Helping people help themselves - Evidence: A review of the evidence considering whether it is worthwhile to support self-management

 
Helping people help themselves - Evidence: A review of the evidence considering whether it is worthwhile to support self-management
Evidence:
Helping people
help themselves
A review of the evidence considering whether it is
worthwhile to support self-management

May 2011

Identify Innovate Demonstrate Encourage
Author                               Institution           Contact
Dr Debra de Silva                    The Evidence Centre   Debra@evidencecentre.com

© 2011 Health Foundation

Evidence: Helping people help themselves
is published by the Health Foundation
90 Long Acre, London WC2E 9RA

ISBN 978–1–906461–26–3
Contents

Foreword		                                                                            iv

Executive summary                                                                      v

Chapter 1    What is self-management support?                                          1

Chapter 2    Impacts of self-management                                                3

Chapter 3    What works to support self-management                                    10

Chapter 4    Issues that need more attention                                          18

References		                                                                          20

Appendix 1   Review methods                                                           38

                                                     Helping people help themselves   iii
Foreword

When it comes to putting self-management              Thus, it is essential that healthcare providers
support at the heart of routine healthcare, there     critically appraise this evidence and focus efforts
is a huge gulf between political rhetoric and the     on those methods with the strongest evidence.
reality of UK clinical practice. Many clinicians
question the notion that their role should change     Second, it shows that proactively supporting
to support self-management. Why should clinical       self-management and focusing on behaviour
practice change? What is the evidence that            change can have an impact, in some circumstances,
self-management support works?                        on clinical outcomes and emergency service
                                                      use. Furthermore a focus on behaviour change
The Health Foundation has produced this               is a necessary component in facilitating the
literature review to respond to the questions         effectiveness of other methods such as information
and challenges of clinicians wanting to appraise      provision.
the benefits of self-management support. The
literature shows that proactive, behaviourally        The review reminds us that self-management
focused self-management support designed              support is still in its infancy. While there is a
to increase self-efficacy can have a positive         growing research base, we know much less about
impact on people’s clinical symptoms, attitudes       how to replicate the positive results produced in
and behaviours, quality of life and patterns of       research contexts in real-world healthcare. We
healthcare resource use. This echoes the experience   need many more opportunities, like those provided
of the hundreds of clinicians and patients across     by Co-creating Health, that allow healthcare
the UK that have been involved in Co-creating         professionals and system leaders to explore the best
Health, our demonstration programme to test           ways to make self-management support a part of
the implementation of strategies for embedding        routine healthcare.
self-management into routine care. Our
                                                      The UK healthcare system can’t afford to ignore
independent evaluation of the programme will
                                                      this evidence. Already the 30% of the population
report in 2011.
                                                      with long term conditions accounts for 70% of NHS
So what is to be done? Two conclusions of             spending. Reducing people’s dependence on health
this review stand out. First, it provides a new       professionals and increasing their sense of control
perspective on self-management support.               and wellbeing is a more intelligent and effective
Traditionally, a wide range of methods have           way of working.
been described as supporting self-management –
interventions as varied as handing out leaflets,
tele-monitoring, intensive telephone coaching         Natalie Grazin
and structured education. This review shows that      Assistant Director
some approaches are significantly more effective      Improvement Programmes
than others.                                          The Health Foundation

iv    tHE HEALtH FoUNDAtIoN
Executive summary

Self-management works                                     Supporting self-management is not a panacea, and
                                                          is likely to work best when implemented as part of
This review of more than 550 pieces of high quality       wider initiatives to improve care through educating
research suggests that it is worthwhile to support        practitioners, applying best evidence, and using
self-management, in particular through focusing           technology, decision aids and community
on behaviour change and supporting self-efficacy.         partnerships effectively.
Hundreds of systematic reviews, randomised
controlled trials and large observational studies         Proactive strategies work best
have examined the impact of supporting
self-management for people with long term                 There are a wide range of initiatives to support
conditions. Whilst the findings of individual             self-management. These can be categorised
studies are mixed, the totality of evidence suggests      along a continuum of interventions, with passive
that supporting self-management can have benefits         information provision about healthy behaviours
for people’s attitudes and behaviours, quality of life,   and other ‘technical’ topics at one end of the scale
clinical symptoms and use of healthcare resources.        and initiatives that more actively seek to support
                                                          behaviour change and increase self-efficacy at the
 Some suggest that the evidence for supporting            other end of the continuum.
 self-management is only moderate but this is
 because a wide range of activity is described as         Different clinical conditions may require varying
‘self-management support’ and some interventions           approaches to support self-management. For
 may be more effective than others. Past reviews           instance, people with conditions such as diabetes
 have tended to combine initiatives that focus             may benefit from structured education about
 solely on information provision with interventions        how to eat, exercise and take medications. For
 that more actively target behaviour change and            conditions such as depression or chronic pain on
 self-efficacy. However, these varying interventions       the other hand, less ‘technical’ or clinical education
 may have different outcomes so combining them             may be needed because the service user has less
 could dilute the findings.                               ‘technical work’ to do.1 Therefore, evidence about
                                                           self-management support for these groups tends to
Supporting self-management has the potential to            focus on cognitive and behavioural interventions.
alleviate the pressure on health and social services       Such interventions may be equally valuable
caused by workforce shortages, rising demand               for people with diabetes and other conditions,
for services, population increases and budgetary           even though the focus to date has been mainly
constraints. However, implementing one off                ‘technical’.2–4
interventions is unlikely to make a significant
impact on the overall health of the population or on
the sustainability of health and social care systems.

