Professor Emeritus, Medicine - Immunology & Rheumatology
Emeritus Faculty, Acad Council, Medicine - Immunology & Rheumatology
Member, Stanford Cancer Institute
DrPH, UC Berkeley Public Health, Health Education (1980)
MS, UC San Francisco, Nursing (1968)
BS, Boston University, Nursing (1964)
Community and International Work
Expert Patient Internet Project, England
Patient Education Chronic Disease
National Health Service England
Chronic Disease Pts England
Opportunities for Student Involvement
Current Research and Scholarly Interests
Outcomes (behavior, health status, health care utilization) of community based chronic disease patient education in English and Spanish.
Ongoing studies include small group diabetes self-management for Spanish speakers. Internet self-management for chronic disease, arthritis, and diabetes (3 separtate projects). Low cost mailed arthritis programs for Spanish Speakers and evaluation of an Internet based chronic disease self management program for the National Health Service (Expert Patient Program) in the UK.
Healthier Living Canada
This study will evaluate the effectiveness of an online Chronic Disease Self-Management Program for participants in Canada living with chronic health conditions. This pilot will look for improvements in health status, health behaviors and health care utilization.
Stanford is currently not accepting patients for this trial. For more information, please contact Diana Laurent, MPH, 650-723-7935.
Building Better Caregivers Online: An Online Workshop for Caregivers of Those With Traumatic Brain Injury, Post Traumatic Stress Disorder, or Alzheimer's or Other Dementia
The workshop is a 6-week online workshop for caregivers of people with traumatic brain injury, post traumatic stress disorder, or dementia. It is being conducted jointly by the Stanford Patient Education Research Center and the VA Greater Los Angeles Healthcare System and is supported by a grant from the Department of Veterans Affairs, Patient Care Services, Office of Care Management and Social Work. The goal of the study is to determine whether an online caregiver education and support workshop can have lasting beneficial effects in helping caregivers improve their self-management of health skills, stress, and improve their caregiving abilities.
Stanford is currently not accepting patients for this trial. For more information, please contact Diana Laurent, (650) 723 - 7935.
English Diabetes Self-Management Program
We propose a diabetes self-management program evaluation and dissemination project with three components. 1. A six-month randomized trial to evaluate the effect of a community-based small group Diabetes Self Management Program (DSMP) on the health related quality of life, metabolic control and health care utilization of people with type 2 diabetes. 2. A long-term (12 month) longitudinal evaluation of the same program. 3. Two 5 day workshops to train others in California in how to lead and administer the program.
Stanford is currently not accepting patients for this trial. For more information, please contact kate lorig, (650) 725 - 4617.
Doctors and Web-based Self-management Support Pilot Study
Doctors and web-based self-management support pilot study will test whether health professionals' observation of an online patient workshop on self-management of diabetes and participation in structured learning sessions on self-management strategies will change the attitudes and confidence of physicians and other health professionals regarding their willingness and ability to perform self-management interventions with patients. If this pilot suggests that attitudes and confidence levels can change, we hope to launch a larger study to examine this method of learning and its effectiveness in more detail.
Stanford is currently not accepting patients for this trial. For more information, please contact Diana Laurent, (650) 723 - 7935.
Active Living Tool Kit for Chronic Conditions
The development and pilot testing of a self-management program that would be delivered in a one time mailing.
Stanford is currently not accepting patients for this trial. For more information, please contact Kate Lorig, DrPH, 650-723-7935.
Internet Diabetes Self-Management
Diabetes is a growing health problem causing personal suffering, comorbid conditions, premature death, and high costs to the individual, the health care system and society. Many of these problems can be prevented or delayed by controlling the disease. This in turn requires daily self-management by patients. We will evaluate an Internet based small group Diabetes Self-Management Program. This program will be adapted from the Chronic Disease Self-Management Program Online, already developed and currently being evaluated by the investigators. Participants with type 2 diabetes will be randomized to participate in the Internet Program or serve as controls continuing with usual care. Treatment subjects will participate in a structured 6 week interactive web-based online class with 20-24 other participants and 2 trained peer moderators. If successful, this project will result in a new and effective means of reaching the CDC objective and more importantly in improving the quality of life and health status of people with diabetes while reducing health care utilization and thus costs.
Stanford is currently not accepting patients for this trial. For more information, please contact Diana Laurent, (650) 723 - 7935.
Cancer: Thriving and Surviving Online Workshop and Study for Cancer Survivors
Cancer: Surviving and Thriving is a 6-week workshop for cancer survivors. The overall goal of the study is to determine whether an online cancer survivor education and support workshop can have lasting beneficial effects in helping survivors improve their self-management of health skills and quality of life.
Stanford is currently not accepting patients for this trial. For more information, please contact Kathryn Plant, MPH, 650-723-4863.
Internet Chronic Disease Self-Management Program for Australia
The Internet Chronic Disease Self-Management Program (ICDSMP) is a pilot study of our existing, previous approved, Chronic Disease Self-Management Program Online. The online programme will be offered to 300 people with chronic disease in South Australia and evaluated for effectiveness, as well as satisfaction of both the South Australian peer facilitators and the participants with chronic disease. All participants will be recruited by the State of South Australia, after which they will complete informed consent and a questionnaire on a secure website housed at Stanford. They will take a 6-week online self-management program in groups of 20-25, and they fill our additional online questionnaires at 6 month and one year.
Internet Diabetes Self-Management Workshop
The purpose of this study is to determine of the effectiveness of an Internet based Diabetes Self-Management workshop for people with type II diabetes. Half of the people who complete the workshop will be invited to continue their education by participating in a email discussion group. Thus, we will be able to learn both the efficacy of the original program as well as its efficacy when reinforced by the discussion group. Diabetes is a disease that must be managed day by day by the individual with the disease. Although we know a great deal about the self-management of type II diabetes, most self-management is less than optimal. In addition, most people with diabetes do not have an opportunity to participate in formal diabetes education. This study will determine if an Internet delivered educational workshop will help people with diabetes manage their disease. Thus we will be measuring changes in behaviors, changes in symptoms and changes in HbA1c, blood pressure, cholesterol, and weight. If successful the workshop will serve as a prototype for Internet diabetes education.
Dissecting an Online Intervention for Cancer Survivors: Four Exploratory Analyses of Internet Engagement and Its Effects on Health Status and Health Behaviors
HEALTH EDUCATION & BEHAVIOR
2015; 42 (1): 32-45
The Internet has been used extensively to offer health education content and also for social support. More recently, we have seen the advent of Internet-based health education interventions that combine content with structured social networking. In many ways this is the Internet equivalent to small group interventions. While we have some knowledge about the efficacy of these interventions, few studies have examined how participants engage with programs and how that might affect outcomes. This study seeks to explore (a) the content of posts and (b) the nature of participant engagement with an online, 6-week workshop for cancer survivors and how such engagement may affect health outcomes. Using methodologies related to computational linguistics (latent Dirichlet allocation) and more standard statistical approaches, we identified (a) discussion board themes; (b) the relationship between reading and posting messages and outcomes; (c) how making, completing, or not completing action plans is related to outcome; and (d) how self-tailoring relates to outcomes. When considering all posts, emotional support is a key theme. However, different sets of themes are expressed in the first workshop post where participants are asked to express their primary concern. Writing posts was related to improved outcomes, but reading posts was less important. Completing, but not merely making, action plans and self-tailoring are statistically associated with future positive health outcomes. The findings from these exploratory studies can be considered when shaping future electronically mediated social networking interventions. In addition, the methods used here can be used in analyzing other large electronically mediated social-networking interventions.
View details for DOI 10.1177/1090198114550822
View details for Web of Science ID 000347981700005
View details for PubMedID 25288489
Effects of chronic disease self-management programs for participants with higher depression scores: secondary analyses of an on-line and a small-group program.
Translational behavioral medicine
2014; 4 (4): 398-406
Depression often accompanies chronic illness. Study aims included determining (1) the level of current depression (Patient Health Questionnaire (PHQ)-8 ≥ 10) for two sets of Chronic Disease Self-Management Programs (CDSMP) participants; (2) if depression or other outcomes improved for those with PHQ-8 ≥ 10; and (3) if outcomes differed for participants with or without depression. This study utilized longitudinal secondary data analysis of depression cohorts (PHQ-8 ≥ 10) from two independent translational implementations of the CDSMP, small-group (N = 175) and Internet-based (N = 110). At baseline, 27 and 55 % of the two samples had PHQ-8 10 or greater. This decreased to 16 and 37 % by 12 months (p < 0.001). Both depressed and non-depressed cohorts demonstrated improvements in most 12-month outcomes (pain, fatigue, activity limitations, and medication adherence). The CDSMP was associated with long-term improvements in depression regardless of delivery mode or location, and the programs appeared beneficial for participants with and without depression.
View details for DOI 10.1007/s13142-014-0277-9
View details for PubMedID 25584089
The components of action planning and their associations with behavior and health outcomes.
