Based in cognitive theory, self-efficacy is a person’s self-perceived belief in achieving desired outcomes and is frequently referred to in terms of managing the symptoms of a disease with confidence (198). Arnold et al. suggest that it is control over behaviours required to manage an illness (199). Bandura suggests that people’s convictions regarding their effectiveness affects their coping (200).
Page 38 of 288 He and Schunk also made the connection between the fostering of intrinsic motivations in order to cultivate competence and self-efficacy (201). O’Leary also emphasises the significance of behavioural medicine and self-efficacy in health (202). Lorig et al. discuss the need to measure self-efficacy in arthritis care and the development of a self-efficacy scale.
The self-efficacy for managing chronic disease six-item scale (Stanford) represents a validated method for the brief evaluation of the confidence with which people can manage common symptoms of chronic disease (203).
‘Empowering and engaging people is about providing the opportunity, skills and resources that people need to be articulate and empowered users of health services.’ (204, 205)
The WHO global strategy on people-centred and integrated health services (p 21) makes the empowering and engaging of people (in the statement above) their first strategic direction within their 2015 Interim report. The WHO established in 1948 clearly states its objective for all people worldwide to attain ‘the highest possible level of health’ (206). This objective appearing at the forefront (chapter1 article1 p2 of the forty-eighth edition) of the WHO basic documents. Gibson (207) describes empowerment as a
‘social process of recognizing, promoting, and enhancing people’s abilities to meet their own needs, solve their own problems, and mobilize necessary resources to take control of their own lives.’ p.359
In order to support empowerment equitably it is important to consider how to reach the whole population. Lau (208) advocates combining the knowledge of patients as experts of their illness and healthcare professionals as experts on healthcare resources. This mutual recognition of skill provides a platform for teamwork and partnership to maintain functional ability described by Holman and Lorig (209). The beginnings of academic interest in people caring for themselves and hence promoting their health developed in the seventies (210) and were espoused by the women’s movement in particular in relation to self-care skills relating to reproduction evidenced by the publication ‘Our Bodies Ourselves’ (211). In the United States a major journal relating to health promotion was published as ‘medical self-care’ for a number of years. This decade of increasingly popular self-help heralded groups encouraging learning and support to boost independence and coping with chronic illness.
Page 39 of 288 The influence of people on their health was highlighted with the success of self- help in addiction (212).
Nancy Milio discussed the impact of socio-economic circumstances and their influence on behavioural choices or lifestyles (213).
Pivotal works related to health promotion convincingly make the case for this approach below.
‘Health promotion represents a comprehensive social and political process; it not only embraces actions directed at strengthening the skills and capabilities of individuals, but also action directed towards changing social, environmental and economic conditions so as to alleviate their impact on public and individual health. Health promotion is the process of enabling people to increase control over the determinants of health and thereby improve their health. Participation is essential to sustain health promotion action.’
Organization WH. Ottawa charter. Geneva: World Health Organization. 1986. Wanless D.
The Wanless Report. Securing our Future Health: Taking a Long-Term View London:
HM Treasury. 2002.
Advised engaging people in their own health Darzi A.
High quality care for all: NHS next stage review final report: The Stationery Office; 2008.
Emphasises prevention (health promotion)
Marmot MG, Allen J, Goldblatt P, Boyce T, McNeish D, Grady M, et al.
Fair society, healthy lives: Strategic review of health inequalities in England post-2010.
2010.
Again advocates prevention as one of six strategies
Goodwin N, Smith J, Davies A, Perry C, Rosen R, Dixon A, et al., editors.
Integrated care for patients and populations: Improving outcomes by working together.
A report to the Department of Health and the NHS Future Forum London: The King’s Fund and Nuffield Trust; 2012.
Presentation of making every contact count (below)
Lawrence W, Black C, Tinati T, Cradock S, Begum R, Jarman M, et al.
‘Making every contact count’: Evaluation of the impact of an intervention to train health and social care practitioners in skills to support health behaviour change. Journal of health psychology. 2016; 21(2):138-51.
Page 40 of 288 The WHO drove forward health promotion with ‘Indicators of behaviours conducive to health promotion’ (214) and ‘Targets for health for all’ (215).
