Adapting self-management support strategies to the needs of individuals and groups

Roy BatterhamSenior Research FellowPublic Health Innovation, Deakin

April 11th 2012

OutlineOutline• What is self management and self management

support• Understanding individual needs and

customising SMS to the needs of individuals– Summarising behaviour change research, 5

pillars and stages of change– Levels of self management– Functional/life needs approach– Health literacy

• Understanding group needs and customising SMS to the needs of groups

What is self-management and self-management support?

Recommended referenceHealth Behavior Change and Treatment Adherence, Evidence-based Guidelines for Improving Healthcare, 2009Martin, Leslie, Professor of Psychology, La Sierra University, Riverside

Haskard-Zolnierek, Kelly, Assistant Professor of Psychology, Texas State University, San MarcosDiMatteo, M. Robin, Distinguished Professor of Psychology, University of California, Riverside

• 1 Understanding Behavior Change: The Theory Behind Informing, Motivating, and Planning for Health

• 2 Persuading and Motivating Positive Health Behaviors

• 3 Understanding and Remembering

• 4 Improving Health Through the Development and Management of Habits

• 5 Evaluation of Risks, Decision Making, and Outcomes

• 6 Relationships and Communication Between Caregivers and Patients

• 7 Effective Collaboration with Patients—On a Tight Schedule

• 8 Partnering for Adherence in the Healthcare System

Health care

Health careworkers

Management of chronic disease

Self management+/- carer & family+/- community

Health care

Management of chronic disease

Self-management support interventions

Jordan JE, Osborne RH. Chronic disease self-management education programs: challenges ahead Med J Aust 2007;186(2):84-7.

Variability: Understanding individual needs and customising SMS to the needs of individuals

Three types of behaviour change theories

1. Predictive theories: Theories that try to predict which people in a group are likely to change and which are not

2. Stages of change theories: Theories that try and help people understand the process of change and how they can help it

3. Integrative theories: Theories that try and draw all of the above together

Predictive theories have emphasised...

• Cues and stimuli (health beliefs model)• Beliefs (and attitudes) (health beliefs model)• Personal perceptions of what is normal and

other competing values (personal norms) (theory of reasoned action)

• Perceived behavioural control (general: locus of control; specific: self-efficacy) (modified health beliefs model theory of planned behaviour)

• Intentions (theory of reasoned action)• Environmental factors (social cognitive theory)

Predictive theories have emphasised...

Environmental factors

Theory of reasoned action

Theory of planned behaviour Social cognitive

theory

Health beliefs model

Modified health beliefs model

Likelihood of engaging in a

health-enhancing behaviour

Likelihood of engaging in a

health-enhancing behaviour

Stages of change theory 1:Trans-theoretical model

Main positives: •highlighting the amount of work that people do in their minds before they make a change•understand that for different types of changes the hardest work can be at different changes

Main misuses: •people often forget that it is specific to every different behaviour and NOT a characteristic of the person •used as a reason for unequal practices – target services to people with high ‘readiness to change’

Integrated model 2:Integrated model 2:Five pillars of health behaviour Five pillars of health behaviour changechange

Integrated model 2:Integrated model 2:Every one will be different in what Every one will be different in what they need and what they have...they need and what they have...

KnowledgeBeliefs

Confidence – self efficacy

Problem solving

Environment/ stimuli

What they need

What they have

Integrated model 2:Integrated model 2:Every one will be different in what Every one will be different in what they need and what they have...they need and what they have...

KnowledgeBeliefs

Confidence – self efficacy Problem

solvingEnvironment/

stimuli

What they need

What they have

Conceptualising ‘self-Conceptualising ‘self-management’management’

C

A

B

C: Shift whole curve

A: Get people into “self-managing” categoryB: Prevent decline in those at risk of deterioration and hospitalisation

RecruitmentRecruitment

C

A

BC: Match intervention to person rather than person to intervention

A: Volunteers

B: Risk assessment tools

Risk assessment tools

• The best risk assessment tools in the world predict a maximum of about 20% variance in hospital utilisation over 12 months or more. Most do much worse.

• If a biological screening tool had a false positive and false negative rates > 80% anyone who suggested using it would be laughed out of town

• Only useful for 2 month readmission risk

• Risk assessment tools should be used for care-planning NOT screening

Variability: thinking about complexity

Conceptualising ‘self-management’ – Conceptualising ‘self-management’ – its not yes or no, it’s a continuumits not yes or no, it’s a continuum

Health and fitness fanatics

Comatose, or equivalent. Has ‘stuff done to them’

Very little understanding of what is done to them and no emotional buy in or commitment. Cooperation ad hoc and reactive if at all.