2014; 10 (1): 50-59
Based on the works of Kiesler and Bandura, action plans have become important tools in patient self-management programs. One such program, shown effective in randomized trials, is the Internet Chronic Disease Self-Management Program. An implementation of this program, Healthy Living Canada, included detailed information on action plans and health-related outcome measures.Action plans were coded by type, and associations between action plans, confidence in completion and completion were examined. Numbers of Action Plans attempted and competed and completion rates were calculated for participants and compared to six-month changes in outcomes using regression models.Five of seven outcome measures significantly improved at six-months. A total of 1136 action plans were posted by 254 participants in 12 workshops (mean 3.9 out of 5 possible); 59% of action plans involved exercise, 16% food, and 14% role management. Confidence of completion was associated with completion. Action plan completion measures were associated with improvements in activity limitation, aerobic exercise, and self-efficacy. Baseline self-efficacy was associated with at least partial completion of action plans.Action planning appears to be an important component of self-management interventions, with successful completion associated with improved health and self-efficacy outcomes.
View details for DOI 10.1177/1742395313495572
View details for PubMedID 23838837
Surviving and Thriving With Cancer Using a Web-Based Health Behavior Change Intervention: Randomized Controlled Trial
JOURNAL OF MEDICAL INTERNET RESEARCH
2014; 16 (2)
Given the substantial improvements in cancer screening and cancer treatment in the United States, millions of adult cancer survivors live for years following their initial cancer diagnosis and treatment. However, latent side effects can occur and some symptoms can be alleviated or managed effectively via changes in lifestyle behaviors.The purpose of this study was to test the effectiveness of a six-week Web-based multiple health behavior change program for adult survivors.Participants (n=352) were recruited from oncology clinics, a tumor registry, as well as through online mechanisms, such as Facebook and the Association of Cancer Online Resources (ACOR). Cancer survivors were eligible if they had completed their primary cancer treatment from 4 weeks to 5 years before enrollment. Participants were randomly assigned to the Web-based program or a delayed-treatment control condition.In total, 303 survivors completed the follow-up survey (six months after completion of the baseline survey) and participants in the Web-based intervention condition had significantly greater reductions in insomnia and greater increases in minutes per week of vigorous exercise and stretching compared to controls. There were no significant changes in fruit and vegetable consumption or other outcomes.The Web-based intervention impacted insomnia and exercise; however, a majority of the sample met or exceeded national recommendations for health behaviors and were not suffering from depression or fatigue at baseline. Thus, the survivors were very healthy and well-adjusted upon entry and their ability to make substantial health behavior changes may have been limited. Future work is discussed, with emphasis placed on ways in which Web-based interventions can be more specifically analyzed for benefit, such as in regard to social networking.Clinicaltrials.gov NCT00962494; http://www.clinicaltrials.gov/ct2/show/NCT00962494 (Archived by WebCite at http://www.webcitation.org/6NIv8Dc6Q).
View details for DOI 10.2196/jmir.3020
View details for Web of Science ID 000332397500009
View details for PubMedID 24566820
Effectiveness of the Chronic Disease Self-Management Program for Persons with a Serious Mental Illness: A Translation Study
COMMUNITY MENTAL HEALTH JOURNAL
2014; 50 (1): 96-103
Evaluation of evidence-based interventions in new settings and new populations is the hallmark of successful translation. We evaluated the Chronic Disease Self-Management Program in persons with serious mental illness who were receiving care through Michigan Community Mental Health Services (N = 139). At 6-months, participants demonstrated improvements in health indicators (fatigue, quality of life, sleep, depression, health distress, and days health bad) and health behaviors (medical adherence and communication with doctor). The program was successfully administrated in a "real world" setting and continues to be used. In addition, the program appears to be an effective resource for people with serious mental illness.
View details for DOI 10.1007/s10597-013-9615-5
View details for Web of Science ID 000330123500014
View details for PubMedID 23748554
Successes of a National Study of the Chronic Disease Self-Management Program Meeting the Triple Aim of Health Care Reform
2013; 51 (11): 992-998
Emerging health care reform initiatives are of growing importance amidst concerns about providing care to increasing numbers of adults with multiple chronic conditions. Evidence-based self-management strategies are recognized as central to managing a variety of chronic diseases by improving the medical, emotional, and social role management demands of chronic conditions.To examine the effectiveness of the Chronic Disease Self-Management Program (CDSMP) among a national sample of participants organized around the Triple Aim goals of better health, better health care, and better value in terms of reduced health care utilization.Utilizing data collected from small-group CDSMP workshops, baseline, 6-month, and 12-month assessments were examined using 3 types of mixed-effects models to provide unbiased estimates of intervention effects.Data were analyzed from 1170 community-dwelling CDSMP participants.Triple Aim-related outcome measures: better health (eg, self-reported health, pain, fatigue, depression), better health care (eg, patient-physician communication, medication compliance, confidence completing medical forms), and better value [eg, reductions in emergency room (ER) visits and hospitalizations in the past 6 mo].Significant improvements for all better health and better health care outcome measures were observed from baseline to 12-month follow-up. The odds of ER visits significantly reduced from baseline to 12-month follow-up, whereas significant reductions in hospitalization were only observed from baseline to 6-month follow-up.This National Study of CDSMP (National Study) demonstrates the successful translation of CDSMP into widespread practice and its potential for helping the nation achieve the triple aims of health care reform.
View details for DOI 10.1097/MLR.0b013e3182a95dd1
View details for Web of Science ID 000326033800007
View details for PubMedID 24113813
National Study of Chronic Disease Self-Management Six-Month Outcome Findings
JOURNAL OF AGING AND HEALTH
2013; 25 (7): 1258-1274
To investigate how the Chronic Disease Self-Management Program (CDSMP) changes health outcomes, lifestyle behaviors, and health care service utilization over a 6 month period.The participants were 1,170 adults enrolled in the National Study of CDSMP in 2010-2012 (M age=65.4 years). Six-month assessments were available for 903 participants. Linear mixed models and generalized linear mixed models were used to assess the changes between baseline and 6-month assessment for primary and secondary outcomes among CDSMP participants.Social/role activities limitations, depression, and communication with physicians improved significantly from baseline to 6-month follow-up. Study participants reported significant improvements in more physical activity and less emergency room (ER) visits and hospitalization during that period.Nationally, CDSMP not only improves health outcomes and lifestyle behaviors but also decreases costly ER visits and hospitalization. Geriatricians and other primary care providers should be encouraged to refer patients with chronic conditions to such self-management programs.
View details for DOI 10.1177/0898264313502531
View details for Web of Science ID 000324317900009
View details for PubMedID 24029414
Effectiveness of a Generic Chronic Disease Self-Management Program for People With Type 2 Diabetes A Translation Study
2013; 39 (5): 655-663
PurposeThe purpose of the study was to determine the feasibility and efficacy of a generic chronic disease self-management program for people with type 2 diabetes.MethodsEnglish-speaking adults with type 2 diabetes who were part of a larger US national translation study of the Stanford Chronic Disease Self-Management Program (CDSMP) were invited to be part of the current study. In addition to completing self-report questionnaires, participants submitted blood samples at baseline, 6 months, and 12 months. Of the 114 participants, half had A1C values between 6% and 6.9% and half had values of 7.0% or more.ResultsAdults with diabetes successfully participated in CDSMP workshops in a community health setting. Participants demonstrated statistically significant improvements in health indicators and behaviors but no reductions in health care utilization. Participants with A1C of 7% and above had A1C reductions at 6 months, with smaller reductions at 12 months. Those with baseline A1C less than 7% had no changes in A1C at 6 or 12 months.ConclusionsThe results suggest that the CDSMP is a useful and appropriate program for lowering A1C among those with A1C above 7% and for improving health status for people with diabetes, regardless of their A1C.
View details for DOI 10.1177/0145721713492567
View details for Web of Science ID 000324832200008
View details for PubMedID 23782621
Coding and Evaluating Facilitator Posts for an Online Cancer Survivor Workshop
JOURNAL OF PSYCHOSOCIAL ONCOLOGY
2013; 31 (2): 219-234
One-hundred and forty-five people attended six online cancer survivor workshops. Each workshop was monitored by two facilitators, who generated a total of 1,537 online posts. The authors developed a scheme for coding facilitator posts, combining grounded codes with categories developed by Spiegel and Classen for coding therapist responses in cancer support groups. Participants received a mean of 10.6 facilitator posts. Improvement in two health outcomes (practice of mental relaxation and illness intrusiveness) were significantly correlated with supportive posts and total number of posts. The coding scheme was easily applied and appears reliable. The data suggests that more facilitation is better.
View details for DOI 10.1080/07347332.2012.761321
View details for Web of Science ID 000316331100007
View details for PubMedID 23514256
Development and Feasibility of a Self-management Intervention for Chronic Obstructive Pulmonary Disease Delivered With Motivational Interviewing Strategies
JOURNAL OF CARDIOPULMONARY REHABILITATION AND PREVENTION
2013; 33 (2): 113-122
Self-management is proposed as the standard of care in chronic obstructive pulmonary disease (COPD), but details of the process and training required to deliver effective self-management are not widely available. In addition, recent data suggest that patient engagement and motivation are critical ingredients for effective self-management. This article carefully describes a self-management intervention using motivational interviewing skills, aimed to increase engagement and commitment in severe COPD patients.The intervention was developed and pilot tested for fidelity to protocol, for patient and interventionist feedback (qualitative) and effect on quality of life. Engagement between patient and interventionists was measured by the Working Alliance Inventory. The intervention was refined on the basis of the results of the pilot study and delivered in the active arm of a prospective randomized study.The pilot study suggested improvements in quality of life, fidelity to theory, and patient acceptability. The refined self-management intervention was delivered 540 times in the active arm of a randomized study. We observed a retention rate of 86% (patients missing or not available for only 14% the scheduled encounters).A self-management intervention that includes motivational interviewing as the way if guiding patients into behavior change is feasible in severe COPD and may increase patient engagement and commitment to self-management. This provides a very detailed description of the process for the specifics of training and delivering the intervention, which facilitates replicability in other settings and could be translated to cardiac rehabilitation.
