Recommendations to Promote Patient Self-management: a Social Network Approach

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Recommendations to Promote Patient Self-management: a Social Network Approach

There is no evidence to suggest a benefit of self-management interventions on clinical endpoints in CHF at the present time and the composition of such programmes is empirically unsubstantiated.^6,24 Specialist CHF outpatient programmes have yet to demonstrate an improvement in patient adherence compared to rates achieved in primary care.²⁵ A small number of studies have observed benefits of group self-management interventions in other chronic disease settings, such as diabetes;^26,27 however, the active component/s driving success of these programmes is unknown.^14,28 We do know that patient education is not sufficient to engender self-care,^1,29 but that it may be useful when embedded in e-health programmes.³⁰

Lainscak et al² suggest that patient self-management may be improved through “comprehensive CHF education and counselling that is not only focused on knowledge, but also on skills and behaviour” (p.21). The extent to which health professionals are equipped to enact such strategies, such as to provide a “non-threatening climate and an inspiring learning atmosphere” (p.3), is varied³¹ and requires specialist education and training.³² Kennedy et al¹⁴ suggest that, even after having participated in training, healthcare staff may be resistant to engaging in interventions designed to optimise patient self-management. They recommend a systems approach to self- management that integrates support for patients, practitioners and service providers; however, evidence of efficacy and the training and resource requirements to implement such programmes are needed.

Wingham et al³³ suggest that self-management “is dependent on a range of factors including social and personal influences in conjunction with healthcare systems and health professionals” (p.150). Indeed, research suggests that the link between patient confidence and self- care^1,34 may depend on the quality of the patient–health professional relationship.³⁵ However, problematic patient-physician interactions continue to be among the most commonly reported barriers to patient self-management,³⁶ e-health strategies will likely form a pivotal role in addressing these shortfalls. Trials in progress, such as PROMETHUS³⁷, BEAT-HF³⁸ and CHF-CePPORT³⁹ will examine whether e-health platforms can overcome patient barriers, such as cognitive impairment, to improve self-management in CHF. Related work points to the potential for e-health to be integrated into patient social networks to optimise self-management.

Health-promoting, social support may improve patient self- management behaviours.^7,40,41 Vassilev et al⁴² recommend a shift in the way we conceptualise patient self-management “from individualised, behaviour-based interventions to community and network-centred approaches” (p. 73); i.e. from patient self-efficacy towards collective efficacy.⁴³ Peer-support programmes have shown improvements in patient self-management in some chronic diseases settings, such as diabetes. For example, the ROMEO trial²⁷ showed a significant benefit of group education sessions for diabetes patients, scheduled quarterly over a period of two years, on knowledge, health behaviours and quality of life outcomes compared with usual care. Reeves et al⁴⁴ found that self-management was associated with social connectedness and that the support offered by social networks was responsive to the changing needs of heart disease and diabetes patients. Although Heisler et al⁴⁵ found no benefit of a CHF peer-support programme compared to usual care on hospital readmissions or mortality, most of the participants did not engage with the programme. Poor engagement in self-management interventions, whether at the level of the patient or practitioner, is common; e-health strategies may offer a means by which to more seamlessly integrate programmes into existing systems of care, patient lifestyles, and their social networks.⁴⁶

E-health self-management interventions may improve symptom control and monitoring in chronic disease;^28,47,48 however, the long-term benefits (such as reduction in hospital admissions and mortality risk) are not yet clear. Nonetheless, there is potential to harness social networks via social media platforms to enhance self-management⁴⁹ and some evidence to support this approach in diabetes patients.⁵⁰ The Internet Chronic Disease Self-Management Program (ICDSMP) is a web-based programme with links to self-management tools and resources and social discussion forums to explore “problem solving, action planning, difficult emotions, and celebrations”.⁵¹ From baseline to 6 months post-enrolment in the ICDSMP, the authors reported a significant reduction in hospital emergency attendances, with a non-significant trend at 12 months (P=0.049); a randomised trial is needed to confirm these benefits. Other approaches, such as the PLANS initiative, use e-health platforms to tailor access to community resources as a means by which to support self-management as it is contextualised in everyday life.⁵² Future investment in randomised controlled trials will enable us to evaluate the clinical, quality of life, and economic benefits of these interventions.