Interdisciplinary Research Centre in Health, School of Health & Social Sciences, Coventry University, Priory Street, Coventry CV1 5FB, UK
SIR, I wholeheartedly support the contentions concerning self-management expressed in an Editorial by Newman et al. [1], which confirms that rheumatology is among the leaders in the field of patient education, including self-management. Indeed, it is interesting to note that other disciplines (e.g. asthma and diabetes) focus mainly on managing medication, contrasting with the more holistic approach of rheumatology.
The points made by Newman et al. reiterate and affirm my own views arising from 10 yr working in the field of self-management and psychosocial rheumatology. I have frequently warned of the dangers of perceiving self-management as the current magic bullet that will provide the solution to all patients needs. As we all know, there is no one magic bullet (e.g. a drug, educational intervention or other therapeutic modality) that will resolve every patient's needs. Each patient is an individual with a unique set of circumstances, belief systems and ways of responding. A patient requires a repertoire of skills and coping strategies, as well as the confidence, knowledge and ability to select and carry out a behaviour or response that will help to meet a given need. There is no doubt that evidence-based self-management interventions are a useful method for disseminating and sharing such skills. It is likely that patients needs and circumstances will change over the course of their condition, given its long-term chronic nature. Thus, regular revision and reassessment of effective self-management skills are called for.
I certainly agree with the conclusion of Newman et al. that more attention needs to be paid to the content of interventions. The onus is on authors of studies to publish more detail about the educational content in order to share best practice with others and to prevent reinvention of the wheel.
While reviewers and grant-giving bodies expect designs to replicate the controlled circumstances of clinic-based drug trials or laboratory experiments, it remains difficult to secure research funding for educational interventions. Moreover, good quality measures that translate quality-of-life benefits for patients into economic terms are sadly lacking.
The fact that self-selection is now cited as a big issue in the self-management field suggests that self-management is coming of age. Thus, there is sufficient evidence from a range of interventions that the approach works. However, the issue of self-selection is somewhat of a red herring in relation to educational interventions, including self-management. Such interventions demand much more time, effort and soul-searching of the patient than simply popping pills. Not only do participants need to make the effort to attend an intervention, but they may also be required to do homework (e.g. exercise), read manuals or interact with computer programs. Moreover, interventions that address issues such as emotional reactions to arthritis and its consequences can prove challenging and necessitate disclosure of one's innermost thoughts to others (i.e. risky behaviour). Thus, it is not surprising that educational interventions are often evaluated using self-selected participants (i.e. volunteers who enrol on an intervention). Of course, similar arguments can be attributed to drug studies. Only patients willing to risk not knowing whether they are receiving the active drug or placebo would be willing to participate in a trial. Such patients may be those with less severe disease and a distinctive personality style. Finally, self-selection could be deemed essential in pragmatic trials that aim to represent how an intervention operates in reality outside the research setting. The key question to consider is how much time and effort those who recruit patients to interventions will be able to devote to recruitment once a trial is finished and the intervention moves into service delivery mode. Trials comparing different educational interventions (e.g. self-management vs leaflet) are currently under way and do appear in the literature, although they are few and far between.
One area that has received little attention is that of motivation to attend self-management or other educational interventions. It is likely that only a minority of people with arthritis in the UK have attended a self-management intervention. Although non-attendance will be linked to lack of availability for some patients, for many it may derive from lack of motivation to change. Thus, a key question concerns what can be done to assist people in reaching the stage at which they are interested in participation, whether this be self-management, cognitivebehavioural, self-regulation, the use of written materials or other forms of intervention. The transtheoretical model of change may be useful in this regard. This model was developed in the area of smoking cessation and has since been found to be relevant across 12 different behaviours, some of which are salient to people with arthritis (e.g. weight loss and exercise) [2]. Motivation to initiate and sustain behavioural change is represented as a series of stages (Table 1) that can be used as a basis for tailoring educational messages. Cluster analyses of patients with a confirmed diagnosis of osteoarthritis (n=74) or rheumatoid arthritis (RA; n=103) showed that the largest group (44%) comprised patients in the precontemplation stage [3]. Keefe et al. [3] suggest that interventions need to be tailored to the needs of people within each stage. Thus, precontemplaters may benefit from interventions that raise their awareness of the benefits of self-management and facilitate development of a supportive relationship with a friend, i.e. a peer with arthritis.
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