Self-management approaches for people with chronic conditions: a review

Patient Education and Counseling 48 (2002) 177±187

Self-management approaches for people with chronic conditions: a review Julie Barlow*, Chris Wright, Janice Sheasby, Andy Turner, Jenny Hainsworth Interdisciplinary Research Centre in Health, Psychosocial Research Centre, School of Health and Social Sciences, Coventry University, Priory St., Coventry CV1 5FB, England, UK Received 2 January 2001; received in revised form 11 July 2001; accepted 6 January 2002

Abstract The purpose of this paper is to provide an overview of self-management approaches for people with chronic conditions. The literature reviewed was assessed in terms of the nature of the self-management approach and the effectiveness. Findings are discussed under the headings of: chronic conditions targeted, country where intervention was based, type of approach (e.g. format, content, tutor, setting), outcomes and effectiveness. The last of these focused on reports of randomised controlled studies. # 2002 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Self-management; Chronic conditions; Effectiveness

1. Introduction Longer life expectancy and increasing numbers of people living with chronic conditions accompany the greying of the demographic pro®le. The burden of meeting the needs of this growing number of people will fall upon already overstretched health care services that are struggling to cope with the demands of acute care let alone the needs of those with long-term health conditions. A parallel development is the shift away from paternalistic models of health care that sited the patient in the role of passive recipient. The more active involvement demanded by many patients is in keeping with the realities of chronic disease whereby responsibility for day-to-day disease management gradually shifts from health care professionals to the individual. Indeed, the UK initiatives such as NHS Direct and the Expert Patients Task Force are based on the notion of patients as `experts' able to access information relevant to their health care needs and to carry out the self-management tasks needed for their condition at a given point of time. 1.1. Definition of self-management There is no `gold standard' de®nition of self-management. Alderson et al. [1] refer to self-management as *

Corresponding author. Tel.: ‡44-24-7688-7452; fax: ‡44-24-7688-7498. E-mail address: [email protected] (J. Barlow).

inter-disciplinary group education, based on the principles of adult learning, individualised treatment and case management theory. Clearly, this de®nition excludes any individualised approaches to self-management. Nakagawa-Kogan et al. [2] describe self-management as a treatment that combines biological, psychological and social intervention techniques, with a goal of maximal functioning of regulatory processes. A review by Clark et al. [3] suggests that, in general, authors interpret `self-care' as a preventative strategy (i.e. tasks performed by healthy people at home). In contrast, they maintain that `self-management' is interpreted as the day-to-day tasks an individual must undertake to control or reduce the impact of disease on physical health status. At-home managementtasksandstrategies areundertaken with the collaboration and guidance of the individual's physician and other health care providers ([3], p. 5). Clark et al. [3] suggest that individuals also have to cope with the psychosocial problems generated by chronic disease and must manage daily living according to their ®nancial and social conditions. They further suggest that successful self-management of chronic conditions requires suf®cient knowledge of the condition and its treatment, performance of condition management activities and application of the necessary skills to maintain adequate psychosocial functioning. Thus, for the purpose of this review, selfmanagement is de®ned as follows.

0738-3991/02/$ ± see front matter # 2002 Elsevier Science Ireland Ltd. All rights reserved. PII: S 0 7 3 8 - 3 9 9 1 ( 0 2 ) 0 0 0 3 2 - 0