Health promotion has developed beyond public health messages of sanitation and immunisation to individual behaviours impacting health such as smoking. Kickbusch (210) refers to a definition of lifestyle proposed by WHO as ‘individual and collective experiences relating to conditions in life’ and Coreil et al. (216) suggest that in this socio-cultural context it is essential and that behaviour modification is not a personal responsibility alone. In order to promote health, individual avoidance of risks, self-monitoring and adoption of rituals enabling well-being are required within a broader supportive context. Self-care actions may be easier when ritualised as a part of everyday life.
The WHO health promotion glossary (217) defines health literacy:
‘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.’(p357)
The importance of health literacy in meeting the knowledge and care requirements of health in society are emphasised by Sørensen et al. (218). We know that deprivation is correlated with a greater burden of chronic disease (219). Deprivation is also associated with poorer literacy.
The effects of hypoxia in chronic lung diseases can result in neurophysical and neuropsychological effects with impact on cognitive ability (220). This may hamper people with respiratory disease in the acquisition and internalisation of essential information relating to their health. Cohen suggests that growth in social skills also positively relate to perceived support (221).
Reduced social contact due to ill-health may affect social skills and compound the isolation experienced acting as a compounded barrier to communication and collaboration with healthcare staff. Although Schulz and Nakamoto (222) set out to link empowerment and health literacy they fall short of actually doing so. However, they do draw attention to the interdependence of the two concepts.
Measures of health literacy and confidence in health communications exist, however, a natural reluctance to being assessed at the outset of a health encounter is a risk that could jeopardise a collaborative interaction.
Page 41 of 288 Wolfe et al. (223) concluded that shame and embarrassment was caused by a literacy evaluation undertaken in order to identify and support people with lower literacy. Consequently, sensitivity in health literacy and confidence assessment and innovative ways to address education for self-management are required. The best chronic disease management requires a level of collaboration and responsibility on the part of all those involved. Worryingly, pressure on resources may create anxiety in patients related to taking personal responsibility for their health and add to their burden of chronic disease. In an illustrative case study Bishop and Brodkey (224) highlight the pitfalls of this approach (within the United States). By disadvantaging hard to reach groups, the danger is that the very people who might benefit the most from a positive and collaborative support and education to achieve self-care and management are further marginalised. Rather than one succinct definition of motivation there are a number of constructs that reflect human diversity and the complexity of the psychology involved. A few of these constructs relevant to self-management are discussed here. Wentzel (225) suggests that a goal is ‘a cognitive representation of what it is that an individual is trying to achieve in a given situation’.
Pintrich (226) views goals as the purposes or reasons that an individual pursues a task. Perceived control is central to self-management in chronic disease.
The ability to affect personal outcomes is central to behaviour change, to the wish to take responsibility for health and to the navigation and collaboration in treatment. Staunton et al. view perceived control and intrinsic motivation as key constructs interacting in self-determined, behaviour change (227).
Understanding differences between extrinsic and intrinsic motivation are important in creating education and support materials (228). Intrinsic motivation relating to a task that is in itself rewarding in some way. In contrast, extrinsic motivation is the means to an end, the task that permits movement towards a goal. In terms of self-management learning about chronic disease might be intrinsic by assuaging curiosity, may be interesting and explain or help understand symptoms, reduce isolation through a realisation that others feel the same and increase confidence and self-worth when collaborating with health professionals.
Page 42 of 288 However, if literacy levels are low or fear is high, knowledge acquisition may be more extrinsic, more of a chore, a necessary evil in order to be able to minimise the disruption presented by ill health and affect future in terms of health.
Similarly help-seeking may seem natural to those with better communication skills where comfort is gained from interaction with a carer or health professional (an intrinsic motivation) or contrarily be viewed with trepidation, used only as a means to an end for access to prescriptions or referral to specialist care (thus extrinsic). Maslow in his theory of human motivation presents a hierarchy of needs (229). Essentially health and quality of life are based on meeting human needs. Thielke et al. advocate using Maslow’s model to help researchers, health providers and patients in evaluating health interventions (230).