View details for DOI 10.1097/HCR.0b013e318284ec67
View details for Web of Science ID 000315595600008
View details for PubMedID 23434613
The South Australia Health Chronic Disease Self-Management Internet Trial
HEALTH EDUCATION & BEHAVIOR
2013; 40 (1): 67-77
To evaluate the effectiveness of an online chronic disease self-management program for South Australia residents.Data were collected online at baseline, 6 months, and 12 months. The intervention was an asynchronous 6-week chronic disease self-management program offered online. The authors measured eight health status measures, seven behaviors, and four utilization measures; self-efficacy; and health care satisfaction.Two hundred fifty-four South Australian adults with one or more chronic conditions completed baseline data. One hundred forty-four completed 6 months and 194 completed 1 year. Significant improvements (p < .05) were found at 6 months for four health status measures, six health behaviors, self-efficacy, and visits to emergency departments. At 12 months, five health status indicators, six health behaviors, self-efficacy, and visits to emergency departments remained significant. Satisfaction with health care trended toward significance.The peer-led online program was both acceptable and useful for this population. It appeared to decrease symptoms, improve health behaviors, self-efficacy, and reduce health care utilization up to 1 year. This intervention also has large potential implications for the use of a public health education model for reaching large numbers of people. It demonstrates that an Internet self-management program, which includes social media, can reach rural and underserved people as well as be effective and reduce health care costs. If this intervention can be brought to scale, it has the potential for improving the lives of large numbers of people with chronic illness. It represents a way the medical care and public health sectors can interact.
View details for DOI 10.1177/1090198112436969
View details for Web of Science ID 000330294000009
View details for PubMedID 22491008
Web-based self-management support training for health professionals: A pilot study
PATIENT EDUCATION AND COUNSELING
2013; 90 (1): 29-37
To evaluate a web-based self-management training for health professionals. Patients spend 99% of their time outside the healthcare system. Thus self-management support from health professionals is central to optimal care. Our objective was to teach health professionals the skills to provide this support.Primary care residents and practicing providers enrolled in six groups. Each group received four web-based interactive training sessions derived from self-efficacy theory. Retrospective-pre/post assessed changes in self-management beliefs and confidence. Wilcoxon signed-rank tests with Bonferroni correction compared responses. Focus groups solicited qualitative feedback.Fifty-seven residents and providers across the United States enrolled. Residents demonstrated positive changes on all belief questions (P 0.001-0.012). Practicing providers had a non-significant positive change on one and significant changes on the remainder (P 0.001-0.018). Both types of participants demonstrated significant increases on confidence questions regarding their ability to support self-management (P<0.01 for all). Participants described learned techniques as being useful, reducing burnout, and increasing acceptance of patient involvement in care planning.The web-based self-management support training for health professionals was feasible and changed beliefs and confidence.The program may maximize patient self-management by increasing provider self-efficacy and skill for self-management support.
View details for DOI 10.1016/j.pec.2012.09.003
View details for Web of Science ID 000314012100006
View details for PubMedID 23031610
- Patient-Centered Care: Depends on the Point of View HEALTH EDUCATION & BEHAVIOR 2012; 39 (5): 523-525
- Building Better Caregivers: A Pilot Online Support Workshop for Family Caregivers of Cognitively Impaired Adults JOURNAL OF APPLIED GERONTOLOGY 2012; 31 (3): 423-437
- The dos and don'ts of patient engagement in busy office practices. The Journal of ambulatory care management 2012; 35 (2): 129-132
Moderators of chronic disease self-management programs: who benefits?
2011; 7 (2): 162-172
The Stanford University Chronic Disease Self-Management Program (CDSMP) has resulted in moderate beneficial outcomes in randomized controlled trials. A study of a modified CDSMP in England suggested that younger participants, those with lower initial self-efficacy and those with greater depression benefited most from the program.Using data from previous CDSMP programs in English and Spanish, we examined whether there were statistically significant interactions between baseline statuses (demographic, disease and health status variables) and randomization (intervention or usual-care control) in estimating 6-month changes in health status (health distress, activity limitation/role function, self-efficacy and self-reported general health). If an interaction was found, post hoc examinations of the relationships between the baseline variables and outcomes determined the directions of the relationships.Six moderating variables were found in the original English-language CDSMP and three in the Spanish program. Each moderator was specific to only one outcome within only one of the two studies.There were no consistent moderating effects across four outcomes and two programs and little evidence to suggest that any groups should be targeted for program recruitment. The CDSMP appears to remain useful to a wide range of people with chronic illness.
View details for DOI 10.1177/1742395311399127
View details for PubMedID 21357642
The internet diabetes self-management workshop for American Indians and Alaska Natives.
Health promotion practice
2011; 12 (2): 261-270
Type 2 diabetes disproportionately affects American Indians and Alaska Natives (AI/ANs). In the larger population, patient self-management has become an increasing focus of the health care system to help reduce the impact of diabetes. However, little is known about patient self-management programs designed for AI/ANs. This study reports on the feasibility of implementing the Stanford Internet Diabetes Self-Management Workshop within the AI/AN population using a participatory research approach. This is a continuation of self-management studies to assist in meeting the needs of both patients and the health care system for health services that are effective (evidence based), efficient, and culturally appropriate. To our knowledge, this is the first study examining the effectiveness of an Internet-based diabetes patient self-management program among AI/ANs. This article reports on a pilot for a larger randomized study that is ongoing.
View details for DOI 10.1177/1524839909335178
View details for PubMedID 20534807
Online Diabetes Self-Management Program A randomized study
2010; 33 (6): 1275-1281
We hypothesized that people with type 2 diabetes in an online diabetes self-management program, compared with usual-care control subjects, would 1) demonstrate reduced A1C at 6 and 18 months, 2) have fewer symptoms, 3) demonstrate increased exercise, and 4) have improved self-efficacy and patient activation. In addition, participants randomized to listserve reinforcement would have better 18-month outcomes than participants receiving no reinforcement.A total of 761 participants were randomized to 1) the program, 2) the program with e-mail reinforcement, or 3) were usual-care control subjects (no treatment). This sample included 110 American Indians/Alaska Natives (AI/ANs). Analyses of covariance models were used at the 6- and 18-month follow-up to compare groups.At 6 months, A1C, patient activation, and self-efficacy were improved for program participants compared with usual care control subjects (P < 0.05). There were no changes in other health or behavioral indicators. The AI/AN program participants demonstrated improvements in health distress and activity limitation compared with usual-care control subjects. The subgroup with initial A1C >7% demonstrated stronger improvement in A1C (P = 0.01). At 18 months, self-efficacy and patient activation were improved for program participants. A1C was not measured. Reinforcement showed no improvement.An online diabetes self-management program is acceptable for people with type 2 diabetes. Although the results were mixed they suggest 1) that the program may have beneficial effects in reducing A1C, 2) AI/AN populations can be engaged in and benefit from online interventions, and 3) our follow-up reinforcement appeared to have no value.
View details for DOI 10.2337/dc09-2153
View details for Web of Science ID 000279304300024
View details for PubMedID 20299481
The Health and Recovery Peer (HARP) Program: A peer-led intervention to improve medical self-management for persons with serious mental illness
2010; 118 (1-3): 264-270
Persons with serious mental illnesses (SMI) have elevated rates of comorbid medical conditions, but may also face challenges in effectively managing those conditions.The study team developed and pilot-tested the Health and Recovery Program (HARP), an adaptation of the Chronic Disease Self-Management Program (CDSMP) for mental health consumers. A manualized, six-session intervention, delivered by mental health peer leaders, helps participants become more effective managers of their chronic illnesses. A pilot trial randomized 80 consumers with one or more chronic medical illness to either the HARP program or usual care.At six month follow-up, participants in the HARP program had a significantly greater improvement in patient activation than those in usual care (7.7% relative improvement vs. 5.7% decline, p=0.03 for group *time interaction), and in rates of having one or more primary care visit (68.4% vs. 51.9% with one or more visit, p=0.046 for group *time interaction). Intervention advantages were observed for physical health related quality of life (HRQOL), physical activity, medication adherence, and, and though not statistically significant, had similar effect sizes as those seen for the CDSMP in general medical populations. Improvements in HRQOL were largest among medically and socially vulnerable subpopulations.This peer-led, medical self-management program was feasible and showed promise for improving a range of health outcomes among mental health consumers with chronic medical comorbidities. The HARP intervention may provide a vehicle for the mental health peer workforce to actively engage in efforts to reduce morbidity and mortality among mental health consumers.
