1
Self-management
in chronic illness
How effective healthcare support systems can
promote individual patient outcomes
Report authors:
Clare Moloney, MSc
2
Why focus on
self-management?
Across all chronic conditions, the role of patients to
self-manage their condition is integral; they are not
simply the recipients of healthcare. There are many
definitions of self-management (SM) as it applies
to both preventative health behaviours1,2,3 and the
behaviors required in the management of a diagnosed
chronic condition.4,5,6,7,8,9
They can be categorized into three perspectives:
• The behaviors an individual should undertake to
self-manage1,4,5,6,7,8
• The features of support initiatives to facilitate
self-management8,9
• The outcomes of effective self-management1,2,3,4,6,7
This different perspectives are important as they
recognize that whilst SM is about the role and abilities
of the individual, it is important to acknowledge that
this cannot occur in isolation from broader social and
healthcare systems. In fact, these support systems play
a pivotal role in facilitating self-management.
Think, Do, Feel
Recognizing the range of
self-management behaviors
To self-manage requires individuals to undertake
different behaviors. When we think about these
behaviors in the context of managing health, it is likely
to be the overt things a person does that first come
to mind. For example, this might be taking a medicine,
measuring blood glucose levels or eating the right
amount of fruit and vegetables in a day. However,
behaviors can also be covert and therefore not
externally observable, such as thoughts and feelings.10
Many health-related support systems, for example,
wearable trackers, pill organizers and weight loss
programs are focused on prompting overt actions;
walk more steps, take your medicine each day, eat
less calories. Yet these behaviors rarely occur without
the influence of thought processes and can also be
influenced by, and in turn influence, how you feel.
Take the example of depression and adherence to
medication. A meta-analysis which reviewed 30 years
of research into non-adherence and its association to
depression found the relationship to be substantial
and significant11. We then consider what can influence
feelings of depression. Many theoretical models of
depression propose a combination of biological,
cognitive and social factors contributing to the
condition,12 indicating the potential of thoughts to
influence how we feel.
Therefore, it is important when considering how to
support self-management behaviors, to be mindful
not only of overt actions, but also the covert
behaviors (thoughts and feelings) that could be
influencing outcomes for that individual. Figure 1
shows a range of behaviors that we have supported
and influenced through our comprehensive selfmanagement programs.
Fig. 1 Example self-management behaviors*
Treatment Communicating Managing
Adherence
Needs
Moods
Adjusting
Life
Accessing
Support
*This is a selection of behaviors and not intended as a comprehensive list of self-management behaviors
Published by Atlantis Healthcare. Copyright© of Atlantis Healthcare Group and its Subsidiaries, 2016.
Physical
Activity
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What is behavior?
“Anything a person does in response to internal or external events. Actions may be
overt (motor or verbal) and directly measurable or, covert (activities not viewable but
involving voluntary muscles) and indirectly measurable; behaviors are physical events
that occur in the body and are controlled by the brain”13
CORE CONCEPT
A unifying patient
centred framework
Atlantis Healthcare’s
approach to driving effective
self-management behaviors
There are many academic theories of behavior
change, one recent compendium cites 83.10 They
range from comprehensive, multi-behavioral
theories14 to discrete, condition or behavior specific
ones.15,16 In addition, other disciplines, such as
behavioral economics and user experience design,
can provide valuable insights into what will influence
people to behave a certain way. Whilst this helps
demonstrate the importance and potential
complexity of changing behavior, it can make the
job of deciding how best to facilitate behavior
change as complex as the behavior change
challenge itself!
Add to this the multiple behaviors someone may
need to do and the fluctuating influencing factors,
and suddenly it can feel like an unassailable endeavor.
However, at the center of all of this, is a person;
a individual with their own history, experiences,
motivations, needs, challenges and circumstances.
At Atlantis Healthcare, through our experience over
time and through working with many different patient
and healthcare groups, we have seen that the key to
supporting people to self-manage is to first identify
their specific needs and the barriers they face when
trying to reach their health goals and outcomes.
