Self-management interventions in the digital age: New approaches to support people with rheumatologic conditions

Best Practice & Research Clinical Rheumatology 26 (2012) 321–333

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Self-management interventions in the digital age: New approaches to support people with rheumatologic conditions Linda C. Li a, b, *, Anne F. Townsend b, Elizabeth M. Badley c, d a

Department of Physical Therapy, University of British Columbia, Vancouver, BC, Canada Arthritis Research Centre of Canada, Vancouver, BC, Canada Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada d Toronto Western Research Institute, Toronto, ON, Canada b c

Self-management interventions are considered a key component of rheumatologic care. Access to these programmes, however, is an issue for some patients, especially those working full time or living in rural and remote communities. Recently, there has been an increase in the use of digital media technologies to deliver selfmanagement interventions. Digital media (e.g., websites, mobile applications, social networking tools, online games and animation) provide tremendous flexibility for delivering health information and resources at a time and place that is chosen by the individual; hence, they are consistent with the patient-centred approach. This review discusses: (1) innovations in self-management interventions for patients with arthritis and (2) research in the use of digital media for delivering self-management interventions. Ó 2012 Elsevier Ltd. All rights reserved.

Musculoskeletal (MSK) conditions are the most common cause of severe chronic pain and disability worldwide [1–4]. They consist of a multitude of conditions, varying from back and knee pain and common degenerative joint disease (e.g., osteoarthritis (OA)) to severe systemic inflammatory diseases, which damage joints and other organs (e.g., rheumatoid arthritis (RA) and lupus). Approximately 33% of US adults report having chronic joint symptoms/arthritis [5]. In Canada, arthritis alone

* Corresponding author. Arthritis Research Centre of Canada, 895 West 10th Avenue, Rm. 324, Vancouver, BC V5Z 1L7, Canada. Tel.: þ1 604 871 4577; fax: þ1 604 879 3791. E-mail address: [email protected] (L.C. Li). 1521-6942/$ – see front matter Ó 2012 Elsevier Ltd. All rights reserved. 10.1016/j.berh.2012.05.005

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affects 4.4 million people (aged 15 years) and is projected to affect 7 million in 20 years [2]. A similar trend has also been observed in Europe [6–8]. Current evidence indicates that patient education, especially with a cognitive behavioural component, can improve pain, physical function and self-efficacy in patients with arthritis [9–11]. These interventions aim to provide knowledge, skills and resources for patients to engage in selfmanagement activities. Most studies of self-management evaluate face-to-face programmes with patients in small groups or individual sessions but, in reality, access to these programmes is challenging to some. For example, those with a high level of pain and fatigue can be limited by these symptoms alone in attending such programmes. Also, interventions may not be accessible to those living in rural and remote communities. To reach those who are hard to reach, there has been an increasing use of digital media technologies to deliver self-management interventions. Digital media, which are electronic media that operate on digital codes, offer a broad range of applications, such as social networking tools, online games, animation, interactive and personalised websites and video/audio recording. They provide tremendous flexibility for delivering health-related information at a time and place that is chosen by the individual. In the past, digital media referred to ‘new media’ for specific applications. Today, digital media is everywhere. With the rapid development of computerised programs and mobile devices, there are a growing number of studies examining the use of new technologies to deliver self-management interventions. The purpose of this review is to describe recent innovations in self-management interventions for patients with arthritis. Specifically, we discuss: (1) the concept of self-management, (2) the role of digital media in supporting self-management in people with arthritis and (3) the current research on interventions delivered via digital media to engage patients in self-management activities. We focus on the use of Internet and mobile devices because they enable access to self-management interventions at a time and/or location chosen by the patient; hence, they are consistent with the patient-centred approach. The article concludes with recommendations for future research in the use of digital media technologies for supporting self-management. The concept of self-management The concept of self-management is not new (Fig. 1). A recent paper by Kendall et al. [12] suggested that examples of self-management activities have existed throughout history, with the earliest activities rooted in a political context. In the early 1500s, self-organising advocacy groups were present to defend the rights of the marginalised population against the ruling elite and the government. The application of self-management for maintaining health and well-being could be dated back to 1747 when John Wesley, founder of the Methodist Church, published books such as Primitive Physic: or, An

Fig. 1. History of self-management.