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Self-management refers to the individual's ability to manage the symptoms, treatment, physical and psychosocial consequences and life style changes inherent in living with a chronic condition. Ef®cacious selfmanagement encompasses ability to monitor one's condition and to effect the cognitive, behavioural and emotional responses necessary to maintain a satisfactory quality of life. Thus, a dynamic and continuous process of self-regulation is established [4]. Hence, it is not surprising that the value of self-management interventions that train patients to utilise relevant skills is the subject of increased attention and was mentioned in recent White papers in the UK [5]. Self-management may be one means of bridging the gap between patients' needs and the capacity of health and social care services to meet those needs. 1.2. Purpose and objectives The purpose of this study was to produce an overview of published literature on self-management in chronic conditions. Objectives were:  to identify approaches to self-management;  to consider the effectiveness of different approaches to self-management. 2. Methods Since there is no `gold standard' de®nition of self-management, searches were conducted to identify papers that purported to be on self-management. Searches on BIOMED, BIDS (Social Sciences and Science database), CINAHL, MEDLINE, PSYCLIT and Cochrane Library (York, UK) using the key words: `self-management and chronic' yielded a total of 1129 papers (a prior search on `self-management and chronic disease' produced few references). Inclusion criteria for the overview were (1) report of a self-management approach, and (2) evaluation of a selfmanagement intervention. Exclusion criteria were (1) commentaries, (2) opinions, (3) identi®cation of self-management behaviours, and (4) scale development. The title of each of the 1129 papers was reviewed. At this stage review papers were included as potential sources of papers or of de®nitions of self-management. Abstracts were obtained for the 323 papers that appeared to meet the inclusion/exclusion criteria or were reviews of self-management. The abstracts were reviewed in accordance with the study inclusion/exclusion criteria. Inter-researcher reliability was checked on a 25% random sample of abstracts. Full text versions of 220 papers, one book, and two theses were obtained. A further review of the papers, book and theses was conducted using the inclusion/exclusion criteria. A total of 145 papers met the study criteria and were read and summarised by the authors. Inter-researcher reliability was addressed in two ways. A record sheet was developed to

ensure consistent documentation of all pertinent information from each paper, including aims and objectives, condition, country, sample description, study design, outcome measures, assessment, self-management approach, key results, study limitations and quality of the study. Study designs were classi®ed as a randomised, controlled trial (RCT) or not a randomised, controlled trial (non-RCT). The record sheet was tested and re®ned on three papers that were independently reviewed by each of the authors. Assessment of three further papers produced agreement on the information recorded in each section of the record sheet. This process generated categories for the creation of summary tables outlining the key elements of each paper included in the review. A 10% audit of the summary tables was conducted to ensure consistency in terms of information summarised. The exclusion criteria were extended to encompass case studies, qualitative papers on small samples and methodological papers. Review papers were excluded from the summary tables. 3. Results Results are presented under the following headings: chronic conditions, country, self-management approach (e.g. format, content, tutors), outcomes and effectiveness. 3.1. Chronic conditions A breakdown of the 145 papers by chronic condition is provided in Table 1. The largest number of papers identi®ed focused on asthma (n ˆ 66), followed by diabetes (n ˆ 18) and arthritis (n ˆ 17). 3.2. Countries The majority of studies (82) were based in USA, with 13 in the UK, 10 in Australia and the remaining 40 from other countries. 3.3. Self-management approaches 3.3.1. Target population The majority of self-management approaches target adults; few have focused on children or carers. There are exceptions particularly in the ®eld of asthma where several studies include both child and adult participants. For example, a UK study [6] reports an age range of 3±49 years, and a study conducted in India reports an age range of 10±45 years [7]. In addition, a few studies have targeted parents of children with asthma [8]. Few interventions have been adapted for use in different cultures. One exception is the Arthritis Self-Management Programme (ASMP), which has been delivered in a number of countries (e.g. USA, UK, The Netherlands, Australia, Canada) and has been adapted for Spanish speaking participants [9]. A RCT has shown the outcomes of the Spanish speaking ASMP to be similar to other ASMP studies

J. Barlow et al. / Patient Education and Counseling 48 (2002) 177±187 Table 1 Classification of papers by chronic condition Condition

Number of papers

References

Arthritis Asthma Attention deficit disorder with hyperactivity (ADHD) Autism Back pain Breast cancer Chronic disease Chronic headache Chronic pain Chronic obstructive pulmonary disease (COPD) Coronary artery disease Cystic fibrosis Depression Diabetes Geriatric Haemophilia Heart disease HIV Hypertensives Insomnia Multiple sclerosis Oral anticoagulation Pica behaviour Psychiatric Schizophrenia Sickle cell Stroke Tinnitus

17 66 1

[1,9,14±18,26±35] [6±8,12,13,19±21,36±93] [94]

