Susan ayers cambridge handbook of psychology he

Disease-specific and generic approaches
Traditionally, self-management interventions have been diseasespecific
but a significant recent development has been the introduction
of a generic programme, the Chronic Disease Self-Management
Programme (CDSMP), developed at Stanford University Patient
Education Research Centre (Lorig et al., 1999, 2001). The approach
of the CDSMP is to focus on problems and strategies which are
common across illnesses. It consists of community-based group
sessions which combine participants with different chronic illnesses.
Strategies such as problem-solving techniques, goal-setting
and behavioural modelling are included as they are considered
to be helpful in all chronic illnesses (see ‘Behaviour therapy’
and ‘Cognitive behaviour therapy’). There is no disease-specific
advice but participants are taught to manage their illness through
correct medication use; relaxation; diet; exercise; managing
sleep and fatigue; and effective communication with health
professionals.
Delivery of self-management interventions
The review by Newman et al. (2004) found that two-thirds of interventions
in arthritis and about half in asthma and diabetes were
delivered in group settings. Comparison of the relative benefits of
group versus individual delivery is rare but one study that compared
them in diabetes found that the group programme resulted in a
greater improvement in blood glucose. Group programmes have
the advantage of the opportunity for group learning and support
as well as reducing costs. In contrast individual programmes can
be tailored to each person’s needs and can be designed to be
more easily incorporated into standard care (Clark & Hampson,
2001). Although it is also likely that some individuals will be less
willing to take part in group programmes, there is no research on
this issue (see ‘Group therapy’).
The duration of self-management interventions varies a great deal
from brief, single sessions to several sessions over many months. The
type of illness has influenced the objectives of self-management
interventions and hence their length. For example in asthma, selfmanagement
interventions have tended to be brief and focused
on symptom monitoring and medication adherence. In diabetes
and arthritis, self-management interventions often address a range
of health behaviours and strategies for managing many aspects
of living with the illnesses and as a consequence involve multiple
sessions. There has been little systematic examination of the
optimum duration of these interventions in different conditions. In
one study, Lorig et al. compared their standard 6-week Arthritis Self-
Management Programme with a reduced 3-week version and found
that the original obtained better results (Lorig et al., 1998). Decisions
about duration are affected not only by breadth of intervention content
but also by cost implications and the greater time demand that
several sessions places on patients, with the consequent risk of lower
participation and higher dropout rates.
Self-management interventions have been delivered by a variety of
healthcare professionals, including dieticians, nurses, occupational
therapists, physicians, physiotherapists, psychologists and social
workers. Although many self-management interventions are multidisciplinary,
nursing is the professional group which tends to dominate,
perhaps because of nurses’ greater numbers and availability,
but also because of their ability to provide detailed illness-related
information. There is also a trend, as evidenced in the Arthritis
Self-Management Programme (Lorig, 1986), the Chronic Disease
Self-Management Programme (Lorig et al., 1999, 2001) and the
Expert Patient Programme in the UK (Wright et al., 2003), for trained
lay people, most of whom themselves have a chronic illness, to
deliver self-management interventions.
Regardless of who delivers the intervention, effective delivery
requires appropriate training and experience in facilitation skills
and behaviour change strategies. Leaders need to be trained to
deal with emotional issues that may arise. These skills are not
taught routinely to most healthcare professionals and this raises
the issue of what training is needed for both professional and lay
leaders. This issue is frequently neglected and inappropriate
assumptions are made regarding the ability, of both professionals
and lay individuals, to easily take on the role of facilitating selfmanagement
interventions.
Uptake and attrition
Many self-management interventions require a considerable commitment
by participants in terms of both time and emotional investment.
One measure of the acceptability of a self-management
intervention is provided by the percentage of people approached
who decide to take part. This information is often not reported,
but in studies recruiting from a circumscribed population the suggestion
is that self-management interventions are not attractive to a
proportion of individuals. If the numbers who choose not to participate
are large it limits the generalizability of the findings from these
studies. The reasons for non-participation are likely to be many and
include convenience, scepticism of the process and likely benefits,
amongst others. There is a need to assess reasons for lack of participation
to understand these processes well.
Another indicator of acceptability is the number of people who
begin but do not complete the intervention. Study attrition rates
vary widely; the reasons are not clear but there is some indication
that longer interventions have higher attrition rates (Newman et al.,
2004). The method of delivery of the self-management intervention
could also affect uptake and attrition rates. Although most interventions
are delivered face-to-face, some with telephone follow-up,
they could also be delivered either partially or fully via a selfadministered
manual or using the internet. These methods have
had limited application to date but are likely to grow in use and
may prove popular to individuals who find travelling to the clinic
and the time of the interventions too burdensome.
Efficacy
Research studies evaluating the efficacy of self-management
interventions typically assess several outcomes such as physiological
measures, symptoms, physical functioning, psychological
wellbeing, performance of health behaviours, quality of life and
use of healthcare resources. In assessing self-management interventions
it is important to be clear about what a self-management
approach can reasonably be expected to influence and to target
the assessment of efficacy accordingly. For example, better selfmanagement
of diet in diabetes would be expected to affect a
Self-management interventions 395