What is meant by self‐management and how can its efficacy be established? (2022)

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Volume 40 Issue 1

January 2001

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S. Newman,

S. Newman

Unit of Health Psychology, Department of Psychiatry and Behavioural Sciences, Royal Free and University College Medical School, 48 Riding House Street, London W1N 8AA, UK

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K. Mulligan,

K. Mulligan

Unit of Health Psychology, Department of Psychiatry and Behavioural Sciences, Royal Free and University College Medical School, 48 Riding House Street, London W1N 8AA, UK

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L. Steed

L. Steed

Unit of Health Psychology, Department of Psychiatry and Behavioural Sciences, Royal Free and University College Medical School, 48 Riding House Street, London W1N 8AA, UK

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Rheumatology, Volume 40, Issue 1, January 2001, Pages 1–4, https://doi.org/10.1093/rheumatology/40.1.1

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01 January 2001

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    S. Newman, K. Mulligan, L. Steed, What is meant by self‐management and how can its efficacy be established?, Rheumatology, Volume 40, Issue 1, January 2001, Pages 1–4, https://doi.org/10.1093/rheumatology/40.1.1

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There has been a significant shift in recent years towards patients being seen as consumers of health‐care. This has been accompanied by changes in the amount of patient involvement in health‐care. At the macro level, patients and patient organizations are increasingly involved in consultation and the setting of health‐care priorities. At the level of direct patient care, approaches have been developed where patients are more closely involved in decisions regarding their treatment [1]. There has been an increased recognition of the need for patients' involvement in, and commitment to, their treatment regimens in chronic illness. In addition there has been increased appreciation of the broader ramifications of the impact of chronic illness on psychological and social well‐being. These factors, amongst others, have led to an increase in patient participation in care. Historically, this involved providing patients with information about their condition, which was commonly integrated with clinical care [2] but more recently has evolved into the development of patient programmes. These aim to enable patients to become more directly involved in the management of their chronic condition, and are referred to variously as education, psycho‐education or, more recently, ‘self‐management’ interventions. The term ‘self‐management’ implies a shift of responsibility from the health‐care professional to the individual for the day‐to‐day management of their condition. The programmes aim to achieve this transfer of responsibility by providing principally information and skills to the participants.

Within arthritis, a number of self‐management interventions have been designed and implemented and some have been subjected to evaluation. Several reviews [3–7] have reported the beneficial effects of such interventions on a number of outcomes, including changes in pain, disability and psychological well‐being. These benefits are over and above those already being obtained from medication, as patients normally continue with conventional medical treatment while participating in these programmes. These interventions do, however, vary considerably. Their most common feature is that the main focus is not drug treatment.

Early self‐management programmes focused on education as it was thought that the provision of information would affect patients' knowledge, and this in turn would have the desired impact on behaviour. Recent programmes have become more comprehensive, addressing both practical and psychosocial issues in addition to information. These programmes imply a more complex set of changes, which are assumed to have an impact on the individual's thoughts, feelings and behaviours [8]. To varying degrees these interventions recognize that behaviour changes need to relate to the individual's social world as the bulk of behaviours associated with arthritis take place outside the clinic. Self‐management interventions therefore aim to teach skills which patients can incorporate into their daily lives.

The most widely known self‐management intervention in arthritis is the Arthritis Self‐Management Programme (ASMP) [9]. This is a community‐based group programme led by lay people who themselves have arthritis. This programme teaches a variety of skills and aims to enhance participants' self‐efficacy to deal with their condition. It is important to recognize that the ASMP is only one type of self‐management programme and differs in approach from many others. Other interventions are more typically led by health professionals in a hospital setting, with patients who have been recruited through clinics. Participants all usually have the same diagnosis, in contrast with the ASMP, in which people with different types of arthritis can attend the same group.

Self‐management programmes also differ in a range of other dimensions. For example, their content varies significantly: they can include disease information, discussion, cognitive pain management skills, exercise, training in activities of daily living, the teaching of problem‐solving skills, social skills training, relaxation training, different forms of counselling and therapy, biofeedback and social support, amongst others. Even where the content is similar, the programmes may differ in the extent to which they focus on different aspects of arthritis (e.g. pain or stress). The number of sessions within each programme varies enormously. For example, programmes can range from a single session [10] to twelve or more [11, 12]. The duration of each session can range from as little as 20 min [13] to 2 h or more [14–17]. While most interventions are delivered by direct contact between the programme leader and the participant(s), some use telephone contact [18, 19] or self‐instruction with a computer programme or a manual [20, 21]. Some are individual‐based [10, 22], while others are group programmes [9, 11, 12, 14–16, 22–24].

To an extent, the diversity of these programmes reflects different theoretical approaches. These approaches locate the point of change in particular psychological concepts, which are presumed to underlie any changes that occur as a result of the programme. One approach is based on the social learning theory of Bandura [25]. This has, as one of its central concepts, ‘self‐efficacy’—the individual's sense of his or her ability to perform certain tasks and/or use information. It is common, therefore, for studies using this approach [14, 26] to assess self‐efficacy and to have a programme that is directed towards influencing it. Another theoretical approach is based on the Leventhal Self Regulation Model [27], which suggests that individuals hold certain views about their condition (illness representations) which determine how they attempt to cope with their arthritis and their consequent quality of life and emotional well‐being. Studies using this approach commonly assess these illness representations and seek to find changes in them after a self‐management intervention [28, 29]. Other interventions use theoretical approaches more linked to clinical psychology, such as cognitive–behavioural interventions [15, 22, 30–34], and others adopt an approach located in theories about the role and importance of social support [35, 36].