1 3 1 18 1 1 1 3 2 1 1 1 1 1 3 1 1 1

Total

145

3 2 1 3 6 2 2

[95±97] [98,99] [100] [101±103] [104±109] [110,111] [112,113] [114] [115±117] [118] [10,11,22±25,119±131] [132] [133] [134] [135±137] [2,138] [139] [140] [141] [142] [143] [144±146] [147] [148] [149]

in terms of improvement on pain, self-ef®cacy and exercise at 4 months. In the ®eld of diabetes, Brown and Hanis [10] described the development of a community-based education and support group for bilingual Mexican±American adults with Type II diabetes. Preliminary ®ndings of a RCT showed that the intervention was effective in reducing blood glucose level. However, the authors note the high attrition rate when the intervention moved from education to support only a situation that necessitated greater staff time and attention. 3.3.2. Delivery location Self-management interventions are delivered in a variety of settings with the most popular being clinical locations (e.g. hospital) or the home environment. Settings reported in the studies reviewed were: adult education, community (e.g. church hall), home, home for psychiatric patients, hospital, primary care, rehabilitation centre, research centre residential camp (usually for children), school, tertiary care centre and work site. 3.3.3. Self-management tutors A range of tutors delivered self-management interventions, the majority being health professionals. The self-

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management interventions developed by Lorig et al. in the USA are the exception; lay tutors with chronic conditions are trained to deliver the intervention. Tutors reported in reviewed papers were: dieticians/nutritionists, doctors, educators, lay people with chronic conditions, nurses, occupational therapists, pharmacists, physiotherapists/physical therapists, psychologists, researchers/social scientists, social workers, and speech and language therapists. 3.3.4. Mode Self-management approaches were either group-based, an individualised approach, or a combination of both. Group approaches typically comprised between 6 and 12 participants and were often supplemented with written materials and audiotapes. The range of group-based approaches is summarised as: group, group …1 session† ‡ computer package to use at home, group ‡ individual counselling from a health professional (e.g. nurse) either face-to-face or by telephone, group ‡ individual telephone follow-up, group ‡ individual treatment/consultation, group ‡ manual ‡ audiotapes/videotapes and group ‡ written materials (booklet, handout, manual). Individual approaches ranged from manuals that participants work through at home, to sessions with a health professional on a one-to-one basis in a clinical setting. Individual approaches included: book and audiotape given to individual by doctor, computer-generated, written advice mailed to individuals, credit card (asthma), internet, manual, one-to-one with health professional, TV and radio programmes, video of group session ‡ written materials, workbook and videotape. 3.3.5. Format The format of self-management approaches varied and included booklets, lectures, role play and contracting (goal setting). Most approaches combined at least two formats of delivery (e.g. lectures and manual). Self-management for chronic conditions such as autism and schizophrenia often included behavioural conditioning and included use of reward systems or a wrist counter for social interactions. A full list of formats used comprises: audiotapes, behavioural ratings (ADHD), booklet, buddy system, computer generated, individualised written advice, contracting, counselling, credit card (asthma), exercise sessions (usually led by physiotherapist), ¯ip cards, goal setting, group discussion, individual plans (e.g. diet, exercise), instruction from health professional (e.g. use of medication), lecturettes/ lectures/talks by health professionals, manual, problem solving, reward systems, role play, sharing experiences, swimming, videotapes, and wrist counter for verbal interaction (autism). 3.3.6. Content A diverse range of self-management components was identi®ed (see Table 2). These were broadly classi®ed as providing information, drug management, symptom man-

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Table 2 Self-management components Main component

Variations and sub-categories

Information

About condition treatment

Drug management

Fieldtrip (to practice taking medication) Overcoming barriers to adherence to drugs

Symptom management

Breathing (asthma) Cognitive symptom management (e.g. visualisation, distraction, guided imagery) Emergency treatment (asthma) Fatigue management Managing sleep (e.g. insomnia, sleep disturbance) Pain management Provoking aggravating factors and warning signs (e.g. asthma, headaches, arthritis flares) Relaxation Self-monitoring (e.g. chest pain, blood glucose)

Management of psychological consequences

Anger management Dealing with depression Disease acceptance Emotions Stress management

Life style (including exercise)

Exercise (on land, hydrotherapy, posture) Exercise motivation/overcoming barriers to exercise adherence Holidays Leisure activities Nutrition and diet Smoking

Social support

Family support Relationships with peers family

Communication

Assertiveness Communication strategies (e.g. with doctors)