View details for DOI 10.1016/j.schres.2010.01.026
View details for Web of Science ID 000278214500038
View details for PubMedID 20185272
- Some not so random thoughts about participation. The Journal of ambulatory care management 2009; 32 (4): 278-279
Mail-Delivered Arthritis Self-Management Tool Kit: A Randomized Trial and Longitudinal Followup
ARTHRITIS & RHEUMATISM-ARTHRITIS CARE & RESEARCH
2009; 61 (7): 867-875
To determine the effectiveness of an intervention Tool Kit of arthritis self-management materials to be sent once through the mail, and to describe the populations reached.Spanish speakers (n = 335), non-Hispanic English-speaking African Americans (n = 156), and other non-Hispanic English speakers (n = 404) were recruited separately and randomized within each of the 3 ethnic/racial categories to immediately receive the intervention Tool Kit (n = 458) or to a 4-month wait-list control status (n = 463). At the end of 4 months, controls were sent the Tool Kit. All subjects were followed in a longitudinal study for 9 months. Self-administered measures included health status, health behavior, arthritis self-efficacy, medical care utilization, and demographic variables. Using analyses of covariance and t-tests, analyses were conducted for all participants and for Spanish- and English-language groups.At 4 months, comparing all intervention subjects with randomized wait-list controls, there were significant (P < 0.01) benefits in all outcomes except medical care utilization and self-rated health. The results were maintained at 9 months compared with baseline. On average, the Tool Kit reached persons ages 50-56 years with 12-15 years of schooling. There were few differences between English- and Spanish-language participants in either the effectiveness or reach variables.A mailed Arthritis Self-Management Tool Kit proved effective in improving health status, health behavior, and self-efficacy variables for up to 9 months. It also reached younger persons in both English- and Spanish-language groups and Spanish speakers with higher education levels than previous studies of the small-group Arthritis Self-Management Program.
View details for DOI 10.1002/art.24587
View details for Web of Science ID 000268151100002
View details for PubMedID 19565554
Community-Based Peer-Led Diabetes Self-management A Randomized Trial
2009; 35 (4): 641-651
The purpose of this study is to determine the effectiveness of a community-based diabetes self-management program comparing treatment participants to a randomized usual-care control group at 6 months.A total of 345 adults with type 2 diabetes but no criteria for high A1C were randomized to a usual-care control group or 6-week community-based, peer-led diabetes self-management program (DSMP). Randomized participants were compared at 6 months. The DSMP intervention participants were followed for an additional 6 months (12 months total). A1C and body mass index were measured at baseline, 6 months, and 12 months. All other data were collected by self-administered questionnaires.At 6 months, DSMP participants did not demonstrate improvements in A1C as compared with controls. Baseline A1C was much lower than in similar trials. Participants did have significant improvements in depression, symptoms of hypoglycemia, communication with physicians, healthy eating, and reading food labels (P < .01). They also had significant improvements in patient activation and self-efficacy. At 12 months, DSMP intervention participants continued to demonstrate improvements in depression, communication with physicians, healthy eating, patient activation, and self-efficacy (P < .01). There were no significant changes in utilization measures.These findings suggest that people with diabetes without elevated A1C can benefit from a community-based, peer-led diabetes program. Given the large number of people with diabetes and lack of low-cost diabetes education, the DSMP deserves consideration for implementation.
View details for DOI 10.1177/0145721709335006
View details for Web of Science ID 000268306800009
View details for PubMedID 19407333
Content and Frequency of Writing on Diabetes Bulletin Boards: Does Race Make a Difference?
JOURNAL OF MEDICAL INTERNET RESEARCH
2009; 11 (2)
Diabetes-related disparities are well documented among racial minority groups in the United States. Online programs hold great potential for reducing these disparities. However, little is known about how people of different races utilize and communicate in such groups. This type of research is necessary to ensure that online programs respond to the needs of diverse populations.This exploratory study investigated message frequency and content on bulletin boards by race in the Internet Diabetes Self-Management Program (IDSMP). Two questions were asked: (1) Do participants of different races utilize bulletin boards with different frequency? (2) Do message, content, and communication style differ by race? If so, how?Subjects were drawn by purposeful sampling from participants in an ongoing study of the effectiveness of the IDSMP. All subjects had completed a 6-week intervention that included the opportunity to use four diabetes-specific bulletin boards. The sample (N = 45) consisted of three groups of 15 participants, each who self-identified as American Indian or Alaskan Native (AI/AN), African American (AA), or Caucasian, and was stratified by gender, age, and education. Utilization was assessed by counting the number of messages per participant and the range of days of participation. Messages were coded blindly for message type, content, and communication style. Data were analyzed using descriptive and nonparametric statistics.In assessing board utilization, AAs wrote fewer overall messages (P = .02) and AIs/ANs wrote fewer action planning posts (P = .05) compared with Caucasians. AIs/ANs logged in to the program for a shorter time period than Caucasians (P = .04). For message content, there were no statistical (P
View details for DOI 10.2196/jmir.1153
View details for Web of Science ID 000274632700006
View details for PubMedID 19632975
The Expert Patients Programme online, a 1-year study of an Internet-based self-management programme for people with long-term conditions.
2008; 4 (4): 247-256
Evaluate the effectiveness of an online self-management programme (EPP Online) for England residents with long-term conditions.A prospective longitudinal study. Data were collected online at baseline, 6 and 12 months. The intervention was an asynchronous 6-week chronic-disease self-management programme offered online. We measured seven health status measures (health distress, self-rated health, illness intrusiveness, disability, fatigue, pain and shortness of breath), four behaviours (aerobic exercise, stretching exercise, stress management and communications with physician), and five utilization measures (GP visits, pharmacy visits, PT/OT visits, emergency visits and hospitalizations). We also measured self-efficacy and satisfaction with the health care system.A total of 568 completed baseline data: 546 (81%) completed 6 months and 443 (78%) completed 1 year. Significant improvements (p < 0.01) were found at 6 months for all variables except self-rated health, disability, stretching, hospitalizations and nights in hospital. At 12 months only decrease in disability, nights in hospital and hospitalizations were not significant with reduction in visits to emergency departments being marginally significant (p = 0.012). Both self-efficacy and satisfaction with the health care system improved significantly.The peer-led online programme conditions appears to decrease symptoms, improve health behaviours, self-efficacy and satisfaction with the health care system and reducing health care utilization up to 1 year.
View details for DOI 10.1177/1742395308098886
View details for PubMedID 19091933
The Internet-based Arthritis Self-Management Program: A one-year randomized trial for patients with arthritis or fibromyalgia
ARTHRITIS & RHEUMATISM-ARTHRITIS CARE & RESEARCH
2008; 59 (7): 1009-1017
To determine the efficacy of an Internet-based Arthritis Self-Management Program (ASMP) as a resource for arthritis patients unable or unwilling to attend small-group ASMPs, which have proven effective in changing health-related behaviors and improving health status measures.Randomized intervention participants were compared with usual care controls at 6 months and 1 year using repeated-measures analyses of variance. Patients with rheumatoid arthritis, osteoarthritis, or fibromyalgia and Internet and e-mail access (n = 855) were randomized to an intervention (n = 433) or usual care control (n = 422) group. Measures included 6 health status variables (pain, fatigue, activity limitation, health distress, disability, and self-reported global health), 4 health behaviors (aerobic exercise, stretching and strengthening exercise, practice of stress management, and communication with physicians), 5 utilization variables (physician visits, emergency room visits, chiropractic visits, physical therapist visits, and nights in hospital), and self-efficacy.At 1 year, the intervention group significantly improved in 4 of 6 health status measures and self-efficacy. No significant differences in health behaviors or health care utilization were found.The Internet-based ASMP proved effective in improving health status measures at 1 year and is a viable alternative to the small-group ASMP.
View details for DOI 10.1002/art.23817
View details for Web of Science ID 000257602000015
View details for PubMedID 18576310
Spanish diabetes self-management with and without automated telephone reinforcement - Two randomized trials
2008; 31 (3): 408-414
To determine 1) whether participants in the Spanish Diabetes Self-Management Program (SDSMP), when compared at 6 months to randomized control subjects, would demonstrate improvements in health status, health behaviors, and self-efficacy; and 2) whether SDSMP participants receiving monthly automated telephone reinforcement would maintain improvements at 18 months better than those not receiving reinforcement.A total of 567 Spanish-speaking adults with type 2 diabetes were randomized to a usual-care control group or 6-week community-based, peer-led SDSMP. SDSMP participants were re-randomized to receive 15 months of automated telephone messages or no reinforcement. A1C was measured at baseline and 6 and 18 months. All other data were collected by self-administered questionnaires.At 6 months SDSMP participants compared with control subjects demonstrated improvements in A1C (-0.4%), health distress, symptoms of hypo- and hyperglycemia, and self-efficacy (P < 0.05). At 18 months all improvements persisted (P < 0.05). SDSMP participants also demonstrated improvements in self-rated health and communication with physicians, had fewer emergency room visits (-0.18 visits in 6 months, P < 0.05), and trended toward fewer visits to physicians. At 18 months the only difference between reinforced and nonreinforced participants was increased glucose monitoring for the reinforcement group.The SDSMP demonstrated effectiveness in lowering A1C and improving health status. Reinforcement did not add to its effectiveness. Given the high needs of the Spanish-speaking population, the SDSMP deserves consideration for implementation.