Locus of control is recognised in Rotter’s social learning theory (231) reflecting the extent to which people attribute the consequences of their behaviours to external or internal factors. When related to health this is the subjective belief in control over health or illness (232). An internal locus of control reflects belief that our own behaviour affects our health. This belief is central to coping mechanisms and to self-efficacy. External locus of control and avoidance are associated with poor coping (233) and negative impact on health.
Choice as a concept has been made much of in the NHS. Unless roles and responsibilities in the clinician-patient relationship are made clear then barriers to choice ensue.
Gafni, Charles and Whelan (234) explain with clarity the opportunities and pitfalls of two models of interaction described here. The person seeking advice in the informed treatment model is informed of risks and benefits and makes their choice accordingly. In the agency model the patient delegates the health professional to make health decisions for them based on their preferences. Brief consultation times in both general practice and hospital outpatient consultation may create difficulty for physicians in utilising these models in the UK.
Page 43 of 288 Ryan and Deci (228) suggest that people can be engaged and constructive or alienated and passive depending on their social conditions. They explain that self-determination hinges on the psychological need for competence, autonomy and relatedness which in turn influence motivation or apathy.
In selecting motivators for action Sibitz et al. suggest that it is important to remember that extrinsic motivators such as bribes, coercion, fear of evaluation or failure have less motivational longevity and may cause long term harm (235), whereas intrinsic motivators, tasks which are intrinsically valued by the individual are internalised and retained more easily. In education, Cheon et al. noted that students taught in a more controlling manner display less initiative, whilst those taught with supportive autonomy (236) show greater enthusiasm, curiosity and skills which put them at an advantage in facing future challenges. Security and attachment in infants predict greater exploratory behaviour and hence Ryan and Deci’s third psychological requirement for relatedness.
Fear of being branded as incompetent, dependent or powerless affect help-seeking behaviour according to Lee (237). Seeking assistance is an interpersonal exchange requiring trust (238). By framing the request the individual has defined their vision of the issue requiring resolution. Availability of skilled assistance does not necessarily mean that this will be sought when required. Understanding the mechanisms of how help can be best provided and most frequently accessed should help design better services. Help-seeking also applies within inter-disciplinary teams and should be encouraged (239). Shared knowledge, greater efficiency, an atmosphere of collegiality and shared goals provide an environment of greater job satisfaction and teamwork, valued specialist contribution and increased individual development exposure to knowledgeable others (240).
As the burden of chronic disease increases it is inevitable that family and friends provide support between appointments (241). Awareness of family, friends and carers as part of the collaborative care team in chronic disease management is necessary to preserve those supportive structures maintaining the emotional and physical wellbeing of all concerned (242). Chronic disease often has an isolating effect, the support of a partner in life can be particularly important in sickness as well as in health (243, 244). The impact of ill health on relationships can be toxic (245) and sadly lead to separation (246).
Page 44 of 288 Social changes that have affected the duration of marital union also affect health and wellbeing (247). The geographical distribution of families can make caregiving difficult, where it is possible the responsibility brings a combination of satisfaction and stress (248, 249).
The increase of the older adult population, longevity and commensurate chronic morbidity may outstrip support available from offspring. Involvement of caregivers in education interventions is a positive way of supporting both the carers themselves and the individual cared for (250).
Discussion
The diagnosis of bronchiectasis does little to address the accompanying burden of multiple and varied associated issues including emotional, social, cognitive and economic impacts discussed by Akyil and Ergüney with relevance to Roy’s adaptation to chronic disease (118). These frequently affect roles within life, within families and perception of self and self-perceived ability to self-care and self-manage. This chapter has reviewed the foundations of a collaborative self-management approach through literature relating to a variety of chronic conditions. Models of care, sociological and psychological perspectives are summarised to form the foundation for understanding the concept of self-management and inherent barriers and opportunities affecting it. The multi-disciplinary, multi-process, multi-factorial, context-dependent basis of informed self-management are illustrated by the diagrams on pages 28, 29, 30 and 96. Of the concepts discussed, self-efficacy (a person’s self-perceived confidence in managing the symptoms of their disease) seems most appropriate as a self-reported measure of the impact of self-management.