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Easy and Natural Method of Curing Most Diseases [13]. Wesley aimed to help those who could not afford medical care to stay healthy by teaching ways to prevent illness and disability. His teaching, such as being physically active, eating healthy, practising proper hygiene and paying attention to mental health, is similar to what is covered today in self-management programmes. Integral to Wesley’s teaching was the implication that one could maintain good health and minimise suffering from disease through participation in self-care. The acceptance of Wesley’s publications by the public was not dissimilar to the current use of the Internet by patients to seek medical information. A large online survey of people with chronic disease in the USA (n ¼ 10 069), published in 2002, found that those who lacked insurance coverage or had poor access to care tended to use the Internet as a surrogate for medical advice [14]. Fast forward to the 1960s, and self-management was brought to the forefront when the term ‘health consumer’ began to gain popularity, particularly in the USA [12]. The term implies an equal and reciprocal relationship between health-care providers and users. Health consumers embrace the power to make treatment choices and assume an active role in managing their own health. Kate Lorig and colleagues [15], pioneers in arthritis patient education, noted that medical literature began to use the term ‘self-management’ in the mid-1970s to indicate the active participation of patients [16]. These authors acknowledged that the term was based on Albert Bandura’s work on the social cognitive theory [17]. The practice of self-management was further enhanced in the 1980s with the availability of affordable equipment for self-monitoring, such as portable blood glucose meters for people with diabetes. In the 1990s, a number of randomised controlled trials (RCTs) on self-management programmes demonstrated effectiveness for improving knowledge, self-efficacy and health outcomes [18]. These RCTs built on years of research on the arthritis self-management programme, which has revolutionised patient education in arthritis care [19–24]. To date, self-management is seen as a mechanism to improve patient outcome and reduce the costs associated with chronic disease [12]. Self-management education: do they meet patients’ needs? Recent literature suggests that self-management education can empower patients to become effective health-care consumers [25,26], in addition to improving clinical outcomes. Lorig and Holman [15] distinguished patient education from self-management education. The latter employs a standardised approach to facilitate development of skills in problem solving, decision making, finding resources, forming partnerships with health-care providers and taking action. This is different from traditional patient education, which focusses mainly on imparting knowledge. While health professionals embrace self-management education, because these programmes are standardised, concerns have been raised that contemporary self-management programmes lack the flexibility to incorporate individuals’ existing self-management skills, life circumstances and resources [12]. A literature review by Newbould and colleagues [27] found that those who benefit from structured self-management programmes tended to have a higher education level. This suggests that structured programmes may not be sufficient for all patients with arthritis. Also, most programmes are face-to-face interventions, which may be difficult for those who work full-time to attend a programme during the day. Although some programmes offer evening sessions, participation can be hindered by fatigue after a long workday. Also, for those living in rural and remote areas, such programmes may not be readily available. Another issue is the timing of self-management interventions. Most arthritis self-management programmes were tested in patients 5–10 years after their diagnosis [28]. The advantage of offering these interventions to patients who are newly diagnosed has not been fully explored. Sociopsychological research suggests that after a major life experience (e.g., having a child) or a health event (e.g., a new diagnosis) people tend to be more amenable to adopting healthy behaviours [29,30]. This ‘teachable moment’ [31] is thought to be the ideal time for self-management interventions because people are more motivated. A study in people with previously undiagnosed knee OA found that about 40% of participants started exercising within the first month after receiving a pamphlet on OA and completing a lay person-led self-management programme [32]. Although the mechanism of this behaviour change was unclear, the diagnosis of arthritis may present a teachable moment for engaging patients in self-management behaviours, such as becoming physically active.

