The concept of self-management of chronic diseases, including osteoarthritis (OA), is receiving increasing attention in this era of health care reform. Supporting patient self-management is a component of Wagner's chronic care model1 and of the patient-centered medical home model,2 and it's one of the four goals in the U.S. Department of Health and Human Services' framework for addressing multiple chronic conditions.3 While these efforts aren't specific to OA, the 27 million Americans who have the condition will no doubt benefit from this increased attention.
Self-management is critical in managing OA. In its guidelines for the management of hip and knee OA, the American College of Rheumatology (ACR) identified self-management education (SME), physical activity, and weight management as critical strategies.4 In A National Public Health Agenda for Osteoarthritis 2010 (known as the OA Agenda), these strategies are also declared to be ready for widespread public health dissemination.5 While there's general consensus on what self-management activities are best for patients with arthritis, less attention has been paid to determining strategies health care professionals can use to support their patients' self-management.
In conducting broad reviews of the literature, I searched several databases-MEDLINE, PsycINFO, Embase, the Education Resources Information Center (ERIC), and the Cumulative Index to Nursing and Allied Health Literature (CINAHL)-on three separate occasions. I used the search terms self-management, self-management support, patient education, and behavior change combined with osteoarthritis, arthritis, and chronic disease.
In this article I define and distinguish among the related concepts of self-management, self-management support (SMS), and SME. I also describe various SMS interventions, provide evidence-based examples of SMS strategies that are useful in OA, and identify elements common to a variety of such strategies. Where available, OA-specific strategies are used to illustrate the various categories of SMS. Where no OA-specific example is available, strategies used for arthritis in general or other chronic diseases are described.
CONCEPTUAL CLARIFICATIONS
While the terms are sometimes used interchangeably, self-management, self-management support, and self-management education refer to discrete sets of activities that are performed by people in different roles. The conceptual distinctions among these terms-and between SME and patient education-are applicable to all chronic diseases, not only to OA.
Self-management is defined as the tasks or activities performed by the person with the chronic condition. The most widely used definition in the United States was published by the Institute of Medicine6 and adopted for the OA Agenda. (See Table 1.6, 7) Put simply, self-management is what people with chronic diseases do on a daily basis to feel better and pursue the life they desire.8
Self-management support. SMS describes actions taken by health care professionals and others to support a person's self-management. Much of the early discussion on SMS focused on support provided by the health care system, as the definitions indicate. But recently SMS is recognized as also coming from outside the health care system,9 and it includes environmental factors that support self-management.10, 11 Bodenheimer and colleagues wrote that from the perspective of health care delivery organizations, SMS can be viewed in two ways: "as a portfolio of techniques and tools that help patients choose healthy behaviors; and a fundamental transformation of the patient-caregiver relationship into a collaborative partnership."12
Self-management education is interactive education designed to enhance self-management by building skills such as goal setting, decision making, problem solving, and self-monitoring.5 SME is a type of SMS. It can be provided by health care professionals, but trained lay leaders can also be effective.13 Nurses and other health care professionals might assume that they already have expertise in SME because of their extensive experience in patient education. But the interactive nature of SME, along with its focus on building skills such as problem solving and decision making, may require professionals to develop new competencies in SMS.14
STUDIES ON SMS INTERVENTIONS
Of the many SMS interventions, none is specific to OA. These interventions can target a variety of health behaviors, be delivered in a variety of settings by people of various backgrounds and skills, and vary in intensity from five-minute interactions to 20-hour, protocol-driven interventions. Such diversity is necessary to meet patients' needs and preferences and to match them with cost-effective services.15
One note of caution: the majority of studies on SMS, whether specific to arthritis or not, have enrolled primarily white subjects, particularly women, and so we have less knowledge of how effective these interventions are with men and racially or ethnically diverse populations. In a Cochrane review of studies of layperson-led SME, 70% of the recruited participants were female, and in 11 of the 17 studies reviewed more than 90% were white, although some did include subjects who were, for example, Chinese, Vietnamese, and Bangladeshi.13 Similarly, in a systematic review of behavioral counseling studies, Lin and colleagues noted that men made up only 17% of participants, and among U.S. studies, only 18% of participants were nonwhite.16 Some of the more recent studies have achieved greater diversity, as noted below.
FIVE CATEGORIES OF SMS
To simplify the discussion of the many types of SMS, I categorized interventions according to the efforts required of the person with the chronic disease. I created these categories over years of experience and watching this fairly new field develop. The five categories are not mutually exclusive; the first two-taking part in SME and other skill-building and behavior-change interventions-require the patient to enroll, sign up, or otherwise indicate a willingness to participate. The third category, participating in supportive provider interactions, focuses on transforming the interaction between the patient and the provider. The fourth category, receiving ongoing supportive follow-up, is achieved with outreach by a provider or other organization. The fifth category is creating environments that support self-management.
All interventions in the five categories vary according to who delivers the intervention and where and how it takes place. (For specific examples, see Table 2.17-21) The strategies must rest on a foundation of supportive policies and system change. The categories of SMS interventions that appear promising or have evidence supporting their usefulness in all forms of arthritis are set out below.
