop innovative approaches to rehabilitation. A potential solution is to develop and implement a digital self-management rehabilitation programme focussing on optimising recovery, improving function and reducing pain. Before developing this programme, we aimed to identify the barriers and facilitators to using a digital health intervention (DHI) for self-management of DUL-MSDs. This study aimed to investigate the potential barriers and facilitators to using a DHI with people living with DUL-MSDs and healthcare professionals (HCPs). A qualitative exploratory study was carried out with purposely selected participants consisting of 15 participants with DUL-MSDs and 13 HCPs. Three focus groups (FGs) and four semistructured interviews with DUL-MSD participants and semistructured interviews with 13 HCPs were conducted. FGs and interviews were digitally recorded, transcribed and analysed using reflexive thematic analysis. To address challenges in the care and management of DUL-MSDs, both HCPs and people living with a DUL-MSD welcomed the development of a DHI. This study identified several barriers and facilitators that would influence engagement with a digital intervention. Findings suggest that in developing a DHI, attention needs to be paid to digital design features, usability, tailoring, personalisation and consideration of how well usual care could be replicated digitally without direct HCP involvement. The identified digital design features of importance to participants will inform the design of a digital self-management rehabilitation programme for people living with DUL-MSDs. Addressing the barriers and facilitators to engagement with a DHI is essential in ensuring its relevance and acceptability to those who will use it. Patient and Public Involvement and Engagement (PPIE) was integral throughout the study. PPIE members contributed to the development and planning of this study, checked and confirmed the relevance of the findings and are involved in the dissemination plans.

EMBARK: A Randomized, Controlled Trial Comparing Three Approaches to Reducing Diabetes Distress and Improving HbA1c in Adults With Type 1 Diabetes.

To compare the effectiveness of three interventions to reduce diabetes distress (DD) and improve HbA1c among adults with type 1 diabetes (T1D). Individuals with T1D (n = 276) with elevated DD (a score >2 on the total Type 1 Diabetes Distress Scale) and HbA1c (>7.5%) were recruited from multiple settings and randomly assigned to one of three virtual group-based programs: 1) Streamline, an educator-led education and diabetes self-management program; 2) TunedIn, a psychologist-led program focused exclusively on emotional-focused DD reduction; or 3) FixIt, an integration of Streamline and TunedIn. Assessments of the primary outcomes of DD and HbA1c occurred at baseline and at 3, 6, and 12 months. All three programs demonstrated substantive and sustained reductions in DD (Cohen's d = 0.58-1.14) and HbA1c (range, -0.4 to -0.72) at 12-month follow-up. TunedIn and FixIt participants reported significantly greater DD reductions compared with Streamline participants (P = 0.007). Streamline and TunedIn participants achieved significantly greater HbA1c reductions than did FixIt participants (P = 0.006). DD can be successfully reduced among individuals with T1D with elevated HbA1c using both the educational/behavioral and emotion-focused approaches included in the study. Although both approaches are associated with significant and clinically meaningful reductions in DD and HbA1c, TunedIn, the emotion-focused program, had the most consistent benefits across both DD and HbA1c. The study findings suggest the overall value of group-based, fully virtual, and time-limited emotion-focused strategies, like those used in TunedIn, for adults with T1D.

Self-Management Programs and the Pursuit of Behavior Change.

A self-management intervention is a personalized approach to individuals aiming to engage individuals in a behavior change to develop skills to live better with their condition. Self-management involves an iterative process between participants and providers in which goals are formulated and feedback is given. All respiratory societies advocate self-management as part of chronic care because it may improve quality of life and health-care utilization. Self-management is an integral part of pulmonary rehabilitation. Self-management interventions usually involve education and exercise prescription, and that is an asset of current programs; however, recent reports indicate that effective strategies for motivation and a behavior change focus are often missed. A recent systematic review on self-management urges the need for a specific aspect and characteristic of self-management interventions: iterative interactions between participants and health-care professionals competent in using behavior change practices to elicit participants' motivation, confidence, and competence to develop skills to better manage their disease. A recent review of self-care intervention in chronic disease states that the major deficits found in self-care interventions included a lack of attention and/or innovation to the psychological consequences of chronic illness, technology, and behavior change techniques to help patients manage symptoms. There is a need for exploration of mechanisms to explain the relationships between both anxiety and depression, and adherence to treatment in COPD. The latter is particularly appropriate for pulmonary rehabilitation, for which greater adherence is needed. This report aims to introduce basic aspects of behavior change and a proposed roadmap to introduce behavior change into pulmonary rehabilitation and chronic care programs.

Pengaruh Edukasi Self Management terhadap Kualitas Hidup Pasien Kanker Payudara

This study aims to identify the effectiveness of education or self-management programs on the quality of life of breast cancer patients. The method used was a systematic review using a systematic search through the Proquest, Science Direct, and EBSCOhost databases with articles that met the inclusion criteria with publications between 2014 and 2023 as well as an article search technique using the PRISMA scheme stages. The results of the research showed that the search results identified ten articles in which various self-management programs stated that self-management program education had a positive effect on the quality of life of breast cancer patients. The conclusion obtained is that the self-management program can be an effective intervention to improve the quality of life of breast cancer patients. Keywords:, Breast Cancer, Self Management, Quality of Life