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Compared to the medical literature, sociology research offers a broader insight into the reality of how patients with chronic illnesses manage their health problems. Sociological inquiries shift the focus from studying the need to teach self-management skills to understanding the means to support selfmanagement [12,33,34]. They take the viewpoint that most people have the desire and skills to stay healthy, and continuously manage their health. To quote Lorig and colleagues, ‘One cannot not manage. it is impossible not to manage one’s health. The only question is how one manages’ [15]. In a recent study, Townsend et al. [34] interviewed 23 patients with multiple chronic diseases in Scotland and found that people used multiple techniques to manage symptoms even without attending an education programme. In general, participants felt a moral obligation to ‘manage well’. However, if the action to minimise symptoms compromised their ability to maintain valued activities (e.g., caring for a child), coherent identities (e.g., being a mother) and a normal life, self-management would be relegated to a lower priority. In light of these findings, the authors suggested that self-management education programmes ought to be supplemented by resources that address personal and psychosocial barriers, with an ultimate goal to support patients to self-manage. Digital media offer new ways for supporting self-management Current evidence supports the use of digital media for improving the dissemination of healthrelated information and resources to support self-management [35–38]. Using display platforms that vary from large screen displays to small mobile devices, applications that comprise multi-media elements can be used to deliver tailored information [39]. Various artistic forms, such as drama, music, dance and photography, may also be presented through the Internet and mobile applications to express experiences, capture perspectives and engage with others in ways that cannot be accomplished by written material or didactic presentations. The versatility of digital media offers new platforms for these art forms to be delivered creatively, allowing patients to acquire knowledge and skills in their preferred way. Furthermore, the information can be readily tailored according to age, language, level of education and cultural background [40,41]. Programmes that use animation are particularly gaining popularity in patient education and selfmanagement programmes because they can improve the delivery and presentation of the content. Animation refers to the rapid display of a sequence of two-dimensional images or three-dimensional images to create an illusion of movement [42]. Several advantages have been identified for the use of animation in education programmes. First, it provides a non-threatening and entertaining environment for the users. This approach is known as edutainment, a form of entertainment that is designed to educate and amuse [41,43]. Within the sphere of edutainment falls the interactive narrative, a form of computer-based story telling that allows the viewer to participate in how the story unfolds [44,45]. The most widely applied theoretical framework to explain the process by which edutainment works is Bandura’s social cognitive theory [46], which suggests that people can learn vicariously by observing models who can convey knowledge, values, cognitive skills and behaviours to the viewer. Sood [47] verified this hypothesis by showing that viewer involvement in the narrative not only led to changes in attitudes, beliefs and values, but also increased self-efficacy in relation to the behaviours portrayed by characters in the narrative. The more viewers are emotionally involved in a narrative, the higher the likelihood that they will make changes similar to the story character with whom they relate [48]. Second, the use of visual graphics and speech in animations provides a more user-friendly means to the population with poor literacy. Third, since the information can be delivered in different languages with minor modifications to the programme, it can be used to reach non-English speaking populations with relatively low additional costs. Finally, research suggests that computer animation has potential to increase engagement of younger patients in learning about medical information [49,50]; hence, it offers a useful medium to deliver self-management interventions to a computer-savvy generation living with arthritis. Online self-management interventions for patients with arthritis For this review, we searched Medline from 1990 to March 2012 using the key terms ‘arthritis’ and ‘self-management’. Eligible articles were those that described or evaluated self-management