View details for DOI 10.2337/dc07-1313
View details for Web of Science ID 000253801100006
View details for PubMedID 18096810
Participation in patient self-management programs
ARTHRITIS & RHEUMATISM-ARTHRITIS CARE & RESEARCH
2007; 57 (5): 851-854
Participation in evidenced-based arthritis self-management programs (SMPs) has not been well documented. The purpose of this study was to investigate the participation rate and participant characteristics in a closed cohort of subjects in a geographic region where arthritis SMPs have been offered multiple times and continuously for 2 decades.Data were from osteoarthritis (OA) and rheumatoid arthritis subjects participating in the Arthritis, Rheumatism, and Aging Medical Information System (ARAMIS) who resided in the San Francisco (SF) Bay area who had responded to questions about ever participating in an SMP. Differences between participants and nonparticipants were examined by t-tests and chi-square tests.Questions added to the Health Assessment Questionnaire were returned by 1,176 patients; 618 resided in the SF Bay area. Of the SF Bay area sample, 41.9% had participated in an SMP. Small group SMPs, which had been offered multiple times, in diverse settings, continuously over the past 2 decades, were attended by the highest proportion (28%) of participants. Characteristics of participants and nonparticipants in the SF Bay area were similar ( approximately 70 years old, 15 years of education, and the majority had OA [ approximately 72%]). However, a higher proportion of participants were white (88% versus 82%; P = 0.046) and female (82% versus 73%; P < 0.05).When arthritis SMPs were offered multiple times in diverse settings and continuously over many years, >40% of the cohort was reached. More research is needed with larger samples and different geographic regions to identify participation rates in more diverse populations.
View details for DOI 10.1002/art.22776
View details for Web of Science ID 000247129900022
View details for PubMedID 17530686
Does self-management lead to sustainable health benefits in people with arthritis? A 2-year transition study of 452 Australians
JOURNAL OF RHEUMATOLOGY
2007; 34 (5): 1112-1117
To evaluate the Arthritis Self-Management Course (ASMC) when applied in a nationwide context.Four hundred fifty-two people who participated in the ASMC across Australian states took part in a longitudinal followup study. ASMC is a 6 week, 2 h group educational program designed to assist people with chronic illness to better manage their condition. Measures of program effectiveness included health status and service utilization. Data were collected on 3 occasions: before intervention (baseline) and 6 months and 2 years after the program.Several indicators of health status showed improvement at 6 months following the ASMC. These included reduction in pain (4%; p < 0.001), fatigue (3%; p < 0.01), and health distress (12%; p < 0.001) as well as increase in self-efficacy (6%; p < 0.001). Increased self-efficacy was a significant predictor of positive change in health status. Health-related behaviors such as aerobic exercise also increased, with the proportion of people who did little or no exercise decreasing by up to 8%. These changes were sustained at 2 years. There was an increase in use of analgesics at 6 months and an increase in use of nonsteroidal antiinflammatory drugs at 2 years. No changes in healthcare utilization (physician visits, allied health visits, and hospitalizations) were observed.The ASMC is a widely applied program in which participants benefit through a reduction in pain, fatigue, and health distress. Although the absolute changes in health status are small, the low cost and wide application of the intervention suggests the program may have a substantial public health effect.
View details for Web of Science ID 000246230700031
View details for PubMedID 17343319
Internet-based chronic disease self-management - A randomized trial
2006; 44 (11): 964-971
The small-group Chronic Disease Self-Management Program (CDSMP) has proven effective in changing health-related behaviors and improving health statuses. An Internet-based CDSMP was developed to reach additional chronic-disease patients.We sought to determine the efficacy of the Internet-based CDSMP.We compared randomized intervention participants with usual-care controls at 1 year. We compared intervention participants with the small-group CDSMP at 1 year.Nine-hundred fifty-eight patients with chronic diseases (heart, lung, or type 2 diabetes) and Internet and e-mail access were randomized to intervention (457) or usual care control (501).Measures included 7 health status variables (pain, shortness of breath, fatigue, illness intrusiveness, health distress, disability, and self-reported global health), 4 health behaviors (aerobic exercise, stretching and strengthening exercise, practice of stress management, and communication with physicians), 3 utilization variables (physician visits, emergency room visits, and nights in hospital), and self-efficacy.At 1 year, the intervention group had significant improvements in health statuses compared with usual care control patients. The intervention group had similar results to the small-group CDSMP participants. Change in self-efficacy at 6 months was found to be associated with better health status outcomes at 1 year.The Internet-based CDSMP proved effective in improving health statutes by 1 year and is a viable alternative to the small-group Chronic Disease Self Management Program.
View details for Web of Science ID 000241956600002
View details for PubMedID 17063127
- Action planning: A call to action JOURNAL OF THE AMERICAN BOARD OF FAMILY MEDICINE 2006; 19 (3): 324-325
Measurement of pain using the visual numeric scale
JOURNAL OF RHEUMATOLOGY
2006; 33 (3): 574-580
We introduce the English-language Visual Numeric Scale (VNS) for self-reported pain and examine its psychometric properties; we compare the VNS to the better known Visual Analog Scale (VAS).We developed the VNS, which combines strong visual cues with an 11-point numeric rating scale. The VNS was administered to 2 sets of subjects with arthritis or chronic disease (N = 175, N = 192, respectively) and responses were examined. To compare the VNS to the VAS, we administered both scales to all subjects and used correlations to compare them to each other and to health distress and overall general health scores. A subset of respondents enrolled in an arthritis self-management program were given the VNS 4 months later, and change scores were used to test the sensitivity of the VNS.The VNS had means of 5.4 and 5.6 in the 2 samples, with distributions across the range of possible values. The VNS correlated well with the VAS (r = 0.85) and correlated slightly better than the VAS with the 2 independent health measures. The VNS was more likely to be completed than the VAS and there were fewer coding errors with the VNS. The VNS showed a significant (effect size 0.28) positive change for participants in a self-management course.The VNS appeared to be a valid measure. It was as successful as the VAS in measuring the underlying pain variable. It was easier to administer and code than the VAS, and was sensitive to change in pain.
View details for Web of Science ID 000235749200023
View details for PubMedID 16511926
A disease-specific self-help program compared with a generalized chronic disease self-help program for arthritis patients
ARTHRITIS & RHEUMATISM-ARTHRITIS CARE & RESEARCH
2005; 53 (6): 950-957
Both the Arthritis Self-Management Program (ASMP) and the generic Chronic Disease Self-Management Program (CDSMP) have been shown to be successful in improving conditions in patients with arthritis. This study compared the relative effectiveness of the 2 programs for individuals with arthritis.Patients whose primary disease was arthritis were randomized to the ASMP (n = 239) or to the CDSMP (n = 116). Analyses of covariance were used to compare the outcome measures for the 2 programs at 4 months and 1 year. Measures included quality of life outcomes (self reported, health distress, disability, activity limitation, global health, pain, and fatigue), health behaviors (practice of mental stress management, stretching and strength exercise, aerobic exercise), self efficacy, and health care utilization (physician visits and hospitalizations).Both programs showed positive results. The disease-specific ASMP appeared to have advantages over the more generic CDSMP for patients with arthritis at 4 months. These advantages had lessened slightly by 1 year.The disease-specific ASMP should be considered first where there are sufficient resources and participants. However, both programs had positive effects, and the CDSMP should be considered a viable alternative.
View details for DOI 10.1002/art.21604
View details for Web of Science ID 000234086100021
View details for PubMedID 16342084
A national dissemination of an evidence-based self-management program: a process evaluation study
PATIENT EDUCATION AND COUNSELING
2005; 59 (1): 69-79
While evidence exists regarding the effectiveness of many health education interventions, few of these evidence-based programs have been systematically or widely disseminated. This paper reports on the dissemination of one such intervention, the 6-week peer-led Chronic Disease Self-Management Program, throughout a large health-care system, Kaiser Permanente. We describe the dissemination process and, using qualitative analysis of interviews and surveys, discuss the factors that aided and hindered this process and make recommendations for similar dissemination projects. Six years after the beginning of the dissemination process, the program is integrated in most of the Kaiser Permanente regions and is being offered to several thousand people a year.
View details for DOI 10.1016/j.pec.2004.10.002
View details for Web of Science ID 000232860700008
View details for PubMedID 16198220
The impact of a moderated e-mail discussion group on use of complementary and alternative therapies in subjects with recurrent back pain
PATIENT EDUCATION AND COUNSELING
2005; 58 (3): 305-311
The purpose was to examine whether or not participation in an e-mail discussion group would affect use of selected complementary and alternative medicine (CAM) modalities during an Internet-based, 1-year randomized, controlled trial on back pain management.Intervention subjects (n = 190) participated in a closed, moderated e-mail discussion group; control subjects (n = 231) received usual care. At 1 year, we compared CAM use over the previous 6-month period during which intervention subjects had had interactive discussions about them. Differences in CAM use between groups were compared using Chi-square and t-tests.Subjects did not differ statistically between groups (p > 0.05). They were Caucasian (approximately 91%), male (approximately 60%), in their mid-40s, well educated, had approximately 13 years back pain duration, a disability level approximately 10 (Roland-Morris scale: 0-23; 23 = worst), and >80% had used the Internet for greater than a year before the randomized trial. During the study period, only small proportions in either group had initiated use of glucosamine (13% versus 8%), chiropractic services (5% versus 4%), acupuncture (3%, both), yoga (6% versus 4%), or magnets (6%, both).Results suggest that participation in interactive discussions over the Internet about these CAM modalities may not affect their use.