                                                                           Helping people help themselves        v
All of the different types of support are important      However, the best strategies for implementing
components of the jigsaw needed to encourage             these principles and the related barriers and
self-management, but information provision alone         facilitators remain uncertain.28 There is a need for
is unlikely to be sufficient to motivate sustainable     high-quality research and evaluation that focuses
behaviour change and improve clinical outcomes.          on building relationships between service users
More active goal setting and behavioural change          and practitioners and exploring the most effective
interventions are necessary. There is also emerging      strategies for encouraging behaviour change.29
evidence that strategies co-created by service users
and professionals or co-led by service users have        Another core component of supporting
positive outcomes.5–7                                    self-management is enabling and encouraging
                                                         clinicians and lay trainers to work with people
     A co-created teaching approach better meets         to improve their motivation to change.30 It is
     the learning needs of adults with type 2 diabetes   important to understand the skills that clinicians
     mellitus and results in enhanced ability to         need to help people make changes and the barriers
     perform the self-care activities required for       that may stop them from offering such support.31–33
     successful diabetes control.8
                                                         Whilst evidence is emerging, there is still a long
                                                         way to go before we understand the education and
Evidence is developing                                   support necessary to optimise clinicians’ attitudes,
                                                         skills and behaviours towards self-management.34
Knowledge in this area is developing so evidence
                                                         This also calls for a fundamental shift in power
about the best strategies to support behaviour
                                                         dynamics and the way both patients and
change may be limited at this stage,9–10 though
                                                         professionals view their roles.35–37
much work suggests that in order to change
behaviour, people need to really want to change.11          Self-management support is the assistance
                                                            caregivers give patients with chronic disease
General components that have been found to work
                                                            in order to encourage daily decisions that
well to support self-management include:12–27
                                                            improve health related behaviors and clinical
–– involving people in decision making                      outcomes. Self-management support can be
–– emphasising problem solving                              viewed in two ways: as a portfolio of techniques
                                                            and tools that help patients choose healthy
–– developing care plans as a partnership between           behaviours; and a fundamental transformation
   service users and professionals                          of the patient–caregiver relationship into a
–– setting goals and following up on the extent to          collaborative partnership.38
   which these are achieved over time
                                                         Some suggest that training strategies need to
–– promoting healthy lifestyles and educating            account for practitioners’ stage of change as well as
   people about their conditions and how to              that of patients.39
   self-manage
–– motivating people to self-manage using targeted       In order to do this we need to understand more
   approaches and structured information                 about how best to increase self-efficacy and
   and support                                           encourage behaviour change, and how we can
                                                         motivate all members of the team, including
–– helping people to monitor their symptoms and          clinicians and patients themselves, to be
   know when to take appropriate action                  part of this.
–– helping people to manage the social, emotional
   and physical impacts of their conditions
–– proactive follow up
–– providing opportunities to share and learn from
   other service users.

vi      tHE HEALtH FoUNDAtIoN
Key messages                                            Based on the results of almost 600 studies published
                                                        in the UK and internationally, there is evidence that
An increasing number of people are living with          supporting self-management can improve people’s
long term health conditions which they manage           quality of life, clinical outcomes and health service
most of the time by themselves. Helping people          use. Research suggests that proactively supporting
to better care for themselves can improve their         self-management and focusing on self-efficacy (a
physical and mental wellbeing and change how            person’s confidence about looking after themselves)
they use services. There is good evidence that          and behaviour change can have an impact on
supporting self-management works.                       clinical outcomes and emergency service use.

                                                        Some studies suggest that the evidence for
What is self-management?                                supporting self-management is only moderate
As the population ages and our lifestyles and habits    but this is because a wide range of initiatives are
change, more and more people are living with long       described as ‘self-management support’ and some
term conditions that cannot currently be cured. In      may be more effective than others. It would dilute
the UK more than 17 million adults have a long          the findings to combine initiatives that focus solely
term condition such as diabetes, asthma, heart          on information provision with interventions that
failure, arthritis dementia or depression.40            target behaviour change and self-efficacy.

Health and social care services support people          Some studies argue that supporting
with long term conditions by providing equipment,       self-management reduces the use and costs of
specialist staff and medicines to control symptoms.     health services. However this focus may be too
In fact, it is estimated that about two thirds of all   simplistic. It is more likely that patterns of service
healthcare resources are spent supporting people        use change rather than reduce overall. For example,
with long term conditions.41                            people may engage more frequently with a practice
                                                        nurse, telephone coach or with peers, but less with
Even so, 80% to 90% of all care for people              hospital services. The aim is not to reduce contact
with long term conditions is undertaken by              overall, but rather to support a different pattern
patients themselves and their families.42 This          of contact which may lead to fewer crises and
self-management or self-care includes eating well,      inpatient admissions.
exercising, taking medicines, keeping in good
mental health, watching for changes, coping if
symptoms worsen and knowing when to seek
                                                        What type of support works?
professional help.                                      There are a wide range of initiatives to support
                                                        self-management including information leaflets,
Supporting self-management involves educating
                                                        online peer support, one to one counselling,
people about their condition and care and
                                                        group education sessions, telephone coaching,
motivating them to care for themselves better.
                                                        monitoring symptoms with technology, and
Self-management support can be viewed in                psychological behaviour change interventions.
two ways: as a portfolio of techniques and tools        Initiatives can be categorised along a continuum,
that help patients choose healthy behaviours;           with passive information provision about people’s
and a fundamental transformation of the                 condition and ‘technical skills’ at one end of the
patient–caregiver relationship into a collaborative     scale and initiatives that more actively seek to
partnership.43                                          support behaviour change and increase self-efficacy
                                                        at the other end of the continuum.

Does self-management work?                              All of the different types of support are
                                                        important components of the jigsaw needed to
Planners and practitioners increasingly recognise       encourage self-management, but information
the benefits of supporting people to manage             provision alone is unlikely to be sufficient to
their own conditions. This rapid review compiles        motivate behaviour change and improve outcomes.
research about supporting self-management.