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interventions for patients with arthritis delivered via the Internet or mobile devices. A total of 257 articles were identified; of those, eight articles [24,51–57] from six studies met the inclusion criteria (Table 1). In 2001, the UK Arthritis Research Campaign developed an Internet-based patient education programme called Arthritis Help. This website featured information on a variety of adult and childhood onset arthritis presented in text, graphical illustrations, animations and audio–visual formats. Wilson et al. [51] surveyed 770 users over a 2-year period; of those, 62.6% reported they were looking for information to manage their arthritis and 15.6% did so for a friend. The majority of respondents used the programme at home and 39% rated the Internet as ‘one of the best sources of information’, followed by instruction by medical staff (25%). This study highlighted the emerging potential of the Internet for delivering information and resources to people with arthritis. One of the most successful online self-management interventions is the Internet Chronic Disease Self-Management Program. This password-protected 6-week programme was a replicate of the original face-to-face programme [58,59]. Patients participated in weekly online workshops moderated by two trained peer moderators. In addition, they were required to log on at least three times a week to read the online content and join the bulletin board discussion. In a 12-month RCT (n ¼ 958; 24.9% had arthritis), Lorig et al. found significant improvement in participants’ health distress (effect size – ES ¼ 0.16), fatigue (ES ¼ 0.15), pain (ES ¼ 0.03), shortness of breath (ES ¼ 0.23), as well as participation in stretching and strengthening exercises (ES ¼ 0.31), compared to the usual care group [52]. The authors subsequently conducted another RCT on the Internet Arthritis Self-Management Program for patients with RA, OA or fibromyalgia [24]. The results demonstrated a significant improvement in health distress, activity limitation, self-reported global health and pain over the 12-month period (Table 1). Another online self-management programme called RAHelp was developed by researchers at the University of Missouri. This 10-week Internet-based programme consisted of self-management modules for patients with RA, a personalised ‘to do’ list, a news feature, a resource library and a journal for tracking the level of pain and stress. In addition, it included an interactive area, the RAHelp Village, where participants can engage in group or individual discussions. This programme was evaluated in an ongoing RCT and the results have not been published [53]. However, during this study, 30 participants in the intervention group were randomly selected to participate in an interview to explore their views on social interactions while using the online programme [53]. Participants in general appreciated the ‘support’ and ‘bonding’ that they received from other users of the programme. They also expressed appreciation that their experience in managing the disease and their problems were validated in these discussions. A subsequent analysis revealed that the burden for administrating the programme was low; hence it would be feasible to implement this intervention in the community setting if it was proven to be effective for enhancing self-management and health outcomes in the RCT [54]. In Canada, Stinson and colleagues developed a comprehensive online programme for young people with juvenile idiopathic arthritis (JIA) and their parents. Teens Taking Charge consisted of 10 online learning modules covering arthritis, treatment, self-management tips, lifestyles and planning for the future [56]. A separate module was developed for parents to address the impact of arthritis and how to prepare their children to take charge in managing their health. The content was developed through individual and focus group interviews with adolescent patients to ascertain their self-management needs [60]. The programme underwent rigorous usability testing to ensure user friendliness of the programme [55]. A pilot study was completed, including 46 patients with JIA. The results showed a significant improvement in participants’ arthritis knowledge (ES ¼ 1.32) and pain (ES ¼ 0.78). The authors mentioned that a full-scale RCT has been planned to study the effectiveness of this programme in the JIA population. Recently, Li et al. developed a novel interactive decision aid for patients with RA, called the ANSWER [57,61]. This programme was designed to enable self-management by guiding patients to consider the pros and cons about using methotrexate. The use of patient decision aids was in response to the shift from traditional authoritative models of care, in which physicians make treatment decisions for patients, to shared decision making, which involves information exchange to prepare patients to participate in making treatment decisions and the process of making decisions between the health-

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Table 1 Characteristics of studies of online self-management interventions for patients with arthritis. Design and sample characteristics

Intervention

Follow-up; dropout

Results

Wilson et al. (2001) [51] UK

Survey (n ¼ 770)

Arthritis Help: a patient education website

N/A

Main reason for using the website  62.3% searched information for themselves.  15.6% searched information for a friend or family. 223/567 respondents rated the Internet one of the best sources of information.