Stanton or Flinders ‘self manager’. Able to set goals and commit to them and take initiative in accessing the means to achieve them)

Some capacity to express aspirations and wishes and understand health implications. Willing to participate in health decisions but easily swayed off track and has difficulty maintaining personal effort

Able to express wishes and preferences and understands how health services and personal actions can contribute to these. Actively participates in health service decisions and cooperates to the best of their ability. Piecemeal approach to personal health care actions

Able to set and commit to personal goals but requires assistance with arrangements to meet these. May have periods of significant personal discouragement and require assistance overcoming setbacks

Varying approaches with client complexity

‘Know what’ support

‘Know how’ support

Assistance, monitoring, ‘small goals’

More complex

Lesscomplex

Likely target group through cold callingLikely target group through community health recruitment

Levels of self managementLevel of self management Strategies

(Classic ‘self manager’) Largely independent in looking after health at least between acute health episodes. Some regular health improvement activities. Initiates engagement with health and related providers when necessary or when they consider it beneficial.

•Classic health education

(Supported ‘self manager’) Able to set and commit to personal goals but requires assistance with arrangements to meet these. May have periods of significant personal discouragement and require assistance to overcome setbacks

•Health education, •‘Coaching’•Referral•linkage to services,•some monitoring• relapse planning

Levels of self managementLevel of self management Strategies

(Prompted ‘self manager’) Able to express wishes and preferences and understands how health services and personal actions can contribute to these. Actively participates in health service decisions and cooperates to the best of their ability. Piecemeal approach to personal health care actions.

•Coaching•Organise environmental stimuli•Assist to establish routines•Work with families

(Reactive co-operator) Some capacity to express aspirations and wishes and understand health implications. Willing to participate in health decisions but easily swayed off track and has difficulty maintaining personal effort

•Assist to establish routines•Address crises•Address mental health conditions•Assist families

Levels of self managementLevel of self management Strategies

(Non-co-operator) Very little understanding of what is done to them and no emotional buy-in or commitment. Cooperation is piecemeal and reactive if given at all.

•Find something they LOVE to do•Ensure crisis needs are met and •Ensure that any mental health conditions are treated,•Assist families or carers•Try to establish a relationship with one or two care providers

People at highest risk require more intensive interventions and cost more...but not as much as multiple admissions to hospital

Variability: adding mental health issues

The ‘complex’ client

Often, clients who don't 'succeed' in traditional self-management programs are dismissed as having no/low self-management capacity.

Some have described these clients as fitting into two broad categories - those with cognitive impairment and those with multiple comorbidities or concerns.

We hope to design 'Stepping up...' in such a way that it also supports this later group. To do so we make a number of ASSUMPTIONS about this group: Most of them are in fact willing and able to make changes to improve

their health and wellbeing (although the extent and type of change may conflict with health professionals priorities).

The lack of 'success' of SMS programs in engaging this group in the past has largely been due to a lack of 'fit' between the program and the client's needs.

Improving the 'fit' between client needs and the program requires a different approach

People perceive their experience of sadness or worry as reasonable and may not realise when it has taken on a life of its own

Effects are mediated by peoples’ internal response to three questions: o What might this mean for my life? (e.g. new diagnosis) o What is this meaning for my life? (e.g. dealing with health services, symptoms) o What has this meant for my life? (e.g. loss of valued roles and dreams)

Depression and/or anxiety can lead to a reduction in a person’s ability to care for their health through a variety of causal processes including:

Lowering of expectations for life and health Reduced sense of personal efficacy Reduced participation and activity Self-management fatigue Self –soothing behaviours (e.g. chocolate, alcohol, shopping)

Improving Treatment ‘Fit’

3 features of the ‘Stepping up...’ model hope to improve treatment fit:

1.Problem prioritisation - using a collaborative case formulation approach

2.Tailored content - rather than a one size fits all approach

3.Flexibility in treatment intensity - capacity to scale down treatment expectations and burden

© 2011, Deakin University, Australia.

Program Structure

Session 2: Taking Stock

(Identifying and formulating an

understanding of the key issues)

Session 2: Taking Stock

(Identifying and formulating an

understanding of the key issues)

Session 1: Managing your musculoskeletal

condition

Session 1: Managing your musculoskeletal

condition

Session 3: Individually

tailored education

session

Session 3: Individually

tailored education

session

Managing a difficult relationship

Managing a difficult relationship

Managing worryManaging worry

Managing fear & panicManaging fear & panic

Managing pain Managing pain

Making a lifestyle or health behaviour change

Making a lifestyle or health behaviour change

Managing moodManaging mood

Managing stressManaging stress

Managing sleepManaging sleep

Sessions 4-7Individually tailored CBT sessions

(up to 4)

Sessions 4-7Individually tailored CBT sessions

(up to 4)

Challenging problematic thoughts

Challenging problematic thoughts

Behavioural activationBehavioural activation

Graded exposureGraded exposure

MindfulnessMindfulness

Sleep patternSleep pattern

Identifying problematic thoughts

Identifying problematic thoughts

Sleep environment & daytime activities

Sleep environment & daytime activities

Relaxation strategies (breathe)