Self-management education. Four meta-analyses of SME in arthritis have been conducted in the last decade.22-25 Each included educational formats ranging from the simple imparting of information to one-on-one teaching and small-group sessions. Most of these meta-analyses examined pain and disability and found small but statistically significant improvements; some authors questioned the clinical significance of these findings. Devos-Comby and colleagues examined the physical and psychological effects of exercise and self-management programs on patients with knee OA and concluded that self-management had clinically important benefits for patients' psychological well-being.25 A 2010 review of self-management strategies that included eight OA-specific interventions (small-group education, individual-delivered interventions, and a combination of SME and exercise) concluded that the studies that reported outcomes at 12 months demonstrated significant, modest effects on pain, self-efficacy, function, and mood.26
The Arthritis Self-Management Program (ASMP) developed at Stanford University is the most studied arthritis-related SME intervention.17 A Cochrane review of 17 layperson-led SME programs (most of which were the ASMP or its sibling, the Chronic Disease Self-Management Program [CDSMP]27) found small to moderate effect sizes in self-efficacy, self-rated health, health behaviors (aerobic exercise, cognitive symptom management), and outcomes (pain, disability, fatigue, and depression).13 These results are not specific to OA patients, but they do include a large number of people with arthritis. Stanford has developed multiple formats for delivering the ASMP, including a Spanish version, an online version, and a self-study version. The few studies that have looked at the effectiveness of these alternative formats have shown promising results.28 In a study comparing the effects of the ASMP and the CDSMP, Goeppinger and colleagues examined the differences between all participants and black respondents and found reasonably similar results for both groups at the four-month follow-up.29
Although the availability of SME programs is expanding,30 there is a clear need to increase participation. The percentage of people with arthritis who reported attending an arthritis education class remained constant at approximately 11% from 2002 to 2006.31 In this investigation, the percentage of people who reported attending an arthritis education class was not significantly different by age, sex, race or ethnicity, or education level.
Skill-building and behavior-change interventions. This category includes interventions such as structured physical activity and weight-control programs that are distinct from SME. Both the ACR guidelines for the treatment of OA and the OA Agenda identify physical activity and weight loss or control as important in OA management.4, 5 A recent meta-analysis of the effects of community-delivered exercise found it produces statistically and clinically significant improvements in pain and function for patients with rheumatic diseases, although the authors noted that further study of dose-response effects is needed. 32
Interventions designed to enhance physical activity can be delivered to individuals or small groups in home, community, health care, or workplace settings. No delivery place or activity type has proved to be superior, but research has suggested that interventions are more effective when they include 12 or more sessions of supervised contact.33
A few behavior-change programs have targeted weight control. The Arthritis, Diet, and Activity Promotion Trial (ADAPT), which combined diet and exercise interventions, improved pain, function, and physical performance measures in moderately overweight or obese adults with knee OA.34 In contrast to the exercise-alone and diet-alone arms of the trial, the combination produced greater weight loss and functional improvement.
Although it wasn't OA specific, a systematic review conducted for the U.S. Preventive Services Task Force concluded that medium-to-high-intensity dietary counseling, with or without physical-activity counseling, produced small but statistically significant changes in body mass index and self-reported behaviors related to diet and activity.16 Ehrlich-Jones and colleagues reported testing a form of motivational interviewing to increase physical activity among people with OA; a randomized, controlled trial is under way.35
Not all SMS can be, or should be, provided in the clinical setting. However, one aspect of providing SMS in clinical settings is linking people to SME or other community resources-an important element of the chronic care model and of the standards for patient-centered medical homes.1, 2
Supportive provider interactions. According to unpublished data reported in 2007 at the ACR's annual meeting, people with arthritis whose health care providers recommend they attend SME programs are 18 times more likely to do so than those who receive no such advice.36 But simply recommending an intervention does not make the patient-provider relationship a collaborative partnership.12 Strategies that can be applied to fundamentally alter the patient-provider relationship are the essence of the interventions in this category of SMS. Very few evidence-based approaches have been used specifically in arthritis, but non-arthritis-specific reports are available. This form of SMS is less developed than the areas of SME and other behavior-change programs, but it's vitally important in caring for people with chronic diseases.
Motivational interviewing (MI), a form of behavioral counseling designed to help patients identify and resolve their ambivalence about behavior change, is a collaborative approach to help people reach their goals. A meta-analysis of randomized, controlled trials showed that it "had a significant and clinically relevant effect in approximately three out of four studies, with an equal effect on physiological (72%) and psychological (75%) diseases."37
MI techniques can be incorporated into routine clinical interactions. Patients whose physicians exhibited only MI-consistent behaviors (asking permission before giving advice, praising small changes, emphasizing control) lost 2.4 lbs. more than patients whose physicians exhibited only MI-inconsistent behaviors (advising without permission, confronting, directing).38 Despite concern that it might be too time consuming, Ranatunga and colleagues reported having no significant problems using MI as an SMS strategy in an academic rheumatology clinic.39
Another form of behavioral counseling is the Five As, a sequence of supportive activities-assess, advise, agree, assist, and arrange-deployed to facilitate behavior change.40 An observational study of interactions between primary care physicians and their overweight or obese patients demonstrated that patients whose physicians used the "assist" (providing materials such as self-monitoring tools) and "arrange" (scheduling a follow-up contact) elements of the Five As were more likely to report improving their diets than were those whose physicians did not.41 In an analysis of obese patients' postvisit surveys on physicians' use of the Five As, patients with higher motivation and intention to change reported that more Five As techniques were used, with each additional technique being associated with greater odds of feeling motivated to lose weight, to eat better, and to exercise regularly.42 This study is noteworthy because while 70% of respondents were female, 92% were black or Hispanic and 54% were considered to have low literacy.