Lorig et al. (2006) [52]

RCT (n ¼ 958)

6 months; 18.3%

Improved at 12 months:

USA

Diagnosis at baseline (n ¼ 780):

Over 50% of respondents were females over the age of 30, and with a diagnosis of RA or OA.

Diabetes (62.8%); Hypertension (46.2%); Lung disease (45.5%); Heart disease (24.0%); Arthritis (24.9%) Age: 57.4 years (22–89); Female: 71.4%; Years of education: 15.4 years (range 8–23) Lorig et al. (2008) [24]

RCT (n ¼ 855)

 Information on RA, OA, SLE, vasculitis and paediatric rheumatology and their treatments.  Presented in text, graphical illustrations, animations, audio-visual material and downloadable documents.

Internet Chronic Disease Self-Management Program: A 6-week internet-based password-protected online program, including:  Interactive web-based instructions, web-based bulletin board discussion groups.  Online workshops moderated by a pair of trained peer moderators.  A book: Living a Healthy Life with Chronic Conditions.  In addition, participants logged on at least 3 times a week to read the web content, post an action plan and join the bulletin board discussion.

Internet ASMP: A 6-week internet-based password-protected, interactive ASMP, including:

12 months; 18.5%

6 months; 25.0%

 Health distress (ES ¼ 0.16)  Fatigue (ES ¼ 0.15)  Pain (ES ¼ 0.03)  Shortness of breath (ES ¼ 0.23)  Participation in stretching and strengthening exercise (ES ¼ 0.31)

Improved over the 12-month period:

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Authors; country

USA

Diagnosis at baseline (n ¼ 866): RA (27.5%); OA (63.6%); FM (50.2%)

Shigaki et al. (2008) [53] Smarr et al. (2011) [54] USA

Qualitative study (n ¼ 30 patients sampled from an RCT). RA (100%) Age: 49.4 years (range 30.1–68.5); Female: 93%; Years of education: 15 years (range 12–20); RA disease duration: 4.79 years (range 0.5–38)

RAHelp: A 10-week secured internet-based program, including:  Self-management education modules.  A personalized ‘To do’ list.  A news feature.  A resource library.  A journal with tools for tracking pain and stress and text boxes for describing weekly events and challenges.  The RAHelp Village (discussion board with postings on a variety of RA related topics; bi-weekly scheduled chats, and a secured messaging system).  The intervention was followed by 8 months of monthly follow-up phone calls.

12 months; 23.9%

N/A

 Health distress  Activity limitation  Self-reported global health  Pain

Participants raised that the ‘support’ of and ‘bonding’ with others with RA was the major advantage offered by the online program. Administration burden of the program appears to be low. Program leaders and administrative staff spent on average 9 h on telephone follow up

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Age: 52.5 years (22–89); Female: 90.2%; Years of education: 15.6 years (range 8–23)

 The Learning Centre (web-based instruction).  The Discussion Centre (bulletin board discussion).  My Tools (exercise logs, medication diaries, tailored exercise programs).  The Arthritis Helpbook.  Online workshops moderated by a pair of trained peer moderators.  In addition, participants logged on at least 3 times (1–2 h) a week to read the web content, post an action plan and join the bulletin board discussion.

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Table 1 (continued) Design and sample characteristics

Intervention

Follow-up; dropout

Results

Stinson et al. (2010) [55,56] Canada

RCT (n ¼ 46)

Teens Taking Charge: Managing Arthritis Online Internet program, including:  Teen website (an introduction, plus 10 sessions covering arthritis, treatment, self-management tips, lifestyle, and planning for the future).  Parent website (an introduction, plus 2 sessions covering the impact of arthritis and ‘letting go’).  Usability test was done during the program development [55].