Other

Accessing support services Action plans Career planning Contracting Coping Decision making Goal setting Group psychotherapy Managing uncertainty Problem solving Rational-emotive therapy Spirituality

agement, dealing with psychosocial consequences, life style (including exercise), social support, communication and other self-management strategies such as career planning, goal setting and accessing support services. The categories are not mutually exclusive and some overlap with the selfmanagement intervention format. Some self-management interventions have drawn on social, cognitive and behavioural theories during their development. For example, several approaches utilise the tenets of self-ef®cacy theory. Thus, content is based around providing participants with mastery experiences (e.g. opportunity to try out a behaviour), role modelling, reinterpretation of

symptoms and psychological consequences (e.g. cognitive reframing), and provision of information from a persuasive and credible source. Self-management approaches that focus primarily on medication and symptom management are necessarily disease-speci®c. Approaches that include management of psychological consequences (e.g. depressed mood), life style (e.g. exercise), social support and communication are usually generic skills that can be used in a disease-speci®c context. The approaches used are not speci®c to the country of origin. For example, courses developed in the US have been used in the UK. In the ®eld of arthritis, the predominant approach is holistic and multi-component, with many interventions addressing knowledge, use of medication, symptom management, management of psychosocial consequences, social support, communication and life style changes, including exercise. Similarly, many self-management approaches in diabetes include not only blood glucose monitoring and critical self-care but also problem solving, diet, exercise, goal setting and psychosocial issues [11]. In contrast, the focus in asthma tends to be on use of medication and symptom management. The Asthma Self-Management Programme [12] and the Wheezers Anonymous [13] being two of the few asthma interventions to adopt a more holistic, multi-component approach. 3.4. Outcomes and effectiveness 3.4.1. Methodological issues Most self-management approaches are multi-component. One limitation of the published literature is that the content is not always described in suf®cient detail to allow a thorough understanding of the intervention. It is dif®cult to tease out the precise mechanisms leading to change among participants in a multi-component approach. However, this dif®culty must be balanced against the fact that multi-component programmes are usually designed to increase the repertoire of participants' self-management skills within the realities of living with a chronic condition. Thus, effective self-managers will feel con®dent in selecting the technique(s) that they believe will meet their speci®c needs at a given point of time and in a given environment or situation. Multi-component programmes are best considered as a `package' of self-management, similar to the standard packages of care provided in clinical settings (e.g. consultation with doctor, goal setting with a nurse, examination, tests, medication, referral to other services such as physiotherapy). Approximately half of the self-management studies reviewed were RCTs and of these, many were based on small sample sizes (e.g. 20±30) with short follow-up periods, typically 4±6 months. A few studies have managed to include follow-ups at 12 months, although frequently this is not under controlled conditions. These time-frames are inadequate when considered against the duration of most

J. Barlow et al. / Patient Education and Counseling 48 (2002) 177±187

chronic conditions. Thus, there is a need to conduct RCTs of suf®cient size to enable change on key outcome measures to be detected. Equally, there is a need to determine whether use of self-management techniques and change on health status is maintained over longer periods of time (i.e. >12 months). The analyses have not always adopted an intention-totreat approach and not all studies make adjustments for the number of tests conducted, hence increasing the likelihood of Type I error. Few studies report effect sizes, thus making comparison of ®ndings dif®cult. In addition, whilst there are standard measures for assessing health status, many of the measures focusing on self-ef®cacy, con®dence, attitudes and use of self-management behaviours do not appear to have been subjected to psychometric testing. Only a few studies have considered cost effectiveness. Those that have addressed this issue have tended to focus exclusively on the direct costs of the self-management intervention and impact on physician visits. The indirect costs to the participant associated with performance of self-management techniques (e.g. relaxation tapes, dietary changes) and change in days lost at work or school are rarely considered. Moreover, the costs of health professionals' time in organising and delivering interventions are largely ignored. Given the time-consuming nature of many interventions, this is a critical omission. Many research designs are based on the use of a waitinglist control group, with follow-up periods of between 3 and 6 months, after which point the control group receives the intervention. Any further follow-ups are therefore uncontrolled but are useful indications of whether any changes are maintained over longer periods of time. Questions remaining to be addressed concern the comparative effectiveness of different approaches, particularly those that have cost implications (e.g. lay- versus professionally-led). There is little information regarding the time in the disease course when self-management may be optimally effective (e.g. immediately after diagnosis or later in the disease course). There is a need to determine whether self-management approaches need to be tailored to different age bands, different cultural settings, and should be extended to include carers and family members. Finally, the impact of the growth of technologies, such as the internet, needs addressing in the self-management ®eld. 3.4.2. Outcome measures The reviewed studies used a wide range of outcome measures that can be classi®ed under the broad categories of physical, psychological and social health status, knowledge of condition and its treatment, laboratory tests, use of medication, self-ef®cacy, self-management behaviours, use of health care resources and cost. Examples of each category are presented in Table 3. Where outcome measures are typically associated with a particular condition, these are noted in the Table. For example, most studies of arthritis assess pain and physical functioning, asthma studies usually