                                                                        Helping people help themselves      vii
Figure 1: continuum strategies to support self management

                                        Focus on self-efficacy
                                                                           motivational interviewing
                                                         telephone coaching
                                  Care plans
                                                                             goal setting
                    patient held records                Active group education
Information provision

                  online courses                           group education          Behaviour change

         Electronic information                                   Self-monitoring

          Written information

                                      Focus on technical skills

More active goal setting and behavioural change           approaches and structured support; helping people
interventions are needed.                                 to monitor their symptoms and know when to take
                                                          appropriate action; promoting healthy lifestyles
Different clinical conditions may require varying         and educating people about their conditions
approaches to support self-management. For                and how to self-manage; and proactive follow up,
instance, because of the nature of conditions             including providing opportunities to share with
such as diabetes, there is a role for structured          and learn from other service users.
patient education focused on technical or clinical
information about diet, exercise and medication.          Knowledge about how to support behaviour change
For conditions such as depression on the other             and put these principles into practice is still being
hand, there may be fewer ‘technical’ changes               developed. Research suggests that in order to
that people can make so the focus is instead on            change behaviour, people need to want to change.
cognitive and behavioural interventions. Such             ‘Stage of change’ models have been found to be
interventions may be equally valuable for people           useful in developing successful programmes.
with diabetes and other conditions where the focus
to date has been mainly on providing ‘technical’          Another core component is supporting clinicians
information, but this remains an emerging field of        to work with people to improve their motivation
knowledge.                                                to change. It is important to understand the skills
                                                          that clinicians need to help people make changes.
                                                          There may also be a need to fundamentally change
What else do we need to know?                             the way patients and practitioners see their roles to
                                                          create more of a partnership approach, but to date
There is evidence that several general principles
                                                          evidence about this is limited.
are important when supporting self-management.
These include: involving people in decision making;       To conclude, research suggests that supporting
developing care plans as a partnership between            self-management works, and can have a real
service users and professionals; setting goals            impact on how people think, feel and act. The
and following up on the extent to which these are         challenge is to explore the best ways to support
achieved over time; helping people manage the social,     self-management and to help service users,
emotional and physical impacts of their conditions;       clinicians and managers make this a reality.
motivating people to self-manage using targeted

viii   THE HEALTH FOUNDATION
Chapter 1
What is self-management
support?

Health services in Britain are facing an enormous      The Department of Health defines
challenge. The population is growing in size and       self-management as:
age and people are more likely to suffer from long
term illnesses that require ongoing care.44 There        The actions individuals and carers take for
is a need to change the way systems work and this        themselves, their children, their families and
includes helping people to help themselves.              others to stay fit and maintain good physical and
                                                         mental health; meet social and psychological
Long term conditions are leading causes of               needs; prevent illness or accidents; care for minor
death and disability worldwide.45 In Britain, the        ailments and long term conditions; and maintain
Department of Health estimates that 17.5 million         health and wellbeing after an acute illness or
adults may be living with one or more long term          discharge from hospital. 50
conditions.46 At least 60% of adults report having
one long term condition and this figure continues      Supporting self-management means providing
to grow due to an aging population and escalating      information and encouragement to help people
risk factors such as obesity.47                        maintain greater control by understanding their
                                                       condition and being able to monitor and take
Medical advances mean that people with illnesses       appropriate action. Interventions to support
such as heart disease and stroke now receive           self-management can be used at different points
treatments that enable them to live longer and to      of the health continuum, from those who do not
enjoy a higher quality of life than would previously   have a long term condition through to those who
have been possible, but this also brings challenges.   are living with severe and multiple long term
Health and social care services provide help when      conditions.
symptoms worsen, but most of the time people and
their families are responsible for making decisions    Health and social care services can support people
and influencing their own wellbeing. In the UK,        to self-manage their conditions by encouraging
about 80% of GP consultations, 60% of days spent       engagement in decision making, educating
in hospital and two thirds of emergency admissions     people about their condition and care, motivating
are related to long term conditions,48 but more than   people to adopt healthy behaviours and helping
80% of the care for people with long term illnesses    them know when and how to seek help from
is undertaken by the patient themselves or their       professionals.51
carers.49 This is known as self-management.

                                                                      Helping people help themselves        1
Over the past decade there has been an increasing      The review methods are summarised at the end
focus in the UK and around the world on                of this document in appendix 1. In brief, two
supporting self-management. Many strategies            reviewers searched more than 10 bibliographic
have been tested, with varying success, including      databases for research evidence published up
providing accessible information; communication        until September 2010. More than 100,000 reports
skills training for service users and professionals;   were scanned and the findings from over 550 high
self-management skills training facilitated            quality studies are included in the review.
by lay people; nurse led telephone support;
self-monitoring of clinical symptoms; and even text    The review does not aim to be exhaustive
messages, computer forums and video games. This        but instead provides a rapid and easy to use
rapid review compiles evidence about the effects of    compilation of up to date evidence. First, we
supporting self-management on people’s quality of      explore whether supporting self-management
life, clinical outcomes and health service use.        improves outcomes, then we examine the most
                                                       effective types of support and areas in need of
                                                       further development.