We do this through the application of our proprietary
Self-Management Framework. This draws on
the academic work of the Theoretical Domains
Framework17 and The Behavior Change Wheel14 as
these are the most comprehensive models at this
time. However, we have designed it to be theory
and behavior agnostic, which means we can apply it
across a range of behaviors (individual and multiple)
and can incorporate insights from multiple disciplines
as appropriate. Fig. 2 shows our framework:
This approach allows us to create support
solutions which are not only effective in driving
change but are engaging, commercially relevant
and utilize the most up to date concepts.
Importantly, these solutions are still built upon a
robust, evidence based foundation.
Published by Atlantis Healthcare. Copyright© of Atlantis Healthcare Group and its Subsidiaries, 2016.
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Fig. 2 Atlantis Healthcare Self-Management Framework
Ab
Memory
Dexterity
Planning
and
organising
Stigma
Em
Emotion
Ability
Illness
management
Depression
or low mood
Confidence
Symptom
management
Anxiety
or worry
Co
Treatment
administration
Self-management
Behavior
Access
Identity
Cd
Condition
Communication
with HCP
Cause
Consequences
Perceived
social
support
Cost
Side
effects
Pr
Ci
Circumstance
Necessity
Pros & Cons
What influences behavior?
CORE CONCEPT
Whilst as a practitioner or a commercial organization, your focus is on the
performance of a specific, observable behavior; this is not occurring in isolation. Being
told to exercise more frequently to reduce your likelihood of developing diabetes is
good advice. But, how does this ‘work’ in reality for the person? Do they have the
confidence to try to exercise? Do they have the resources available to them? Do
the perceived benefits of exercise outweigh the inconvenience and anxiety the
person feels? Whilst the behavior goal may seem to be a singular, overt behavior, it is
facilitated or impeded by thoughts, feelings and circumstances.
Published by Atlantis Healthcare. Copyright© of Atlantis Healthcare Group and its Subsidiaries, 2016.
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John’s story
Understanding our patients
The framework in action
In order to effectively support John in the selfmanagement of his Crohn’s disease, our team of
Health Psychology Specialists gathered evidence
relating to the clinical and psychosocial needs of
people with Crohn’s disease. Research was also
conducted directly with patients and healthcare
professionals to understand the lived experience
of the disease.
Understanding the disease area is obviously important,
but to optimize the effectiveness of interventions
we need to understand the behaviors, barriers and
facilitators that are specific to each individual.
The key self-management behaviors identified as
a priority for this population were:
Treatment
Adherence
Healthy
Eating
Smoking
Cessation
Managing
Symptoms
John is 33 years old and has been diagnosed with
Crohn’s disease for 10 years. For the past 6 months
he has been experiencing more flares and his
ability to work and socialize has been affected.
Following a visit to his doctor, he is prescribed a
new treatment and enrolled onto the accompanying
Atlantis Healthcare support program.
Accessing
Support
The fact that the specific causes of Crohn’s disease are unclear and the
unpredictability of symptoms can have a negative impact on patient perceptions
of cause, control and confidence in their healthcare team.
Published by Atlantis Healthcare. Copyright© of Atlantis Healthcare Group and its Subsidiaries, 2016.
6
Understanding John
Enrolment questions to uncover his specific behavioral
needs and support domains
John’s Profile
Primary Behavioral Need
Treatment
Adherence
Barriers
Pr
Cd
Ci
Pros & Cons
Condition
Circumstance
John’s program experience
John logs into his programme web portal, which has been tailored to his
specific needs, based on the profile responses from his enrolment form.
Included are evidence-based behavior change tools and techniques, designed
by our Health Psychology Specialists, in conjunction with our Digital Creative
team, to help John overcome his barriers and achieve behavior change.
Outcomes for John
After 6 months, John has persisted with his medicine and has
a better understanding of his condition, he also feels a greater
sense of control and has less concerns about his treatment.
Overall program outcomes
persistence
33% higher
at 6 months
compared to people
prescribed the same
treatment but not on
the program.
Winner of patient
Adherence and compliance
program 2013
Pharmaceutical Marketing
European Awards; runner
up in 2015.
Published by Atlantis Healthcare. Copyright© of Atlantis Healthcare Group and its Subsidiaries, 2016.
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Summary
The self-management challenges for people
living with chronic conditions are broad and are
influenced by a range of factors, both internal and
external to the individual.