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assess peak ¯ow, and diabetes studies assess blood glucose level. Outcomes common across a number of chronic conditions are identi®ed as `across conditions'. Psychological outcomes are typically assessed using generic rather than disease-speci®c measures indicating the commonality of psychological consequences across many chronic conditions (e.g. vulnerability to depressed mood, uncertainty). Where self-ef®cacy is assessed, outcome measures tend to be speci®c to the condition or set of selfmanagement behaviours being addressed. This accords with self-ef®cacy theory. A few studies used generic quality of life measures, which although not as sensitive as diseasespeci®c measures, do facilitate comparison across studies and conditions. Comparisons across studies would be enhanced if authors reported effect sizes. Only a minority of studies attempted to address costs, and these tended to be limited to direct costs, with costs of practising self-management by the individual largely ignored. 3.4.3. Effectiveness Overall, there is a growing body of evidence to show that, when compared to no intervention (i.e. standard care), selfmanagement approaches can provide bene®ts for participants particularly in terms of knowledge, performance of self-management behaviours, self-ef®cacy and aspects of health status. There appears to be very little difference in effectiveness between different self-management approaches (e.g. lay- versus health professional-led in arthritis, peak ¯ow-led versus symptom-led in asthma). Individualised approaches appear to be as effective as group approaches, although it should be noted that many group approaches include individualised aspects (e.g. access to counselling). However, one major issue with individualised approaches involving one-to-one contact with health professionals relates to cost. Finally, self-management approaches appear to be as effective as other cognitive-behavioural interventions. The literature on self-management in arthritis is dominated by the Arthritis Self-Management Programme designed as a community-based, group approach led by lay tutors and accompanied by a manual for participants and tutors. The ASMP, and modi®ed versions of the ASMP, show consistent improvements on knowledge, self-ef®cacy and use of self-management behaviours, particularly exercise. Lorig et al. [14] reported costs savings of between US$ 40 and 600 per course, in the USA, using lay rather than professional leaders. Indeed, comparisons of lay versus health professional tutors found no difference in outcomes [14,15]. The effects of the ASMP do not appear to be enhanced by reinforcement through bi-monthly newsletters or attending a second ASMP course designed to reinforce the principles of self-management [16]. Results of a recent RCT of the ASMP in the UK demonstrates that this programme can transcend national boundaries, with results largely in accordance with those previously reported [17]. The Barlow et al. [17] study included assessment of positive

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Table 3 Typical outcome measures in self-management studies Outcome

Condition

Examples

Physical health status

Across conditions Arthritis Asthma Diabetes Coronary artery disease HIV

Fatigue, sleep disturbance Fatigue, pain, joint count, physical functioning Peak flow, symptom free days Body mass index, blood pressure Frequency intensity of chest pain Fatigue, fever, night sweats, pain

Psychological health status

Across conditions

Anxiety Depression Life satisfaction Locus of control Self-esteem Uncertainty

Quality of life/health status

Across conditions

Sickness impact profile, SF36

Medication

Arthritis Asthma

Non-steroidal anti-inflammatories Nebulised salbutamol, oral steroids

Knowledge Laboratory tests

Across conditions Arthritis Diabetes

Condition treatment ESR Blood glucose, cholesterol, glycosylated haemoglobin

Self-efficacy Self-management behaviours

Specific to each condition (e.g. arthritis self-efficacy) Across conditions

Asthma diabetes Health care resources Cost

Across conditions Asthma

well-being as well as the more typical pathological parameters (e.g. depression) and found a signi®cant improvement on this dimension. A RCT of an Arthritis SelfManagement Programme in the USA mailed to participants along with individualised, computer-generated advice produced similar improvements to the group programme [18]. At 6 months, participants had decreased pain, improved joint count, increased self-ef®cacy, increased exercise and made fewer visits to physicians. Randomised controlled trials show that asthma self-management interventions are effective in increasing knowledge, compliance with medication and symptom management when compared to no intervention (i.e. standard care). Charlton et al. [19] found no differences in outcomes between nurse-led peak ¯ow or symptom based approaches; both interventions showed a reduction in doctor consultations and use of oral steroids. Studies of multicomponent programmes report improvement on compliance, symptom management, lung function and days hospitalised (e.g. [20]). Few studies report change in communication skills, diet, and psychological factors although these appear in descriptions of the program and are cited as therapeutic goals. In many studies, it is not clear