This detailing of the differences in self‐management interventions is intended to emphasize their diversity and make the point that any attempt to group them together as if they were generic interventions ignores fundamental differences between them. It implies that, instead of asking the simple question ‘Are self‐management interventions effective?’, we need to ask questions about which of the self‐management interventions work, and what components of these interventions are important. In addition, it is likely that different approaches to self‐management will affect different outcomes. It is this question that we consider first.

A number of studies have examined the impact of the programmes on knowledge [2, 3, 5 (reviews)], based on the assumption that changes in knowledge are necessary for changes in behaviour. Changes in knowledge, however, have been shown to be relatively ineffective in bringing about change in a number of chronic illnesses [e.g. 37] and health‐related behaviours, such as smoking, as well as in arthritis [7]. It is also important that information about arthritis and its treatments is now more freely available, and it is possible that patients are more knowledgeable, making information provision a less potent factor. However, it is probably the case that knowledge is necessary but not sufficient to lead to changes in behaviour.

It should also be taken into account that knowledge and other concepts such as self‐efficacy and coping are potential mediating variables rather than outcome variables. While such variables are valuable in helping to explain our understanding of the process, their real importance lies in the extent to which they predict outcomes such as functional ability, pain and psychological well‐being. It is important to consider which of these outcome measures are the most important and which might be expected to change as a result of a particular type of self‐management intervention. For example, it might be unrealistic to expect a change in erythrocyte sedimentation rate, but reductions in pain and/or disability, which are mediated through cognitive factors, are more likely to be influenced by a self‐management programme. These are therefore more appropriate outcome measures.

The focus of the intervention should also be considered when selecting an outcome measure. For example, it may be inappropriate to expect a change in depression when an intervention neither targets clinically depressed patients nor specifically addresses depression within the programme.

It has become increasingly important to ensure that any intervention for patients is cost‐effective. Assessment of relative costs is primarily related to the hypothesized reduction in health‐care utilization, in particular visits to the doctor. A small number of studies has examined this issue and shown that these non‐pharmacological interventions appear to be cost‐neutral or cost‐beneficial [e.g. 38, 39].

The selection of participants in these programmes raises the issue of how generalizable the findings are. Although selection takes place in all studies (including drug studies), it is particularly pertinent in studies of self‐management, in which patients may have to commit significant amounts of time to participate. Self‐selection to participate is likely to involve those with sufficient time, interest and motivation, and it is therefore possible that these studies will not recruit a representative sample of those with the condition.

Many studies that have assessed the efficacy of self‐management have used ‘pre–post’ designs rather than randomized controlled trials. While randomized controlled trials offer a more powerful design, it is particularly important to have a control group in order to account for fluctuations in arthritis over time.

It is possible that the benefits of some programmes are understated because many of the studies reported in the literature are underpowered. For example, in a review conducted by us, sample sizes in interventions in rheumatoid arthritis (RA) ranged from 11 to 225 and most studies had samples below 50. It is unlikely that sample sizes of this order give sufficient power. In addition, many studies only assess the immediate or short‐term outcome of self‐management programmes. There is a need to establish whether and which of these interventions have a long‐term impact. Unfortunately, few studies have followed up their participants beyond 6 months after intervention.

Although meta‐analysis has been used to examine the impact of self‐management interventions in arthritis and some encouraging effects have been reported [4], it is questionable whether this is a useful approach. One of the difficulties lies in the multi‐component nature of self‐management programmes and their variability in content, intensity, and mode and manner of delivery. Using meta‐analysis to assess the efficacy of interventions is therefore problematic because this form of analysis is only fitting where data are homogeneous [40].

The variety in content of self‐management programmes also makes it difficult to tell which elements of the interventions are most important to their success. Instead of asking whether self‐management interventions work, a more valuable question is to ask which components of self‐management interventions appear to be effective. We have attempted to identify and evaluate the components of each of the self‐management interventions in order to answer this question. This analysis indicated that, in general, interventions that provided information alone did not have an impact on outcomes, confirming previous findings. Other components examined were more effective for certain outcomes, although their efficacy sometimes differed by diagnosis. For example, cognitive approaches, such as the modulation of ways of thinking about arthritis, were fairly successful in reducing pain, but had little impact on disability. Exercise was more often associated with reduced pain and disability in osteoarthritis patients than in RA patients. These findings emphasize that, in order to understand self‐management interventions, it is important to ask what is effective on what outcome variable and in whom.

A further question regarding the analysis of the impact of these interventions relates to the theoretical models that have guided some of the interventions. The heterogeneity of individuals' beliefs and cognitions, as well as their social circumstances at entry into a self‐management intervention, calls into question the assumption that a particular intervention will have beneficial effects for all individuals. It is important for these studies that questions are asked about which individuals will benefit from what type of intervention.

It is clear that self‐management interventions are growing in popularity, and some of them have been shown to be effective in arthritis. This editorial has attempted to make the case that the examination of self‐management in arthritis should not attempt to ignore the heterogeneity in these approaches. To combine all such interventions into an analysis will not improve our understanding of what works and for whom. Greater attention needs to be directed to their content, how they are delivered, the study design and the attitudes and beliefs of the participants. A more systematic approach to self‐management studies which compares different types of programmes will be helpful in targeting resources in the management of rheumatological illness and will lead to more effective self‐management interventions.

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