This report has outlined how when designing support
systems and programmes to aid self-management,
it is important to consider the individual and the
context within which the behaviour will occur.
foundation to determine the optimal support
structure needed in terms of condition, behaviour
and individual factors.
This series of white papers will continue to explore
how we can best ensure all stakeholders (patients,
carers, health service providers, pharma) meet the
challenges of chronic disease management.
Our next publication will focus on the role of digital
health solutions and how these can be optimized
to achieve impactful outcomes.
The Atlantis Healthcare Self-Management
Framework utilizes an academically robust
Find out more
Further information on our self-management processes, products and technology solutions can be
obtained by contacting Atlantis Healthcare.
Atlantis Healthcare is a global leader in the creation and management of unique patient support
solutions to drive improved self-management across chronic disease, including treatment adherence
and quality of life outcomes.
For more information on Atlantis Healthcare go to:
www.atlantishealthcare.com
@AtlantisHtweets
Atlantis Healthcare
Published by Atlantis Healthcare. Copyright© of Atlantis Healthcare Group and its Subsidiaries, 2016.
References
1.
Gruman, J., & Von Korff, M. (1996). Indexed bibliography on Self-management for People with Chronic Disease. Washington, DC:
Center for Advancement in Health.
2.
Gochman, D. S., ed. (1997). Handbook of Health Behavior Research. New York: Plenum.
3.
Conner, M and Norman, P, (1996). (eds.) Predicting Health Behaviour. Buckingham, UK: Open University Press.
Consensus Development.
4.
Lorig, K. (1993). Self-management of chronic illness: A model for the future. Generations XVII(3), 11-14.
5.
Barlow, J., Wright, C., Sheasby, J., Turner, A., & Hainsworth, J. (2002). Self-management approaches for people with chronic
conditions: A review. Patient Education and Counseling, 48, 177-187.
6.
Adams, K., Greiner, A.C., & Corrigan, J.M. (Eds). (2004). Report of a summit. The 1st annual crossing the quality chasm summit-A
focus on communities. Washington, DC: National Academies Press.
7.
The definition of self-management as developed by the Centre for Advancement of Health (Centre for the Advancement of
Health, 1996, p1).
8.
Caskey, F., Hole, B., Riaz, S., Weinman, J. & Turner, N. (2015) What I tell my patients about self-management. British Journal of
Renal Medicine, 20(4), 98-100.
9.
National Health Service (2001). The expert patient: A new approach to chronic disease management for the 21st century. London,
UK: Department of Health
10. Michie, S. F., West, R., Campbell, R., Brown, J., & Gainforth, H. (2014). ABC of behaviour change theories. Great Britain:
Silverback Publishing
11.
DiMatteo, M. R., Lepper, H. S., & Croghan, T. W. (2000). Depression is a risk factor for noncompliance with medical treatment:
meta-analysis of the effects of anxiety and depression on patient adherence. Archives of internal medicine, 160(14), 2101-2107.
12. Schotte, C. K., Van Den Bossche, B., De Doncker, D., Claes, S., & Cosyns, P. (2006). A biopsychosocial model as a guide for
psychoeducation and treatment of depression. Depression and anxiety, 23(5), 312-324.
13. Davis, R., Campbell, R., Hildon, Z., Hobbs, L., & Michie, S. (2015). Theories of behaviour and behaviour change across the social
and behavioural sciences: a scoping review. Health psychology review, 9(3), 323-344.
14. Abraham, C., & Michie, S. (2008). A taxonomy of behavior change techniques used in interventions. Health psychology, 27(3), 379.
15. Catania, J. A., Kegeles, S. M., & Coates, T. J. (1990). Towards an understanding of risk behavior: An AIDS risk reduction model
(ARRM).Health Education & Behavior, 17(1), 53-72.
16. Jackson, C., Eliasson, L., Barber, N., & Weinman, J. (2014). Applying COM-B to medication adherence. A suggested framework for
research and interventions. The European Health Psychologist, 16(1), 7-17.
17.
Cane, J., O’Connor, D., & Michie, S. (2012). Validation of the theoretical domains framework for use in behaviour change and
implementation research. Implementation Science, 7(1), 1.
ATLANTIS
HEALTHCARE
Understand.Connect.Change.
ATLANTIS
HEALTHCARE
Understand.Connect.Change.