12 weeks; 19.5%

Improved post-treatment:

ANSWER[58]: An animated online patient decision aid on methotrexate, including:  Information modules (text, voice recording, graphics and animated patient stories illustrating the benefits and side effects of methotrexate).  Your Preference (an interactive process for patients to consider the pros and cons of using methotrexate).  Your Health (HAQ, RADAI).  Report for Doctor (a printable summary of patients’ questions, concerns and decisions about using methotrexate, and their health status).

N/A

JIA (100%) Age: 14.6 years (SD ¼ 1.5); Female: 67.4%; Disease duration: 6.4 years (4.6)

Li et al. (2011) [61]

Mixed-methods usability study (n ¼ 15)

Canada

RA (100%) Age 50 years or over: 53.3%; Female: 86.7%; University/college graduate: 53.4%; Median disease duration: 5 years (IRQ ¼ 0.83–10)

 Arthritis knowledge (ES ¼ 1.32)  Pain (ES ¼ 0.78)

 System Usability Score was 81.2 (SD ¼ 13.5), indicating high usability.  Four themes that patients focused on while testing the ANSWER: 1) User engagement; 2) Information quality; 3) User-tool interaction; 4) Overall integration of the content and navigation.

Legend: ASMP ¼ Arthritis Self-Management Program; ES ¼ Effect size; FM ¼ Fibromyalgia; IRQ ¼ Interquartile range; JIA ¼ Juvenile idiopathic arthritis; OA ¼ Osteoarthritis; RA ¼ Rheumatoid arthritis; SLE ¼ Systemic lupus erythematosus.

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Authors; country

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care provider and the patient [62]. Decision aids are evidence-based tools that are designed to help individuals to choose between two or more options, which may include using a treatment, watchful waiting or usual care [63,64]. These tools help patients personalise the information about treatment effectiveness, outcomes and the inherent uncertainties of potential benefits versus potential harm. Current evidence indicates that patients who used decision aids had more knowledge about the treatment, more realistic expectations and lower decisional conflict compared to those in usual care. In the ANSWER, patients were asked to consider two options: (1) use methotrexate as prescribed or (2) ask the doctor to recommend a different medication. The content was developed based on a qualitative study of patients who were diagnosed with RA in the past 12 months [65,66] and partnerships with patient organisations, including the Arthritis Consumer Experts and the Consumer Advisory Board of the Arthritis Research Centre of Canada. The programme includes an Information Module consisting of six animated patient stories illustrating the benefits and side effects of methotrexate, a Preference Elicitation Module guiding the patient to consider the pros and cons of using methotrexate and a set of health questionnaires. At completion, the programme provides a one-page summary which can be printed or e-mailed to a physician to guide discussion about patients’ treatment preferences, questions and concerns. An iterative usability test was conducted with 15 patients with RA to ensure smooth navigation and user friendliness [61]. The average usability score was 81.2 (standard deviation (SD) ¼ 13.5) out of 100 on the System Usability Scale [67,68]. A pilot study is currently underway to evaluate the effect of this decision aid on patients’ knowledge of, and decision on, using methotrexate. Online self-management interventions for patients with chronic disease In addition to the eight studies, we identified a Cochrane review (updated in 2009) that examined the effectiveness of interactive health communication applications for people with chronic disease [69]. Interactive health communication applications are computer-based information programmes that aim to provide health information plus social support, decision support and/or behaviour change support. Users of these applications may also interact with clinical experts and other users. Twenty-four RCTs, addressing a variety of conditions, met the eligibility criteria. Conditions included AIDS/HIV, Alzheimer’s disease, asthma, cancer, diabetes, eating disorders, encopresis, obesity and urinary incontinence. The meta-analysis concluded that these applications had a moderately positive effect on knowledge (standardised mean difference (SMD) ¼ 0.46; 95% confidence interval (CI) ¼ 0.22–0.69) and modest effect on the perceived social support (SMD ¼ 0.35; 985% CI ¼ 0.18–0.52), clinical outcomes (SMD ¼ 0.18; 95% CI ¼ 0.01–0.35) and behavioural outcomes (SMD ¼ 0.20; 95% CI ¼ 0.01–0.40; e.g., being physically active and decreasing caloric intake). In addition, there was a positive trend on selfefficacy (SMD ¼ 0.24; 95% CI ¼ 0.00–0.48). Considerations for using online self-management interventions The world is ready for digital media programmes to support self-management. Simple interventions, such as the use of text messaging in mobile devices, have successfully improved the adherence to medication in adults with HIV infection living in developing countries [70]. Other countries, such as Canada, are ideal for the use of computerised and mobile devices to deliver health-related interventions because of the geographically scattered population (nearly 20% living in rural and remote areas according to the 2006 census), and the high uptake of communication technologies. The 2009 Canadian Internet Use survey estimated that 80% of all Canadians and 73% of rural residents were online [71]. Similarly, a recent survey in the USA showed that 74% of the population used the Internet, of whom 80% sought health information [72]. Although traditionally slow to adopt the Internet, seniors are the fastest growing group of Internet users [73]. Ownership of mobile phones and tablet devices is also growing rapidly. However, a few outstanding issues ought to be addressed before the use of online self-management interventions can reach their full potential. In the past, the quality of information on the Internet was a major barrier to patients seeking information on arthritis and MSK conditions [74,75]. In this review, we have identified a number of new developments in online self-management programmes that were developed by independent