2     THE HEALTH FOUNDATION
Chapter 2
Impacts of self-management

Evidence suggests that supporting self-management        There is evidence that improved self-efficacy is
works. Supporting people to look after themselves        correlated with improved health behaviours and
can improve their motivation, the extent to which        clinical outcomes so it is valid to examine the
they eat well and exercise, their symptoms and           impact of self-management support on self-efficacy
clinical outcomes and can even change how they           as representative of other outcomes.59–71
use health services.
                                                         A literature review found that involving
 Interventions to encourage and support                  people in ongoing health decision making and
 self-management vary considerably in their aims,        self-management can increase patient and family
 approach, content, delivery, duration and target        responsibility for the delivery of care, and help
 group.52 Therefore it would be misleading to refer to   people adapt care regimens to their own lifestyles.72
‘self-management initiatives’ as an integrated whole.
This section describes evidence about the impact of      However, the best strategies to encourage
 supporting self-management on people’s attitudes,       self-efficacy remain uncertain. A trial in the
 behaviours and outcomes, but it is important to         US examined the impact of empowerment and
 emphasise from the outset that these results vary       motivation on self-management behaviours. Those
 according to the type of support provided. The          who felt more empowered and active were most
 next section explores differences between various       likely to self-manage effectively. However specific
 approaches.                                             self-management education programmes did not
                                                         seem to make people more activated. The authors
                                                         concluded that more research is needed to examine
2.1 Impact on self-efficacy                              the best ways to support self-management in order
                                                         to increase empowerment and motivation.73 Others
How people think and feel about their condition          suggest that it is important to understand why
can have a big impact on their health behaviours         people wish to receive self-management support in
and outcomes.53–57                                       order to target assistance to their needs.74
   Self-efficacy refers to an individual’s belief in     A number of self-management interventions focus
   their capacity to successfully learn and perform a    on confidence building and providing service
   specific behaviour. A strong sense of self-efficacy   users with the knowledge and skills to set personal
   leads to a feeling of control, and willingness to     goals and develop effective strategies for achieving
   take on and persist with new and difficult tasks.
                                                         them.75–84
   When applied to health, this theory suggests
   that patients are empowered and motivated to
   manage their health problems when they feel
   confident in their ability to achieve this goal.58

                                                                         Helping people help themselves         3
For instance, UK studies suggest that people             For instance, a meta analysis of 82 studies found
with arthritis taking part in self-management            that self-management education improved
programmes feel more confident in their ability          knowledge, self-care behaviour, and metabolic
to manage and control their symptoms, feel less          control in adults with diabetes.125
anxious about their disease, and may visit the
doctor less frequently.85–88 Similar studies are         Another review of randomised trials found that
available for people with heart disease, lung            self-management education increases participants’
disease, diabetes, asthma, stroke and many other         self-efficacy, knowledge, symptom management,
conditions.89–94                                         use of self-management behaviours and aspects of
                                                         health status. The effects for children, young adults,
Some suggest that supporting self-management             and carers remain uncertain.126
can help people move through stages of change
(transtheoretical model), becoming more                  Research has explored the perceived barriers and
motivated to alter their behaviours and sustain          facilitators for lifestyle modification. For example
this long term.95–99 Others have found that the          a qualitative study with people with chronic
effectiveness of self-management support varies          obstructive pulmonary disease (COPD) found
depending on people’s stage of change.100–111            that the most successful self-management support
                                                         requires a multifaceted approach incorporating
                                                         strategies to show people how to change their
Examples of targeting self-efficacy                      behaviour. This and other studies suggest that
                                                         self-management support that includes behaviour
A small randomised trial in Taiwan investigated
                                                         change strategies and problem solving skills is
the effectiveness of an empowerment programme
                                                         more likely to lead to improved self-efficacy and
in 50 people with end stage renal disease. The
                                                         lifestyle modification.130–133
programme included identifying problem areas for
self-management, exploring emotions associated           Programmes which combine multiple support
with these problems, developing a set of goals           strategies often work best. A randomised trial in
and strategies to overcome problems and achieve          New Zealand used interventions including a diary
goals, creating and implementing behavioural             for recording daily weights and goals, attendance
change plans and stress management. There                at a specialist clinic, and three self-management
were improvements in empowerment, self-care,             education sessions for people with heart failure.
self-efficacy and depression.112                         After one year, those taking part in the trial were
                                                         more likely to have better self-management
Similarly, a trial in China examined layperson
                                                         knowledge and behaviours compared to the
led self-management education for 954 people             usual care group. Patients who did not adopt
with hypertension, heart disease, chronic lung           self-management strategies had a greater chance of
disease, arthritis, stroke, or diabetes.113 There were   death or readmission to hospital.134
improvements in self-care behaviour, self-efficacy,
and health status, and reduced hospitalisations six      However, other studies have found no difference
months after the course. Integrating the delivery        between self-management support and usual
model into community organisations and working           care regarding self-efficacy, behaviours and
with service users as lay educators were key             awareness.135 Most of the studies that found
success factors.                                         no benefits were small scale, sometimes
                                                         non-randomised, and often focused on
2.2 Impact on self-care                                  less structured forms of self-management
                                                         support. Thus, while the reported outcomes
behaviour                                                for self-management support vary, this may be
                                                         due to research methods rather than inherent to
There is evidence that self-management support can
                                                         self-management support itself.
improve people’s knowledge about their condition
and care, how they feel about their condition, and
their ability to cope day to day. It also develops
self-management behaviours.114–124