View details for DOI 10.1016/j.pec.2004.08.012
View details for Web of Science ID 000231834800011
View details for PubMedID 16122642
Outcomes of border health Spanish/English chronic disease self-management programs
2005; 31 (3): 401-409
The purpose of this study was to evaluate the community-based Chronic Disease Self-management Program (CDSMP) and the Spanish-language version (Tomando Control de Su Salud) programs as delivered in settings along the Texas/New Mexico/Mexico border. The programs had proven effective in randomized trials, and the authors wished to determine if they would be as effective when administered by others to different populations.The El Paso Diabetes Association administered the CDSMP and Tomando to 445 persons with chronic illness (two thirds with diabetes) in Texas, New Mexico, and Mexico. Four-month and 1-year outcomes were compared to baseline using t tests of change scores. Regression models were used to test whether baseline demographics and self-efficacy were associated with positive outcomes of the programs.Participants showed improvements in health behaviors, health status, and self-efficacy at both 4 month and 1 year. Baseline self-efficacy and 4-month change in self-efficacy were significantly associated with improved 1-year outcomes.The CDSMP and Tomando are effective when used in settings other than that of the original study for populations other than those for which they were initially developed.
View details for DOI 10.1177/0145721705276574
View details for Web of Science ID 000229360600005
View details for PubMedID 15919640
Internet versus mailed questionnaires: A randomized comparison
JOURNAL OF MEDICAL INTERNET RESEARCH
2004; 6 (3): 19-25
The use of Internet-based questionnaires for collection of data to evaluate patient education and other interventions has increased in recent years. Many self-report instruments have been validated using paper-and-pencil versions, but we cannot assume that the psychometric properties of an Internet-based version will be identical.To look at similarities and differences between the Internet versions and the paper-and-pencil versions of 16 existing self-report instruments useful in evaluation of patient interventions.Participants were recruited via the Internet and volunteered to participate (N=397), after which they were randomly assigned to fill out questionnaires online or via mailed paper-and-pencil versions. The self-report instruments measured were overall health, health distress, practice mental stress management, Health Assessment Questionnaire (HAQ) disability, illness intrusiveness, activity limitations, visual numeric for pain, visual numeric for shortness of breath, visual numeric for fatigue, self-efficacy for managing disease, aerobic exercise, stretching and strengthening exercise, visits to MD, hospitalizations, hospital days, and emergency room visits. Means, ranges, and confidence intervals are given for each instrument within each type of questionnaire. The results from the two questionnaires were compared using both parametric and non-parametric tests. Reliability tests were given for multi-item instruments. A separate sample (N=30) filled out identical questionnaires over the Internet within a few days and correlations were used to assess test-retest reliability.Out of 16 instruments, none showed significant differences when the appropriate tests were used. Construct reliability was similar within each type of questionnaire, and Internet test-retest reliability was high. Internet questionnaires required less follow-up to achieve a slightly (non-significant) higher completion rate compared to mailed questionnaires.Among a convenience sample recruited via the Internet, results from those randomly assigned to Internet participation were at least as good as, if not better than, among those assigned mailed questionnaires, with less recruitment effort required. The instruments administered via the Internet appear to be reliable, and to be answered similarly to the way they are answered when they are administered via traditional mailed paper questionnaires.
View details for Web of Science ID 000226554300006
View details for PubMedID 15471755
- Patient self-management: A key to effectiveness and efficiency in care of chronic disease PUBLIC HEALTH REPORTS 2004; 119 (3): 239-243
Long-term randomized controlled trials of tailored-print and small-group arthritis self-management interventions
2004; 42 (4): 346-354
The objective of this study was to test the effectiveness of a mail-delivered, tailored self-management intervention (SMART) and to compare it with the classic Arthritis Self-Management Program (ASMP).We performed 2 randomized controlled trials: 1) a study of 1090 participants randomized to SMART or USUAL CARE, and 2) a study of 341 participants randomized to SMART or ASMP. Dependent variables included disability, pain, depression, role function, global severity, doctor visits, and self-efficacy. SMART interventions were provided in months 0-18 and not reinforced. Results were assessed at 1, 2, and 3 years using analyses of covariance (ANCOVA).Compared with USUAL CARE, SMART participants at 1 year had decreased disability, improved role function, and increased self-efficacy (all P <0.01). At 2 years, decreases in global severity, doctor visits, and increases in self-efficacy (all P <0.01) were noted. At 3 years without reinforcement, no statistically significant effects remained. Compared with ASMP, SMART at 1 year had greater decreases in disability (P = 0.02) and increases in self-efficacy (P = 0.01). There were no differences at 2 years. At 3 years, role function (P = 0.04) and doctor visit (P = 0.03) were improved in ASMP as compared with SMART. Improvements from baseline were seen for nearly all variables in both groups.A mail-delivered arthritis self-management program, SMART, was similarly effective to the classic ASMP, with slightly better results in the first year and a slightly more rapid attenuation over the next 2 years. Results suggest that both programs are effective, and that the addition of a mail-delivered program could improve accessibility to arthritis self-management treatment.
View details for DOI 10.1097/07.mlr.0000118709.74348.65
View details for Web of Science ID 000220475800007
View details for PubMedID 15076811
Taking patient ed to the next level.
2003; 66 (12): 35-38
View details for PubMedID 14725064
Hispanic chronic disease self-management - A randomized community-based outcome trial
2003; 52 (6): 361-369
In light of health disparities and the growing prevalence of chronic disease, there is a need for community-based interventions that improve health behaviors and health status. These interventions should be based on existing theory.This study aimed to evaluate the health and utilization outcomes of a 6-week community-based program for Spanish speakers with heart disease, lung disease, or type 2 diabetes.The treatment participants in this study (n = 327) took a 6-week peer-led program. At 4 months, they were compared with randomized wait-list control subjects (n = 224) using analyses of covariance. The outcomes for all the treatment participants were assessed at 1 year, as compared with baseline scores (n = 271) using t-tests.At 4 months, the participants, as compared with usual-care control subjects, demonstrated improved health status, health behavior, and self-efficacy, as well as fewer emergency room visits (p <.05). At 1 year, the improvements were maintained and remained significantly different from baseline condition.This community-based program has the potential to improve the lives of Hispanics with chronic illness while reducing emergency room use.
View details for Web of Science ID 000186724200003
View details for PubMedID 14639082
Can a back pain e-mail discussion group improve health status and lower health care costs?
ARCHIVES OF INTERNAL MEDICINE
2002; 162 (7): 792-796
Given the high health care utilization, limited evidence for the effectiveness of back pain interventions, and the proliferation of e-mail health discussion groups, this study seeks to determine if the Internet can be used to improve health status and health care utilization for people with chronic back pain.Randomized controlled trial. Participants included 580 people from 49 states with chronic back pain having at least 1 outpatient visit in the past year, no "red-flag" symptoms, and access to e-mail. Major exclusion criteria included continuous back pain for more than 90 days causing major activity intolerance and/or receiving disability payments.Closed, moderated, e-mail discussion group. Participants also received a book and videotape about back pain. Controls received a subscription to a non-health-related magazine of their choice.Pain, disability, role function, health distress, and health care utilization.At 1-year treatment, subjects compared with controls demonstrated improvements in pain (P =.045), disability (P =.02), role function (P =.007), and health distress (P =.001). Physician visits for the past 6 months declined by 1.5 visits for the treatment group and by 0.65 visits for the control group (P =.07). Mean hospital days declined nearly 0.20 days for the treated group vs and increased 0.04 days for the control group (P =.24).An e-mail discussion group can positively affect health status and possibly health care utilization. It may have a place in the treatment of chronic recurrent back pain.
View details for Web of Science ID 000174784800008
Self-care and the doctor-patient relationship.
2002; 40 (4): II40-44
An important factor contributing to the steep rise in health care costs in the late 1960s was a reversal from the predominance of acute illness to that of chronic disease. Beginning with the philosophy of Illich and Levin, and the practical instruments of Fries, Sehnert, Vickery, and Ferguson, a new movement in patient self-care emerged. However, such programs were not integrated into organized medical care plans and though theoretically attractive had not yet proven to improve health or decrease costs.The contributions to the self-care movement made under the intellectual guidance of Halsted Holman and the relevant literature produced are reviewed.While caring for chronic rheumatic diseases, Halsted Holman discovered that patient self-report was a more powerful predictor of outcome than were traditional biologic measures such as anti-DNA antibodies. Realizing the role that patient knowledge of their own disease course might play, he developed the Arthritis Self-Management course, a lay-led self-care program emphasizing patient participation. Holman and colleagues next elucidated the pivotal importance of Bandura's theory of self-efficacy in the improved patient outcomes initially observed. These self-care techniques were woven into the structure of the Midpeninsula Health Service, showing for the first time reductions in subsequent office visits and enhanced quality. In partnership with Kaiser Health Plan, these techniques showed improvements in self-efficacy health behaviors, status, and use in a randomized trial of more than 1,000 patients.Halsted Holman and colleagues have played a seminal role in the translation of academic self-care theory into community practice.
View details for PubMedID 12064580
Self-care and the doctor-patient relationship
2002; 40 (4): 40-44
View details for Web of Science ID 000174779100007
- Partnerships between expert patients and physicians LANCET 2002; 359 (9309): 814-815
Effect of a self-management program on patients with chronic disease.