Relaxation strategies (breathe)

PacingPacing

Role of beliefsRole of beliefs

Sessions 8: Wrap up

(Reflecting on learnings,

maintaining gains, relapse prevention

planning)

Sessions 8: Wrap up

(Reflecting on learnings,

maintaining gains, relapse prevention

planning)

Worry tipsWorry tips

Pain tipsPain tips

Managing fatigueManaging fatigue

Relaxation strategies (muscle relaxation)

Relaxation strategies (muscle relaxation)

Overcoming obstaclesOvercoming obstacles

Habit change tipsHabit change tips

Planning for behaviour change

Planning for behaviour change

Becoming less isolatedBecoming less isolated

Communicating effectively

Communicating effectively

Managing anger and frustration

Managing anger and frustration

Being more assertiveBeing more assertive

© 2011, Deakin University, Australia.

Consumer Concerns

Eight presenting concerns addressed:

1. Pain 2. Fatigue3. Mood4. Anxiety & worry5. Stress6. Sleep7. Relationship issues8. Lifestyle change

© 2011, Deakin University, Australia.

The Model

4-12 weeks

© 2011, Deakin University, Australia.

Clinical Tasks

Clinical Tasks Description Time required

Phone assessment

Establishing rapport Taking client history Determining presenting

concerns

Identifying barriers and facilitators of change

Negotiating appropriate program focus /goal

Determining an appropriate program intensity

1 hr

Tailoring the online program

Selecting 6 to 15 online sessions

Initiating the client’s program 5min

Weekly monitoring

Reading client’s weekly entries in their online session

Monitoring log-in frequency and progression through the program

5min

/week

Weekly email support

Responding to risks and issues identified

Responding to client emails

Providing encouragement & support Challenging unhelpful response

patterns Reminders

5-15min /week

Phone review Progress assessment Relapse prevention planning

Facilitating access to further support where required

30min

Variability: Understanding group needs and customising SMS to the needs of groups

Five pillars and needs in rural Five pillars and needs in rural ThailandThailand

Energy managementBeneficial levels and types of physical activity

Medical knowledge often not privileged above traditional, religious and historical

Success and failure stories mostly re fit with daily routines and family, community and physical environments

Success and failure stories mostly re fit with daily routines and family, community and physical environments

Need for problem solving skills re right

Trial and error approach common

Decision making rarely individual, whole family must decideLow SE re parting from traditional diets

Healthier ageing with HIVHealthier ageing with HIV

Self management beyond the ‘self’

What does self management mean for:– People living in aboriginal communities?– A tired mother whose family rebels at eating

her ‘diabetic’ food?– People living in a village in Thailand?– A person with a disability who is dependent on

others for many care needs?– An adolescent whose priority is developing

and maintaining an acceptable sense of self among her/his peers?

– Anyone whose health related choices are made by, or largely determined by, people other than themselves?

Health Literacy: several Health Literacy: several definitionsdefinitions• “Health literacy represents the cognitive and

social skills which determine the motivation and ability of individuals to gain access to, understand and use information in ways which promote and maintain good health” (World Health Organization)

• “Health literacy is the ability to make sound health decisions in the context of everyday life – at home, in the community, at the workplace, the healthcare system, the market place and the political arena” (Kickbusch, 2001)

Why is everyone talking about Health Literacy?• Previous tools failed• New national / international surveys

– Australia, Taiwan, Europe

• Public Health and Health Promotion still do not meet the needs of those with low literacy

• Accepted as a priority in International Union for Health Promotion and Health Education

Why is everyone talking about Health Literacy?

• Health education, prevention and disease management programs continue to fail to engage and improve outcomes for people who are most at risk–Why is this?

The new person-centred health literacyStrongly Agree—Strongly

disagree1. Healthcare provider

supportI have at least one health provider who

knows me well

2. Perceived information adequacy

I have all the information I need to manage my health properly

3. Taking responsibility for health

I set my own goals about health and fitness

4. Being health focusedMy health is important to me

5. Social supportIf I need help, I have plenty of people I

can rely on

6. Critical appraisalI know which places provide health

information that I can trust

Cannot do—Very easy7. Agency in relationships with providersDiscuss things with healthcare providers until you understand all you need to

8. Navigating the health systemWork out what is the best care for you

9. Ability to access health informationGet health information in words you understand

10. Reading, writing, understandingFollow the instructions from healthcare providers properly

11. Beliefs and valuesGetting sick is part of getting old

Requirements for a Thai Health Literacy evaluation system

• Cultural issues– Alternatives to just focusing on the individual– Beliefs about sickness– Cultural diversity

• Health system issues– ? Health volunteers as ‘health literacy workers’– Health literacy needs of service providers– Priority on equity – historical and present

• Health literacy for the illiterate

Thank you

roy.batterham@deakin.edu.au