Assertiveness Cognitive symptom management Communication skills Diet, food intake Exercise Relaxation Managing medication Doctor/GP/physician visits Emergency treatment Direct costs (e.g. visits to GP, hospital in-patient stay)

whether these outcomes were not assessed, or whether they were assessed but showed no change and therefore were not reported. Kotses et al. [21] report a range of improvements at 6 months follow-up after the Wheezers Anonymous programme; these include peak ¯ow, attack frequency, breathing dif®culty, depression, self-ef®cacy, frequency of self-management behaviours and physician visits. Of note, is the improvement in both the intervention and control groups in terms of coughing and the improvement among control participants on chest tightness. A comparison of the Wheezers Anonymous programme with an individualised selfmanagement programme, based on patient recording procedures, showed improvement in both groups on peak ¯ow and improvements among the individualised group on morning asthma attacks [13]. It is noteworthy that the individualised programme was time consuming and required more effort from patients, more contact by health professionals and was dependent on complex statistical calculations. One of the few studies to focus on carers showed that the Wee Wheezers programme for parents of children with asthma aged under 7 years, improved symptom free days, sleep patterns, preventative medication adherence and use of early intervention procedures [8]. A UK study compared a book, a

J. Barlow et al. / Patient Education and Counseling 48 (2002) 177±187

tape and a combination of book and tape distributed in primary care by a GP [6]. Compared with a control group, the interventions groups improved on knowledge and perceived disability. Interestingly, the intervention groups learned more from the tape but preferred the book. Randomised controlled studies in the ®eld of diabetes show self-management approaches to be effective in increasing use of self-management behaviours, particularly monitoring (e.g. of blood glucose). Brown and Hanis [10] showed a community-based education and support programme to be effective in reducing blood glucose levels. Although a wide range of variables were assessed (e.g. health beliefs), these were not reported in the paper. A multi-component programme targeting older people (>60 years of age) found a signi®cant reduction in calori®c intake, greater weight reduction and increased frequency of glucose testing at 3 and 6 months [11]. No differences were found on quality of life measures, although the authors note that the measures used might not have been the best for this population. For example, they found ceiling effects on self-ef®cacy. A later study [22], evaluated the long-term cost-effectiveness of a brief intervention to facilitate dietary self-management in adults with diabetes. The intervention comprised a computer-assisted, dietary barriers assessment followed by a session with a health professional and a take-home video. Interestingly, the videos distributed differed according to level of self-ef®cacy (high versus low). However, analyses did not appear to differentiate between these two subgroups. Nonetheless, the intervention was effective in changing dietary behaviour and lowering serum cholesterol at 12 months and the authors report the costs, US$ 137 per patient, to be modest in relation to many commonly used practices. Finally, several studies report self-management approaches among children, although these typically have small sample sizes and thus lack suf®cient power to detect change (e.g. [23]). Nonetheless, there are indications that self-management approaches for children can be effective in improving blood glucose level, use of monitoring behaviours [24] and understanding the rationale guidelines for self-management [25]. 4. Discussion The largest proportion of the studies included in this overview was published in the 1990s con®rming that selfmanagement is a growth area for a number of chronic conditions in many countries around the world. Indeed, in the UK the establishment of the Expert Patients Task Force to investigate the feasibility of self-management interventions is testament to the burgeoning interest at governmental level. The number of non-RCT studies reporting within-group change over time or process evaluations exempli®es the current situation in the self-management ®eld. Such studies are necessary in order to ascertain whether the resources inherent in conducting RCTs are justi®ed. The evidence