4     THE HEALTH FOUNDATION
Examples of impact on behaviour                       The programme focused on enhancing problem
                                                      solving skills and resulted in improved mood and
Most of the available research focuses on the         reduced emotional distress, which in turn was
impact of group education sessions. For example,      associated with increased self-efficacy. Functional
a five year randomised trial with more than 1,000     status and quality of life also improved, especially
people in the UK found that self-management           for those who were initially depressed. This
courses were associated with improved healthy         suggests a link between active self-management
behaviours, coping, communication with                education, self-management behaviours and
physicians and self reported health status, and       quality of life.161
fewer days in hospital.127
                                                      Similarly, a randomised trial in the UK found that
A comparison of routinely collected data for 15,190   a self-management planning intervention was
older people with diabetes found that those who       associated with improved self-care for people with
had attended self-management education were           angina, including better diet and more exercise.
more likely to self monitor blood glucose levels,     The programme was also associated with improved
take appropriate medications and go for regular eye   anxiety and quality of life.162
examinations.128
                                                      There are some conflicting findings. A Cochrane
Benefits from other types of support have also been   review found that self-management education by
documented. For instance, researchers in the US       lay educators may lead to short term improvements
found that sending weekly educational newsletters     in self-efficacy, self rated health status and self-care
improved self-management behaviours among             behaviours but no improvements in quality
African Americans with diabetes.129                   of life.163
                                                      Likewise, a randomised trial with 131 people with
2.3 Impact on quality of life                         asthma in Switzerland found that self-management
Research suggests that supporting                     education helped to improve self-management
self-management can improve quality of life.136–142   skills, self-efficacy and people’s knowledge of
A number of studies have found a link between         their condition and care. However there was
self-management education, self-care behaviours       no improvement in quality of life or health
and psychological outcomes, stress, coping or         outcomes.164
quality of life.143–151                               Another small trial in the UK found that
There is evidence that supporting self-management     supporting self-management improved self-efficacy
results in both improved confidence to self-manage    and self-care in people with stroke but did not
and improved quality of life152–155                   improve quality of life.165
and that self-efficacy or perceived control is        Studies that have not found any effect tend to be
correlated with improved quality of life.156–158      small or to use less proactive strategies to support
                                                      self-management, such as written information or
Examples of interlinkages                             short education sessions focusing on providing
                                                      technical information.
There is a close relationship between
self-management attitudes, behaviours and quality
of life. For instance, trials in China found that     2.4 Impact on clinical outcomes
self-management education was associated with         Overall, the evidence suggests that there is
improved self-care behaviours which in turn           likely to be a relationship between supporting
were associated with improvements in quality of       self-management and clinical outcomes. 166–175
life, clinical outcomes and healthcare resource
use.159–160                                           Some studies suggest direct relationships between
                                                      supporting self-management and improved clinical
Another randomised trial in the US assessed a         outcomes.176–183 Other studies show a correlation,
self-management programme for older people with       but not necessarily a causal relationship.184–189
deteriorating eyesight.

                                                                       Helping people help themselves        5
Various types of self-management support have           As with other outcomes, the level of engagement
been found to improve physical symptoms or              and activity may be an important success factor
clinical outcomes in people with arthritis, asthma,     for improving clinical outcomes. A randomised
diabetes, hypertension, heart disease, heart failure,   trial in Argentina compared self-management
stroke, cancer and other conditions, at least in the    education aimed at improving communication
short term.190–196                                      skills and empowerment versus a compliance based
                                                        relationship between patients and professionals.
For instance, a systematic review collated 71 trials    The study found that the self-management
of self-management education for people with long       approach was associated with improved clinical
term conditions. The reviewers found that people        outcomes; in this case increased blood pressure
with diabetes participating in self-management          control.212
education had improved glycaemic control and
blood pressure. People with asthma experienced          The research methods used may be one of the
fewer attacks after self-management education.          reasons for differences in findings between studies.
Arthritis self-management education programmes          A systematic review found that while there were
had no significant effects. The authors concluded       small improvements in mortality and healthcare
that self-management education programmes               resource use from self-management education,
may have small to moderate effects for people with      most studies were small and suffered from biases
selected long term conditions. They noted, however,     or methodological design flaws.213 Thus, whilst
that study methods varied widely and were not           overall findings about supporting self-management
optimal.197                                             generally suggest positive impacts on clinical
                                                        outcomes, the varied quality of research in this
Studies have also assessed interventions involving      area emphasises that ongoing evaluations of
the family members of people with long term             self-management interventions are needed to
conditions.206 For instance a randomised study          continue to build the evidence base.
of children with diabetes found that a family
teamwork intervention prevented deterioration in
glycaemic control.207                                   Examples of clinical improvements
There are exceptions to these positive trends.208       A meta analysis assessed the effectiveness of
Some studies suggest no improvements in clinical        self-management education in children and
outcomes. For instance, a randomised trial in           adolescents with asthma. The reviewers included
London evaluated a card and letter encouraging          32 randomised trials with 3,706 children aged
people to prepare questions to ask at a hospital        between two and 18 years. Self-management
consultation. Half of those sent a card said they got   education was associated with improved lung
more out of their consultation as a result, but there   function and self-efficacy and reduced absenteeism
were no significant differences in outcomes.209         from school, days of restricted activity, and visits to
Another randomised trial with 131 people with           A&E. Programmes based on peak flow monitoring,
asthma found that improved self-management              targeted interventions, and interventions with
skills and self-efficacy did not result in health       children with severe asthma had the most effect on
improvements.210                                        clinical outcomes.198

Others suggest that any improvements are short          Similarly, a cohort study in the US examined the
lived. A systematic review of 31 studies found          relationship between self-management education,
that self-management education for people with          self-management behaviours and clinical
diabetes improves clinical outcomes in the short        outcomes for 428 people with diabetes. Education
term. The longer the self-management intervention,      was associated with improved self-care and more
the longer the effect tends to last. Any benefits       controlled blood glucose.199 People in the early
tend to decrease 1–3 months after the intervention      stages or with less severe illness were more likely
ceases, suggesting that learned behaviours change       to benefit, and this finding has been replicated for
over time.211                                           other conditions.200–201