However, it is not enough to just train providers to change their interaction styles. System changes, such as group medical visits, planned visits, and connections to community services, are also necessary to support patient self-management.43
While no studies on strategies for transforming the clinical interaction specifically address OA, the success of both MI and the Five As has been evaluated in addressing physical activity and weight control, both of which are important self-management activities for people with OA. Many of these studies in clinical practice have focused on physicians, but the findings supporting the use of MI and the Five As may be applicable to nurses and other health care professionals, as well.
Ongoing supportive follow-up. Limited data are available on the effects of follow-up with people with OA, but this strategy has been effective in treating other chronic diseases. For example, telephone calls from a nurse, made twice per week for the first month and weekly for the next two months, helped patients with diabetes lower their blood glucose levels and adhere to diet and blood glucose testing recommendations.44 Ranatunga and colleagues used biweekly telephone calls to track whether patients were meeting their goals in a trial of the chronic care model in an academic rheumatology clinic.39 Despite implementing only part of the chronic care model, they reported that the quality improvement process was worthwhile, even though they found it difficult to sustain the calls when the trial ended. An early study of monthly telephone calls made to people with OA by trained nonmedical personnel showed that they had moderate improvements in pain and functional status.20 Although not labeled so at the time of the study, this is an example of ongoing SMS.
Environmental changes to support self-management. Community and environmental factors, such as the availability of fresh fruits and vegetables and of safe and convenient places to walk, can influence a person's self-management. While not specific to people with OA, the population-based approaches recommended in the Centers for Disease Control and Prevention's Guide to Community Preventive Services can support the self-management efforts of people with arthritis.45 To increase physical activity, the guide recommends strategies such as using urban planning and design at the community or neighborhood level to create safe, accessible, attractive places for people to be physically active and using point-of-decision prompts such as signs at the bottoms of escalators to encourage the use of stairs. To promote dietary changes the guide recommends strategies such as improving access to healthful foods in cafeterias, vending machines, and convenience stores in schools and workplaces.46
COMMON ELEMENTS IN THE CATEGORIES
Glasgow and colleagues identified problem solving as the heart of successful self-management and found that problem solving remained significantly related to self-management after controlling for other factors in the multiracial population they studied.47 Also, action planning is a hallmark of both small-group17 and telephone-based48 SME and other types of SMS; the Action Plan Project provided templates to guide primary care providers in helping their patients to develop action plans to support behavior change during visits.19 Enhancing self-efficacy is common to many SMS strategies. All chronic disease SME programs developed at Stanford University focus on it, and the Action Plan Project also emphasizes training providers to boost patients' self-efficacy.17, 19, 27 In a diabetes trial, King and colleagues demonstrated that problem solving and self-efficacy for a desired behavior, such as increased physical activity, were related to performance of the desired behavior.49 In a review of behavior change-oriented systematic reviews50 and a meta-analysis of healthy-eating and physical-activity interventions,51 self-monitoring, particularly when combined with another control strategy, emerged as the most effective element, improving patient performance in 56% of the studies. Finally, social support also emerged as an important element in van Achterberg and colleagues' review of behavior-change reviews and King and colleagues' empirical study of diabetes self-management.49, 50
CONCLUSIONS
As the field of SMS matures, the concepts related to self-management are becoming clear. Self-management remains the responsibility of the person with OA and consists of the myriad tasks necessary to live well and manage the condition. SMS is the community's and health care system's responsibility to provide educational and other supportive interventions to assist the person in acquiring the knowledge, skills, and confidence to manage the condition and live well. SME is a form of SMS.
SMS interventions can be categorized into five types: SME, other skill-building or behavior-change interventions, supportive provider interactions, supportive follow-up, and environmental changes. Interventions in each of these categories can vary according to the target skills or behaviors, setting, target audience, mode of delivery, and intervention provider. Most of the existing OA-specific forms of SMS fall in the SME and other behavior-change categories, but supportive provider interactions and ongoing follow-up have been utilized with weight-control and physical-activity behaviors that are also important in OA.
Across all types of SMS interventions, several common elements stand out. These include problem solving, action planning, enhancing self-efficacy, self-monitoring, and social support. Nurses are well positioned to provide SMS, but may need to develop competency in fostering these skills. Our knowledge of how well SMS interventions work with men and racial and ethnic minority populations in general and with OA in particular remains limited.
REFERENCES