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from RCTs suggests that self-management approaches are effective in increasing participants' knowledge, symptom management, use of self-management behaviours, self-ef®cacy, and aspects of health status (e.g. depression). Two caveats are that not all approaches target all of these outcomes, and equally, multi-component programmes do not show improvements on all outcomes. Although there are broad similarities across various selfmanagement approaches for people with chronic conditions, there are also differences. Similarities can be seen in relation to course content (e.g. provision of information, use of cognitive-behavioural techniques), and within conditions in terms of targeted outcomes. For example, self-management in asthma focuses largely on the skills needed to manage medication and symptoms, whereas self-management in arthritis tends to adopt a more holistic approach including management of psychosocial consequences and life style changes. Indeed, the overview of self-management reported here has illustrated the variability of approach to self-management both within and across conditions. Moreover, there is variability in the targeted outcomes, methods of evaluation, measurement tools, and the use of theoretical principles both in the development of self-management interventions and in their evaluation. Thus, techniques such as meta-analysis would appear to be of little value in determining effectiveness across such varied literature at the present time. In evaluation of self-management interventions, longer-term follow-ups are needed (i.e. 1, 2, 3 and more years), along with assessment of cost-effectiveness and inclusion of psychosocial outcomes as well as diseaserelated outcomes. In sum, there is an increasing interest in understanding the value of self-management interventions for people with chronic conditions. Collectively, the literature reviewed here suggests that self-management interventions have a bene®cial effect on the well-being of participants in the shortterm. Most interventions achieve their aims of increasing participants' knowledge, self-ef®cacy and use of self-management behaviours. Not all studies set out to either address or assess psychological well-being, but where this does occur, ®ndings are consistent in showing an improvement in mood, particularly depression. These ®ndings provide a ®rm foundation on which systemic expansion of self-management approaches for people with chronic conditions and associated evaluations can be based. 4.1. Conclusion and practice implications Gaps in the literature suggest that greater attention is needed regarding self-management provision for children, young adults and carers. In addition, there is a need to train health professionals to ensure that patients' self-management abilities are maintained and fostered in clinical settings. Participants on self-management interventions can be considered willing volunteers in the majority of cases; they have either sought out an intervention or agreed to take part.

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The issue of those people with chronic conditions who do not come forward to enrol warrants attention. Some of this group may not feel able to embrace the concept of selfmanagement and may need support in making the transition from pre-contemplation to contemplation of making selfmanagement a part of their lives. The dominant mode of delivery is via health professionals. Greater use of peer education may offer a way forward that not only builds on and values the experiences of people with chronic conditions but may also prove to be cost-effective. The variety of self-management interventions identi®ed is healthy in that no one approach will meet the needs of all participants at all points in time. Using a combination or series of disease-speci®c and generic interventions may be one means of optimising the person's ability to effectively self-manage across the course of their disease duration. Although the literature is rapidly increasing and could prove to be a useful source of information for those wishing to implement self-management, the onus is on authors to provide suf®cient details of their intervention so that others can bene®t from their experience. Acknowledgements The authors extend their thanks to the following for their help during the identi®cation and collection of papers for this overview: Michelle Barlow, Kuldeep Kalsi, Suzanne Wright, Dr. L. Wollner, Melanie Peffer from Department of Health, the Long Term Medical Conditions Alliance, National Asthma Campaign, Manic Depression Fellowship and the British Diabetic Association. The paper is based on an overview commissioned by the Department of Health, UK, under remit of the Expert Patients Task Force. References [1] Alderson M, Starr L, Gow S, Moreland J. The program for rheumatic independent self-management: a pilot evaluation. Clin Rheumatol 1999;18:283±92. [2] Nakagawa-Kogan H, Garber A, Jarrett M, Egan KJ, Hendershot S. Self-management of hypertension: predictors of success in diastolic blood pressure reduction. Res Nurs Health 1988;11:105±15. [3] Clark NM, Becker MH, Janz NK, Lorig K, et al. Self-management of chronic disease by older adults: a review and questions for research. J Aging Health 1991;3:3±27. [4] Barlow JH. How to use education as an intervention in osteoarthritis. In: Doherty M, Dougados M, editors. Osteoarthritis. Balliere's best practice research clinical rheumatology, vol. 15. 2001. p. 545±58 [5] Saving lives: our healthier nation. The Department of Health. HMSO, July 1999. [6] Jenkinson D, Davison J, Jones S, Hawtin P. Comparison of effects of a self-management booklet and audiocassette for patients with asthma. Br Med J 1988;297:267±70. [7] Ghosh CS, Ravindran P, Joshi H, Stearns SC. Reductions in hospital use from self-management training for chronic asthmatics. Soc Sci Med 1998;46:1087±93.

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