6     THE HEALTH FOUNDATION
Another study in the US found that active               Other evidence suggests limited impacts on service
self-management education was associated with           use or costs.260–264 A systematic review of nine trials
improved empowerment and engagement between             of self-management education versus usual care
people with diabetes and clinicians. This resulted in   for people with chronic obstructive pulmonary
improved glycaemic control.202                          disease found that self-management education
                                                        reduced the need for rescue medication and
A review of self-management education in arthritis      increased courses of oral steroids and antibiotics for
found reductions in pain and fatigue, improved          respiratory symptoms, but had no effect on hospital
activity levels, aerobic capacity and exercise          admissions, emergency department visits, days lost
endurance, reduced levels of disability and             from work, or lung function.265
functional limitations, and improved self-reported
health status.203 Numerous similar studies are          Similarly, an evaluation of self-management
available about measures of pain and quality of         courses run in the UK by volunteer tutors at
life.204–205                                            Depression Alliance, Diabetes UK, National
                                                        Endometriosis Society, Haemophilia Society,
                                                        British Liver Trust, ME Association, Action for
2.5 Impact on health service use                        ME, National Osteoporosis Society, British Polio
There is evidence from the UK and elsewhere that        Fellowship, Breakthrough Deaf Integration, and
self-management support can alter the pattern of        the LINK centre for Deafened People found
healthcare service use and subsequent healthcare        small improvements in self-efficacy, but no
costs, though the evidence is more varied than for      significant impacts on the use of health services.
clinical outcomes.214–223                               The evaluators suggested that disease specific
                                                        information may need to be included within the
It has been suggested that self-management support      generic course structure.266
programmes may reduce visits to health services by
up to 80%.224–229                                       A randomised trial found that sending reminders
                                                        about GP visits improved primary care visits
Numerous trials are available suggesting a link         and reduced emergency department visits in 174
between self-management education and reduced           children with asthma in Australia.270 However
or altered patterns of health service use.247–252       another trial in the US found that teaching nurses
But we need to be cautious when interpreting            about self-management as well as providing patient
the findings because some research suggests             education did not affect hospitalisations.271 This
correlations rather than direct links. Many studies     demonstrates that the link between supporting
have found that supporting self-management              self-management and outcomes is complex and
improves self-care knowledge or behaviours and          does not necessarily follow a linear pattern.
reduces hospitalisations but they have not proven
that self-care causes reduced resource use.253–257      It also shows that most of the available evidence
                                                        focuses on self-management education courses
The mechanism by which outcomes change                  rather than the wider range of support initiatives
remains uncertain. A randomised trial in                available.
the US for people with chronic depression
and post traumatic stress disorder found that           However, assuming that supporting self-
self-management support led to reduced healthcare       management will reduce healthcare resource use
resource use without any significant change in          is somewhat simplistic. The aim of supporting
self-management behaviours.258 Similar findings         self-management may be to alter the pattern of
are apparent in research about asthma.259               behaviour and service use rather than reducing
                                                        service use itself. Therefore it may be more useful
                                                        to focus on whether different types of services are
                                                        being used (such as primary care versus secondary
                                                        care or telephone and online resources versus in
                                                        person resources).

                                                                         Helping people help themselves       7
Overall however, despite some conflicting findings,      A survey with 1000 people who had attended an
the evidence suggests that proactively supporting        Expert Patient Programme in England found
self-management and focusing on self-efficacy and        that people reported improved self-management,
behaviour change can have an impact on clinical          reduced medication use and fewer unscheduled
outcomes, crises and unplanned admissions or             visits to the GP and A&E,239 but administrative
other costly emergency service use.                      data were not available to confirm this.

                                                         Evidence is available about similar types of
Examples of impact on resources                          self-management courses from around the
                                                         world. A literature review found that structured
Benefits may remain over the long term230–231 and
                                                         Self-management education programmes improve
have been found throughout the world.232
                                                         self-care behaviours and can reduce healthcare
Evidence about health service use tends to focus         resource use and expenditure. Potential benefits
on complex mixed method approaches to support            include fewer A&E visits, fewer hospitalisations,
self-management, or group education courses.             and reduced days spent in hospital.240 Even in
                                                         low income settings, or where resources are poor,
The following randomised trial in the UK can be          supporting self-management has been found to be
used as an example of a mixed method approach.           useful.241
In the trail 203 people with ulcerative colitis who
were undergoing hospital follow up were either           A meta analysis found that self-management
given patient centred self-management training           education programmes improved knowledge
and follow up on request, or usual care and              of diabetes and clinical outcomes and reduced
routine follow up. Self-management training was          medication use. The authors concluded that for
associated with faster access to treatment when          every five people attending a group based education
needed, reduced hospital visits (0.9 versus 2.9 per      programme, one person would be expected to
patient per year), and fewer GP visits (0.3 versus       reduce diabetes medication and this would impact
0.9 per patient per year).233–234 A success factor was   on overall costs.242
giving service users the control to access care when     Another example is a randomised trial in
they felt they needed it.                                seven hospitals in Canada, which evaluated
Another randomised trial in 19 hospitals in              self-management education among people with
northwest England examined whether a whole               moderate to severe chronic obstructive pulmonary
systems approach to self-management was cost             disease hospitalised within the past year.
effective among 700 people. Consultants were             The programme involved weekly visits by health
trained to provide a patient centred approach            professionals over two months, with monthly
to care and patient guidebooks were developed            telephone follow up. Self-management education
in partnership with service users. All patients          was associated with 40% fewer hospital visits for
prepared written self-management plans. After one        chronic obstructive pulmonary disease and 57%
year, the self-management group had fewer hospital       fewer hospital admissions for other problems.
visits and patients felt more able to cope with their    Emergency department visits reduced by 41% and
condition. Cost effectiveness analyses favoured          unscheduled physician visits by 60%.243
self-management over usual care.235
                                                         Similarly, a trial in the US assessed seven weekly
Trials and descriptive studies in the UK suggest that
                                                         sessions of peer facilitated self-management
group education sessions such as the Expert Patient
                                                         education, each of 2.5 hours duration, provided
Programme have the potential to reduce hospital
                                                         in community settings with groups of 15 to 20
admissions and days spent in hospital.236–237
                                                         participants. The programme reduced emergency
However evaluations to date have been uncertain
                                                         department and outpatient visits, improved health
about the impact on healthcare resource use.238
                                                         behaviours, reduced symptoms, and improved
                                                         health status. Reductions in service use and
                                                         emotional distress were evident two years after the
                                                         programme.244