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research groups and non-profit organisations with current evidence-based information. One challenge, however, is the costs of ongoing maintenance and improvement of these programmes. Aside from keeping the content current, the look and feel of the website or mobile application will also need to be updated regularly. The latter has a much shorter shelf life due to the rapid growth of digital media technologies. Also, having adequate information technology (IT) support is crucial. To this end, we recommend that organisations and research teams should carefully budget for the costs of ongoing maintenance and upkeep of this type of intervention. Another issue concerns the usability of these programmes. Despite an increase in online and mobile tools developed for the health sector, most are not user friendly, and are therefore not being used [76– 78]. Because the majority of online products in the health sector are conceptualised, designed and developed by clinicians and health researchers who usually have limited expertise in digital media, it is likely that these can achieve only a fraction of the full potential offered by new and emerging technologies. Hence, we believe that fostering collaboration between health and digital media disciplines is a crucial step to optimising the use of technologies in the design and development of online selfmanagement interventions. Conclusion In the past 30 years, we have witnessed the accumulation of evidence supporting the use of selfmanagement programmes in patients with arthritis. In fact, these programmes are now considered a key component of quality care. To increase access to self-management interventions among those who have difficulties participating in face-to-face programmes, there has been an increasing use of digital media as a delivery method. Research in this area is still at its infancy; however, the early results are promising. To improve the use of these interventions, we recommend research teams to budget sufficiently for ongoing maintenance and IT support. Finally, to fully leverage the potential of new technologies, we strongly encourage collaborations between the health and digital media sectors in the development and evaluation of these programmes.

Practice points  Most people have the desire and skills to stay healthy. However, if the action to minimise symptoms (i.e., self-management) compromises one’s ability to maintain valued activities, coherent identities and a normal life, self-management would be relegated to a lower priority. Hence, self-management should be ‘supported’ rather than ‘taught’.  Creative use of digital media can enhance the presentation and delivery of interventions to support self-management.  Usability testing is crucial in the development of online self-management programmes because the process ensures user friendliness of the intervention.

Research agenda  Expand development and evaluation to new interventions delivered via mobile devices and other digital media platforms, in additional to Internet-based programmes.  Design and evaluate implementation interventions that facilitate the uptake of selfmanagement programmes by the hard-to-reach populations, including those living in rural and remote communities.  Evaluate long-term benefits (longer than 12 months) of digital media-enabled selfmanagement interventions, especially in patients who are newly diagnosed.

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