It’s now accepted that self-management is critical for people with chronic conditions. But what works best? And for which conditions?

The evidence is better for some conditions than others. Also, the literature on self-management is often condition-specific, making it difficult to generalise from one area to another. 

A comprehensive meta-review of the research examined the evidence on self-management for a number of long-term conditions like diabetes, hypertension, asthma, chronic obstructive pulmonary disease, stroke and low back pain. It’s aim was to help healthcare providers better understands what works, for whom and in what setting.

General findings of the study 

Interventions work best when they have different component, can be adapted to different situations, involve different types of healthcare workers and involve collaboration and good communication between the patient and the healthcare worker. It's also important that the healthcare system encourages people to take control of their own health.

No one way to support self-management stood out. But some ‘core components’ are likely to be important in any intervention: 

Information and education about the condition 

As well as providing education the provider needs to understand what the patient already knows and believes about their condition. People will tailor medical treatment and self-management strategies to fit into their own lives and beliefs.

Giving their informal carers and workplace colleagues education and information also benefits people with chronic conditions. 

Practical and psychosocial support to help the person to adjust to life with their condition

The ways people cope and get support should fit the specific condition. For example, if the condition makes it hard to do everyday things, they should get someone to do those activities for them, or support them with ways to do them. They may need help to stick to their treatment or activities. Or if the condition might get worse, they should have a plan in place for that.

Psychological and social support is also important to help patients cope with the effects of long-term conditions.

When healthcare workers are helping someone with a condition, they should think about what that person needs right now. For example, if someone has suffered a sudden, disabling event, the priority should be to help them get back to doing daily living activities. Once that person starts to recover, they might need help to deal with their emotions when they realise they may not recover all their pre-injury abilities. 

A tailored approach

The support needs to be tailored to the patients’ existing health beliefs, preferred lifestyle and cultural background. 

A cultural shift is needed

Making sure that people get the ongoing support they need means that everyone involved in their care must change the way they think about it. As well as the patient, everyone who provides care to them needs to be committed to the idea of people taking charge of their own health.

One format isn’t better than another

Various strategies were used (groups, individual, lay-led, computerised, school or workplace) and many interventions included more than one approach. No one approach was more effective than another.

There was some evidence that interactive learning was more effective than passive education. And there was evidence that only proving education was not effective. 

Supported self-management is a hallmark of, not a substitute for, high-quality professional care

Good self-management should be an in-built part of the care that is provided to everyone with a long-term condition.

Supported self-management didn’t leave patients feeling abandoned and left to fend for themselves. Rather, they felt empowered to access the best care and support.

Healthcare providers should promote a culture where actively supporting patients to self-manage their condition is a normal, expected, monitored and rewarded aspect of care.

A whole-systems approach is needed

Leaders of the healthcare practice need to make sure that self-management is a regular part of care and that everyone involved is committed to it. They should also provide resources and training to help healthcare providers teach patients how to take care of themselves. They should also check in to see if it's working and if patients' health is improving. 

Also, the community as a whole should understands what it means to live with a chronic condition.

Findings specific to low back pain 

• Overall, the studies showed modest improvements of pain and disability in the short- and longer-term as a result of self-management interventions.
• Evidence from studies that aimed to enable patients to manage their own condition with less help from healthcare providers had small effects on pain and disability in people with low back pain
• Studies that involved intensive multidisciplinary biopsychosocial interventions and included psychological strategies showed bigger effects.
• There was little evidence that group programs that teach skills and provide education, graded activity and exercise show much effect.
• Intensive programs seem to be more effective than less intensive programs.

Patients and professionals need to be on the same page about the cause of low back pain and how it should be identified and treated. This is more likely to happen if patients feel believed, respected and listened to and involved in their education and decisions about low back pain. 

When people first start experiencing low back pain, they often go to healthcare professionals to try to get rid of the pain. But as they live with the pain for longer, they expected less and started to care more about getting help to make it easier to participate in their normal activities.

This suggests that people who have learned to live with their pain and focus on managing it, instead of trying to get rid of it completely, are more likely to be happy with the treatment they are getting, and are better able to take care of themselves.

The relationship between professional and self-management 

The study refers to a model that divides people with long-term conditions into 3 levels of need: 

• Level 1 are those with complex needs (around 5% of people) — they need more professional care and less self-management 
• Level 2 are those with a medium level of need (around 25%) — they require ‘equally shared care’
• Level 3 represents the 70% of patients with a low level of need and well controlled chronic conditions — self-management is of high importance for these people.

The authors extend this model to self-management at the individual level. They suggest that patients are responsible for:

• day-to-day lifestyle choices
• whether they adhere (or not) to advice about medication
• monitoring their condition
• recognising if their condition deteriorates and deciding on the actions they will take. 

The role of healthcare professionals is to inform, support and empower the patient to have more confidence to make clinically appropriate decisions and positive behavioural choices.

Practical lessons from the review

The authors took these lesson from the studies to help healthcare professionals support people manage their own health:

• People need to learn about their health condition and have regular check-ins with their healthcare provider.
• Patients can benefit from psychological support, counselling, strategies to solve specific problems and emotional support.
• It's hard for people (including healthcare providers) to change their habits, even if they want to. Healthcare providers need support. Promising approaches include communities of practice an, Plan Do Study Act cycles.
• Healthcare providers need training, work together as a team, have good communication and referral systems, and involve staff members in the design of self-management programs.
• Knowing about a health condition and being able to manage it are two different things.
• Not everyone wants to learn how to manage their health and some people may drop out of programs.
• People may not be able to participate in self-management programs because of issues like schedule conflicts, transportation and cost.
• People may avoid follow-up appointments if they feel like they haven't made progress.
• Telehealth can help people who have trouble participating in person.
• Staff retention is important to ensure skills in teaching self-management aren’t lost. 

Programs that are most likely to work have policies that make sure they are being used in the right way, provide resources and financial support, give healthcare providers training and can be adapted to different cultures and personal circumstances.

Original research

Taylor SJC, Pinnock H, Epiphaniou E, Pearce G, Parke HL, Schwappach A, et al. A rapid synthesis of the evidence on interventions supporting self-management for people with long-term conditions: PRISMS – Practical systematic RevIew of Self-Management Support for long-term conditions. Health Serv Deliv Res 2014, 2(53).