8     THE HEALTH FOUNDATION
Another randomised controlled trial in Norway         Examples of contradictory findings
assessed self-management education for people
with asthma. The intervention included two            A number of studies have found that supporting
education sessions plus two follow ups by nurses or   self-management has little or no effect on the use
physiotherapists.                                     or costs of healthcare resources. For instance, a
                                                      UK cost effectiveness analysis with more than
At one year follow up those taking part in            800 people with arthritis found that a six session
self-management education had reduced visits to       self-management education programme may
GPs, reduced overall costs and improved quality       not save costs overall or be any more effective
of life.245                                           than usual care or providing written information
                                                      alone.267
A randomised trial with children with asthma
examined self-management education using              Another randomised trial in the UK found that a
interactive multimedia tools. The initiative was      self-management cd rom for children with asthma
associated with increased asthma knowledge            improved self-management, self-efficacy and
among children and caregivers, decreased              feelings of control but there were no significant
asthma symptom days, fewer emergency                  reductions in crisis medication use or days off
department visits, and lower average daily doses      school.268
of inhaled corticosteroids. Increased asthma
self-management knowledge and behaviours were         A Cochrane review found that education by lay
associated with fewer urgent physician visits and     educators may lead to short term improvements in
less frequent use of quick relief medicines.246       self-management attitudes and behaviours but no
                                                      improvements in healthcare resource use.269

                                                                      Helping people help themselves       9
Chapter 3
What works to support
self-management

3.1 Self-management support                               3.2 Providing information
approaches                                                Providing information about people’s condition
                                                          and how to manage it is an important component
A multitude of approaches have been tested to
                                                          of supporting self-management. Information can
support self-management. These range from more
                                                          be provided using leaflets, websites, email, text
passive information sharing approaches at one
                                                          messages, electronic forums, by telephone and in
end of the spectrum to more active behavioural
                                                          person individually or in groups.
change interventions at the other. Another way
to conceptualise self-management support is               A great deal has been written about different ways
to divide interventions into those that focus on          to provide information to people with health
building knowledge and technical skills (such as          conditions. We identified more than 60 systematic
insulin management) versus those that aim to              reviews and randomised trials about providing
build self-efficacy (confidence in self-care). Figure 1   accessible information through written materials,
illustrates these typologies and positions various        educational sessions, and technologies such as the
types of self-management support along the                internet and video.
continuum.
                                                          Researchers have examined the value of different
It is difficult to categorise interventions in this       approaches for supporting people with long term
way because there is wide variation. For instance,        conditions generally as well as subgroups such
one type of group education may focus solely              as children and young people, older people and
on information provision whereas another                  those from minority ethnic groups and deprived
group education programme may seek to build               neighbourhoods.
confidence and change behaviours.

While the placement of each individual                    Written information
intervention is illustrative only, and a matter for
debate, conceptualising support approaches as a           A number of written information materials to
continuum is useful. Evidence from hundreds of            support self-management have been evaluated,
studies suggests that the proactive interventions         including guidebooks and printed educational
located in the top right hand quadrant of figure 1        materials.272 There is some evidence that written
may be associated with greater change or more             motivational leaflets or letters can help people feel
sustained levels of behavioural and clinical benefits.    more confident to raise their concerns and discuss
This section provides a summary of key evidence           their symptoms,273 but there is sparse evidence
about what works to support self-management.              that such methods improve self-management
                                                          behaviours or clinical outcomes.274–275

10    THE HEALTH FOUNDATION
Figure 1: continuum strategies to support self-management

                                       Focus on self-efficacy
                                                                          motivational interviewing
                                                       telephone coaching
                                 Care plans
                                                                            goal setting
                    patient held records              Active group education
Information provision

                  online courses                         group education            Behaviour change