Effective clinical practice : ECP
2001; 4 (6): 256-262
For patients with chronic disease, there is growing interest in "self-management" programs that emphasize the patients' central role in managing their illness. A recent randomized clinical trial demonstrated the potential of self-management to improve health status and reduce health care utilization in patients with chronic diseases.To evaluate outcomes of a chronic disease self-management program in a real-world" setting.Before-after cohort study.Of the 613 patients from various Kaiser Permanente hospitals and clinics recruited for the study, 489 had complete baseline and follow-up data.The Chronic Disease Self-Management Program is a 7-week, small-group intervention attended by people with different chronic conditions. It is taught largely by peer instructors from a highly structured manual. The program is based on self-efficacy theory and emphasizes problem solving, decision making, and confidence building.Health behavior, self-efficacy (confidence in ability to deal with health problems), health status, and health care utilization, assessed at baseline and at 12 months by self-administered questionnaires.At 1 year, participants in the program experienced statistically significant improvements in health behaviors (exercise, cognitive symptom management, and communication with physicians), self-efficacy, and health status (fatigue, shortness of breath, pain, role function, depression, and health distress) and had fewer visits to the emergency department (ED) (0.4 visits in the 6 months prior to baseline, compared with 0.3 in the 6 months prior to follow-up; P = 0.05). There were slightly fewer outpatient visits to physicians and fewer days in hospital, but the differences were not statistically significant. Results were of about the same magnitude as those observed in a previous randomized, controlled trial. Program costs were estimated to be about $200 per participant.We replicated the results of our previous clinical trial of a chronic disease self-management program in a "real-world" setting. One year after exposure to the program, most patients experienced statistically significant improvements in a variety of health outcomes and had fewer ED visits.
View details for PubMedID 11769298
Chronic disease self-management program - 2-year health status and health care utilization outcomes
2001; 39 (11): 1217-1223
To assess the 1- and 2-year health status, health care utilization and self-efficacy outcomes for the Chronic Disease Self-Management Program (CDSMP). The major hypothesis is that during the 2-year period CDSMP participants will experience improvements or less deterioration than expected in health status and reductions in health care utilization.Longitudinal design as follow-up to a randomized trial.Community.Eight hundred thirty-one participants 40 years and older with heart disease, lung disease, stroke, or arthritis participated in the CDSMP. At 1- and 2-year intervals respectively 82% and 76% of eligible participants completed data.Health status (self-rated health, disability, social/role activities limitations, energy/fatigue, and health distress), health care utilization (ER/outpatient visits, times hospitalized, and days in hospital), and perceived self-efficacy were measured.Compared with baseline for each of the 2 years, ER/outpatient visits and health distress were reduced (P <0.05). Self-efficacy improved (P <0.05). The rate of increase is that which is expected in 1 year. There were no other significant changes.A low-cost program for promoting health self-management can improve elements of health status while reducing health care costs in populations with diverse chronic diseases.
View details for Web of Science ID 000171821000008
View details for PubMedID 11606875
Self-reports of health care utilization compared to provider records
JOURNAL OF CLINICAL EPIDEMIOLOGY
2001; 54 (2): 136-141
This study compares self-reports of medical utilization with provider records. As part of a chronic disease self-management intervention study, patients completed self-reports of their last six months of health care utilization. A subgroup of patients was selected from the larger study and their self-reports of utilization were compared to computerized utilization records. Consistent with earlier studies, patients tended to report less physician utilization than was recorded in the computerized provider records. However, they also tended to report slightly more emergency room visits than were reported in the computerized utilization records. There was no association between demographic or health variables and the tendency toward discrepancy between self-report and computerized utilization record reports. However, there was a tendency for the discrepancy to increase as the amount of record utilization increased. Thus, the likelihood of bias caused by differing demographic factors is low, but researchers should take into account that underreporting occurs and is likely to increase as utilization increases.
View details for Web of Science ID 000166819400006
View details for PubMedID 11166528
Community-based Spanish language arthritis education program - A randomized trial
1999; 37 (9): 957-963
To determine 4-month and 1-year health-related outcomes of a 6-week, lay-led, and community-based arthritis self-management program for Spanish-speaking participants and to determine the role of self-efficacy in predicting health status for this population.Three hundred and thirty one subjects were randomized to the program or to a 4-month wait list control group. One hundred ninety eight subjects continued in a 1-year longitudinal study. Data were collected via mailed questionnaires with telephone follow up.At 4 months, treatment subjects, compared with controls, demonstrated positive changes in exercise, disability, pain, and self-efficacy (P < 0.05). At 1 year, compared with baseline, treatment subjects demonstrated improvements in exercise, general health, disability, pain, self-efficacy, and depression (P < 0.05). Baseline and 4-month changes in self-efficacy predicted health status at 1 year.Spanish-speaking participants of an arthritis self-management program demonstrate short- and long-term benefits (improved health behaviors, health status, and self-efficacy).
View details for Web of Science ID 000082515500011
View details for PubMedID 10493473
Evidence suggesting that a chronic disease self-management program can improve health status while reducing hospitalization - A randomized trial
1999; 37 (1): 5-14
This study evaluated the effectiveness (changes in health behaviors, health status, and health service utilization) of a self-management program for chronic disease designed for use with a heterogeneous group of chronic disease patients. It also explored the differential effectiveness of the intervention for subjects with specific diseases and comorbidities.The study was a six-month randomized, controlled trial at community-based sites comparing treatment subjects with wait-list control subjects. Participants were 952 patients 40 years of age or older with a physician-confirmed diagnosis of heart disease, lung disease, stroke, or arthritis. Health behaviors, health status, and health service utilization, as determined by mailed, self-administered questionnaires, were measured.Treatment subjects, when compared with control subjects, demonstrated improvements at 6 months in weekly minutes of exercise, frequency of cognitive symptom management, communication with physicians, self-reported health, health distress, fatigue, disability, and social/role activities limitations. They also had fewer hospitalizations and days in the hospital. No differences were found in pain/physical discomfort, shortness of breath, or psychological well-being.An intervention designed specifically to meet the needs of a heterogeneous group of chronic disease patients, including those with comorbid conditions, was feasible and beneficial beyond usual care in terms of improved health behaviors and health status. It also resulted in fewer hospitalizations and days of hospitalization.
View details for Web of Science ID 000077870400002
View details for PubMedID 10413387
Arthritis self-management program variations: Three studies
ARTHRITIS CARE AND RESEARCH
1998; 11 (6): 448-454
1) Determine strengths and weaknesses of the Arthritis Self-Management Program (ASMP). 2) Compare 3- and 6-week ASMP. 3) Evaluate 1.5-hour arthritis program.Study 1: Qualitative methods incorporating incomplete block design. Study 2: Comparison of 3- and 6-week outcomes. Study 3: Pretest/posttest comparison.Study 1: Pain management, exercise, and sharing ranked as the most useful aspects of the ASMP. Nutrition, medications, and making decisions about nontraditional treatments ranked least useful. Study 2: Six-week ASMP subjects improved pain, health distress, illness impact, exercise, cognitive pain management, self-efficacy, and reduced visits to physicians (P < 0.05). Three-week subjects improved health distress, cognitive pain management, and self-efficacy (P < 0.05). Study 3: Improved knowledge, self-efficacy, and pain (P < 0.05).The traditional 6-week ASMP is more effective than a 3-week version. A 1.5-hour community program is effective in increasing knowledge, self-efficacy, and contact with the Arthritis Foundation.
View details for Web of Science ID 000077922300003
View details for PubMedID 10030176
- Arthritis self-efficacy scales measure self-efficacy ARTHRITIS CARE AND RESEARCH 1998; 11 (3): 155-157
[Chronic disease self-management: a model for tertiary prevention].
Kango kenkyu. The Japanese journal of nursing research
1998; 31 (1): 23-29
View details for PubMedID 10437456
- Overcoming barriers to successful aging - Self-management of osteoarthritis WESTERN JOURNAL OF MEDICINE 1997; 167 (4): 265-268
- Comparison of three methods of data collection in an urban Spanish-speaking population NURSING RESEARCH 1997; 46 (4): 230-234
Patient education interventions in osteoarthritis and rheumatoid arthritis: A meta-analytic comparison with nonsteroidal antiinflammatory drug treatment
ARTHRITIS CARE AND RESEARCH
1996; 9 (4): 292-301
To compare the effects of education interventions and nonsteroidal antiinflammatory drug (NSAID) treatment on pain and functional disability in patients with osteoarthritis (OA), and on pain, functional disability, and tender joint counts in patients with rheumatoid arthritis (RA).Two meta-analyses were performed: one of controlled trials of patient education interventions and one of placebo-controlled trials of NSAID treatments.Nineteen patient education trials comprised of 32 treatment arms and 28 NSAID trials comprised of 46 treatment arms were included. The weighted average effect size for pain was 0.17 in the education trials and 0.66 in the NSAID trials. The average effect size for functional disability was 0.03 in the education trials and 0.34 in the NSAID trials; effects of education were much larger in RA studies than in OA studies. In RA studies, the average effect size for the tender joint count was 0.34 in the education trials and 0.43 in the NSAID trials. Because most patients in the education trials were being treated with medications, the effect sizes of these trials represent the additional, or marginal, effects of patient education interventions beyond those achieved by medication.Based on this meta-analysis, patient education interventions provide additional benefits that are 20-30% as great as the effects of NSAID treatment for pain relief in OA and RA, 40% as great as NSAID treatment for improvement in functional ability in RA, and 60-80% as great as NSAID treatment in reduction in tender joint counts in RA.
View details for Web of Science ID A1996WM82600013
View details for PubMedID 8997918
TRANSLATION AND VALIDATION OF ARTHRITIS OUTCOME MEASURES INTO SPANISH
ARTHRITIS AND RHEUMATISM
1995; 38 (10): 1429-1446
To produce Spanish versions of common arthritis outcome measures: the Health Assessment Questionnaire (HAQ) Disability Scale, the Center for Epidemiologic Studies Depression Scale (CES-D), the Medical Outcomes Study (MOS) Pain Severity Scale, the Arthritis Self-Efficacy Scale for Pain and Other Symptoms (with the addition of 2 new items), the Visual Analogue Pain Scale, the MOS Self-Rated Health Item, and a Physical Activities Scale that would be usable by most Hispanics living in the US. We tested these translated measures for reliability and, where appropriate, validity.Instruments were translated and back translated by bilingual persons from 5 different countries of origin. Translators met to resolve variations in translation. The instruments were then administered to Hispanic arthritis patients in 6 geographic locations (5 in the United States and 1 in Latin America). All instruments underwent standard psychometric testing. As appropriate, the sample was stratified by level of acculturation, nation of origin, and geographic location.The translated instruments, with slight modification, met acceptable levels of reliability and validity. They are understood and easily usable by diverse Spanish-speaking populations.The availability of these translated outcome measures should enable investigators to include monolingual Spanish-speakers into their studies, and should facilitate study of cross-cultural differences with respect to these specific outcomes.
View details for Web of Science ID A1995TA57400009
View details for PubMedID 7575693
Arthritis self-help course.
HMO practice / HMO Group
1995; 9 (2): 60-61
View details for PubMedID 10143154
BALANCED INCOMPLETE BLOCK DESIGN - DESCRIPTION, CASE-STUDY, AND IMPLICATIONS FOR PRACTICE
HEALTH EDUCATION QUARTERLY
1995; 22 (2): 201-210
This article discusses the use of balanced incomplete block design for process evaluation and presents a case study of its use. This technique produces a weighted ranking of program elements, showing the relative importance of each element and allowing comparison of process and content elements. The article presents a case study in which the technique was used to evaluate the Chronic Disease Self-Management Program. Participants and lay course leaders were asked to rank 13 course elements for their helpfulness. The most valued element, sharing or unstructured interactions among participants, was not an explicitly planned part of the intervention. Some of the elements least valued (nutrition, use of community resources, and medication use) are elements most emphasized by the health care system and by patient education. We found that balanced incomplete block design was easy to administer and tally. The results could be readily applied to program redesign and to needs assessment.
View details for Web of Science ID A1995TB46400005
View details for PubMedID 7622388
EVIDENCE SUGGESTING THAT HEALTH-EDUCATION FOR SELF-MANAGEMENT IN PATIENTS WITH CHRONIC ARTHRITIS HAS SUSTAINED HEALTH BENEFITS WHILE REDUCING HEALTH-CARE COSTS
ARTHRITIS AND RHEUMATISM
1993; 36 (4): 439-446
To determine the effects of the Arthritis Self-Management Program 4 years after participation in it.Valid self-administered instruments were used to measure health status, psychological states, and health service utilization.Pain had declined a mean of 20% and visits to physicians 40%, while physical disability had increased 9%. Comparison groups did not show similar changes. Estimated 4-year savings were $648 per rheumatoid arthritis patient and $189 per osteoarthritis patient.Health education in chronic arthritis may add significant and sustained benefits to conventional therapy while reducing costs.
View details for Web of Science ID A1993KW02600002
View details for PubMedID 8457219
- ARTHRITIS SELF-MANAGEMENT STUDIES - A 12-YEAR REVIEW HEALTH EDUCATION QUARTERLY 1993; 20 (1): 17-28
THE INTEGRATION OF THEORY WITH PRACTICE - A 12-YEAR CASE-STUDY
HEALTH EDUCATION QUARTERLY
1992; 19 (3): 355-368
Although the integration of health education theory with practice has always been taught, this linkage has not always occurred as a systematic part of program or theory development. This paper reflects the 12-year experience of one health education program which started from a base not soundly grounded in theory and moved to one tightly linked with theory. Throughout this process, outcome data were collected allowing for evaluations of both practice and theory.
View details for Web of Science ID A1992JJ52800006
View details for PubMedID 1517098
Obstacles to and future goals of ten comprehensive community health promotion projects.
Journal of community health
1991; 16 (6): 299-314
Over 100 project staff, community coalition members, and other representatives from 10 comprehensive community health promotion projects in the western United States were surveyed two years into a three year funding cycle about: (1) the problems or obstacles they judged as preventing successful completion of their current goals and objectives, and (2) future goals and objectives they envisioned for their projects. The key issues confronting respondents were diverse, although issues around the process of implementing community health promotion programs were cited more frequently than issues related to the content of health promotion. When respondents were asked to prioritize Future Goals in the second survey, consensus across communities was obtained despite broad differences in the type of community surveyed and the health problem targeted. This study identifies the common organizational and community development problems faced by newly emerging community health promotion programs and has implications for other communities involved in designing, implementing, and evaluating community-wide health promotion programs.
View details for PubMedID 1774346
- HEALTH-EDUCATION FOR SELF-MANAGEMENT HAS SIGNIFICANT EARLY AND SUSTAINED BENEFITS IN CHRONIC ARTHRITIS ASSOC AMER PHYSICIANS. 1989: 204-208
THE BENEFICIAL OUTCOMES OF THE ARTHRITIS SELF-MANAGEMENT COURSE ARE NOT ADEQUATELY EXPLAINED BY BEHAVIOR-CHANGE
ARTHRITIS AND RHEUMATISM
1989; 32 (1): 91-95
Evaluation of the Arthritis Self-Management Course revealed significant positive changes in the practice of behaviors that were taught and in health outcomes. However, utilizing a variety of statistical techniques, we were able to demonstrate only weak associations between changes in behavior and changes in health status. This suggests the need to examine the mechanisms by which health education affects health status.
View details for Web of Science ID A1989R917000015
View details for PubMedID 2912467
DEVELOPMENT AND EVALUATION OF A SCALE TO MEASURE PERCEIVED SELF-EFFICACY IN PEOPLE WITH ARTHRITIS
ARTHRITIS AND RHEUMATISM
1989; 32 (1): 37-44
There is evidence that the psychological attribute of perceived self-efficacy plays a role in mediating health outcomes for persons with chronic arthritis who take the Arthritis Self-Management Course. An instrument to measure perceived self-efficacy was developed through consultation with patients and physicians and through study of 4 groups of patients. Tests of construct and concurrent validity and of reliability showed that the instrument met appropriate standards. Health outcomes and self-efficacy scores improved during the Arthritis Self-Management Course, and the improvements were correlated.
View details for Web of Science ID A1989R917000006
View details for PubMedID 2912463
LONG-TERM OUTCOMES OF AN ARTHRITIS SELF-MANAGEMENT STUDY - EFFECTS OF REINFORCEMENT EFFORTS
SOCIAL SCIENCE & MEDICINE
1989; 29 (2): 221-224
An underlying assumption of self-care interventions is that they are most effective when reinforced. To test this assumption, 8 months after baseline, 589 subjects who had taken a 6-week Arthritis Self-management Course (ASMC) were randomized to (1) receive a bi-monthly arthritis newsletter, (2) attend a new 6-week Arthritis Reinforcement Course (ARC) or (3) receive no reinforcement. Between 8 and 20 months there were no significant differences among the three randomized groups. The results were unaltered by inclusion of assumed data of no change for the 46 subjects who did not complete the full 20-month study. Between baseline and 20 months all participants reduced their pain by 20%, depression by 14%, and visits to physicians by 35% (P less than 0.01). There were no trends toward loss of these effects over time. These findings indicate that the effects of a self-care intervention were sustained over 20 months and that the tested forms of reinforcement did not alter those effects.
View details for Web of Science ID A1989AB72800012
View details for PubMedID 2665110
A COGNITIVE-BEHAVIORAL TREATMENT FOR RHEUMATOID-ARTHRITIS
1988; 7 (6): 527-544
This experiment tested a cognitive-behavioral rheumatoid arthritis treatment designed to confer skills in managing stress, pain, and other symptoms of the disease. We hypothesized that a mediator of the magnitude of treatment effects might be enhancement of perceived self-efficacy to manage the disease. It was predicted that the treatment would reduce arthritis symptoms and possibly would improve both immunologic competence and psychological functioning. The treatment provided instruction in self-relaxation, cognitive pain management, and goal setting. A control group received a widely available arthritis helpbook containing useful information about arthritis self-management. We obtained suggestive evidence of an enhancement of perceived self-efficacy, reduced pain and joint inflammation, and improved psychosocial functioning in the treated group. No change was demonstrated in numbers or function of T-cell subsets. The magnitude of the improvements was correlated with degree of self-efficacy enhancement.
View details for Web of Science ID A1988R935000004
View details for PubMedID 3063517
OUTCOMES OF SELF-HELP EDUCATION FOR PATIENTS WITH ARTHRITIS
ARTHRITIS AND RHEUMATISM
1985; 28 (6): 680-685
Behavioral and health status outcomes of an unreinforced, self-help education program for arthritis patients taught by lay persons were examined in 2 ways: a 4-month randomized experiment and a 20-month longitudinal study. At 4 months, experimental subjects significantly exceeded control subjects in knowledge, recommended behaviors, and in lessened pain. These changes remained significant at 20 months. The course was inexpensive and well-accepted by patients, physicians, and other health professionals.
View details for Web of Science ID A1985AKL3600011
View details for PubMedID 4004977
- Reasons for the lack of association between changes in health behavior and improved health status: an exploratory study. Pat. Educ. & Counsel. 1984; 2 (6): 69-72