        Electronic information                                    Self-monitoring

         Written information

                                      Focus on technical skills

Other reviews suggest that printed materials can        Electronic information sources
improve knowledge,276–278 but may not impact
behaviour when used alone.279–280                       Self-management support can also be delivered
                                                        using audiovisual technology, computers and the
But findings are mixed. Some trials suggest that        mass media.291–294
postal educational materials are as effective for
improving symptoms and self-efficacy as group           There is evidence that providing structured
education sessions.281 There is also evidence that      education programmes by video/dvd, audio
combining written information with lectures or          or computer may be as effective as in person
other educational activities can be more effective      education groups.295–296 For instance, a randomised
than written information alone.282–283                  trial with older people with long term conditions
                                                        compared group education, a home study
To understand these differences, it is worth            intervention using videotapes and booklets, and
considering the characteristics of the most             a control group. Compared with controls, both
effective written information tools. There is           educational interventions were associated with
some evidence that targeting and personalising          reduced pain, sleep difficulties, and symptoms of
written information is more effective than              depression and anxiety. The video course was also
standardised printed materials.284–287 For              associated with reduced symptoms. The authors
example, a randomised trial in Scotland compared        concluded that lower cost, more accessible home
posting four personalised asthma education              study education using video or dvd may be an
booklets versus conventional oral education at          effective alternative to group instruction for people
outpatient or surgery visits. Personalised booklets     with long term conditions.297 Other research has
improved self-management and reduced hospital           similar findings.298
admissions.288 Other studies have reinforced these
findings.289                                            Other novel approaches have been tried. A
                                                        randomised trial in the US tested an asthma
                                                        education video game as part of a self-management
                                                        programme for high risk children with asthma.
                                                        The video game was associated with improved
                                                        quality of life and asthma knowledge.299
                                                                          Helping people help themselves   11
Researchers in many parts of the world have tested      Systematic reviews, randomised trials and other
using computers to provide self-management              high quality research has found that when used
information and education.300–310 For instance, a       alone, information provision can improve some
systematic review of 22 randomised trials found         health behaviours but this does not tend to have
that computerised patient education improved            lasting follow on effects on clinical outcomes or
health status in people with various conditions.311     health service use. However, when used as part of a
Studies also suggest some benefits for children         broader support initiative, information provision
and young people312–313 and less advantaged             has been found to be useful, especially if it is
socio-economic and ethnic groups.314                    targeted or personalised to account for people’s
                                                        individual needs.329
However while there are some positive trends,
other studies have found limited or mixed
benefits from online information and support            Example of tailored information
programmes.315–317
                                                        A systematic review of 60 randomised control
A number of computer based peer to peer                 trials examined the effectiveness of self help
communities and electronic groups have been set         interventions for smoking cessation. The review
up to support self-management but their effects         found that the personalised written materials
remain uncertain.318 Some descriptive studies           were more effective than individualised advice
suggest that computer chat rooms, coaching and          from a clinician, which was in turn more effective
other online forums can provide a good motivator        than non-personalised written materials. Adding
for self-care,319–321 but the effect on clinical        additional face-to-face or other advice to tailored
outcomes is uncertain.                                  written materials did not improve effectiveness
                                                        compared to personalised materials alone.290
Another novel approach is using text messages
or pager messages as reminders and support
mechanisms.322–323 One trial found that, when           3.3 Providing support
combined with other strategies, sending text            Another type of self-management support
messages to young people with diabetes helped to        involves helping people to change their attitudes,
improve self-management behaviours.324                  perhaps through care planning, patient held
 One randomised trial assessed sending                  records, decision support tools or other support
 standardised health promotion email messages to        mechanisms. This is different from information
 people weekly for 12 weeks. People who received        provision alone because the interventions aim to
 emails had better self-management behaviours           provide incentives for change or help people learn
 and reported favourable changes in healthy eating      new skills or practical strategies for coping.
 and physical activity.325 Other studies suggest that
 email interventions can be targeted to the person’s    Decision support tools
‘stage of change’, thus providing more tailored and
 meaningful support.326                                 For example, decision support tools have been
                                                        used to support self-management.330 Such tools
To summarise, evidence suggests that providing          may encourage service users and their carers
information in writing or electronically can            to take more responsibility for their care, help
improve people’s knowledge about their condition        people with long term conditions feel more in
and care. This may or may not translate into feeling    control, encourage health professionals to follow
more confident about looking after themselves and       recommended care protocols, and have some
improved self-management behaviours.327–328             impacts on quality of life.331–332 But reviews
                                                        about written decision aids suggest that such aids
                                                        generally affect attitudes and knowledge rather
                                                        than behaviours.333–334

12    THE HEALTH FOUNDATION
Patient held records                                    There is evidence that action plans or proactive
                                                        planning support may improve self-management
A number of strategies have been trialled to            behaviours for people with long term
increase people’s involvement in healthcare             conditions,345–354 and this may impact on
processes and decision making as a way of               healthcare resource use.355–357
facilitating self-management. Sometimes people
are given their medical records to keep and bring       Numerous examples are available. For instance,
to each consultation, which is known as patient         systematic reviews support an agenda setting
held records.                                           action plan coupled with self adjustment of
                                                        medications and regular medical review for people
A number of reviews and trials suggest that             with asthma.358–359
patient held records have limited effects on
self-management. For instance, a trial of patient       A randomised trial of 140 adults with asthma or
held records for people who had suffered stroke in      chronic obstructive pulmonary disease assessed
the US found that while participants were pleased       developing a written self-management plan in
to have a copy of their records, took them when         groups coupled with individual educational
they visited doctors, and reported learning more        sessions. The plans were associated with improved
about their stroke, there was no difference in health   medication compliance among people with asthma,
practices or behaviours compared to usual care.335      but not chronic obstructive pulmonary disease.360
Randomised trials in the UK have drawn similar
conclusions about patient held records.336–337          In New Zealand, a randomised trial found similar
                                                        benefits from written self-management plans for
There is also interest in making records available      children with asthma.361
electronically for service users.338–340 A randomised
trial in the US provided patient records online to      However, there are questions about whether
people with heart failure. After one year, those        agenda setting and care planning are supported
who had access to their records online were more        by practitioners and service users362 or directly
likely to adhere to treatment, but there were no        impact on clinical outcomes.363 A Cochrane review
differences in self-efficacy or satisfaction with       with seven randomised trials examined whether a
care.341 This suggests that patient held records may    written asthma self-management plan increased
have some impacts on self-management strategies,        adherence to medications and improved clinical
but these impacts are not clear cut. The evidence is    outcomes. There was no strong evidence that
too mixed to suggest that patient held records are a    written plans improved patient outcomes. One
useful enabler for self-management.                     type of agenda setting was not consistently more
                                                        effective than another.364

Planning and agenda setting                             Another review found that adding written
                                                        self treatment guidelines to self-management
A care plan is a written document collaboratively       programmes may improve health outcomes, but
designed by service users and professionals             the only two controlled studies on this topic found
covering issues, interventions and review               no effect.365
processes.342
                                                        A randomised trial in France found that when
Care plans may include both goal setting and            agenda setting and plans were used as part of a
developing plans for how to achieve these               self-management programme, only those who
goals.343 Most of the available evidence about          adhered fully to the self-management plan had
self-management treatment plans focuses on              improved symptoms.366
people with asthma or COPD, though there is
emerging evidence about other conditions.344

                                                                        Helping people help themselves     13
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