Transcript Self-Regulation in Chronic Disease

Self-Regulation in
Chronic Disease
Noreen M. Clark, Ph.D.
March 23, 2002
The day to day manager of chronic
disease is the patient. Under best
circumstance the physician
provides guidelines for effective at
home management.
Most chronic diseases are variable
and an individual must exercise a
significant degree of judgment
regarding management.
Many factors help or hinder
individuals in their management
tasks.
Management by
Patient
Family Involvement
Clinical Expertise
Work/School Support
Community Awareness, Support & Action
Community-Wide Environmental Control Measures
Conducive Policies
Self-regulation is the means by
which people learn how to manage
disease utilizing internal resources
and external factors.
Self-regulation is a dimension of
social cognitive theory - a
comprehensive explanation of
human behavior.
Our research group has been examining
three aspects of self-regulation:
a) its constituents or elements
b) how these are integrated into a model
c) how they predict outcomes related to
chronic disease management
Patient efforts to manage asthma
and heart disease serve as the
context for studying self-regulation.
The elements of self-regulation we
have identified are:
• observation
• judgment
• reaction:
- expectation
- efficacy
These elements are very useful
constructs because means to
improve one’s capacities are
evident within them.
A Model of Self-Regulation
Internal and External Factors
Intrapersonal Factors
Judgments
• Knowledge
• Attitudes
• Feelings
• Beliefs
External Factors
• Role models
• Technical advice and service
• Social support
• Money and material resources
Observations
Reactions (outcome
expectations
& self-efficacy)
Management Strategies
Judgments
Use of Management
Strategies
• Prevention
• Disease control
Observations
Reactions
(outcome
expectations
& self-efficacy)
End Points
Judgments
End Points
• Reaching personal goals
• Physiological status
• Functioning
• Health care use
• Perceptions of quality
Observations
Reactions (outcome
expectations
& self-efficacy)
Elements of
Self-Regulation
End Points
Judgments
• Reaching personal goals
• Physiological status
• Functioning
• Health care use
• Perceptions of quality
Observations
Judgments
Intrapersonal
Factors
Judgments
• Knowledge
• Attitudes
• Feelings
• Beliefs
Use of Management
Strategies
• Prevention
Reactions
• Disease control
(outcome
expectations
& self-efficacy)
Observations
External Factors
• Role models
• Technical advice and service
• Social support
• Money and material resources
Observations
Reactions
(outcome
expectations
& self-efficacy)
Reactions (outcome
expectations
& self-efficacy)
We have conducted a number of
studies to examine the elements of
self-regulation (observation, judgment,
reaction) as presented in this model:
• stability
• predictive ability
A Study of Parent Management
of a Child’s Asthma
• N=637 families in Michigan and
New York
• Data Collection:
– Baseline
– 6 months
– 1 year later
Data Analysis
• Poisson regression models with
generalized estimated equation (GEE)
analysis (baseline to 12-month, 12 to
24-month, and baseline to 24 months).
• Previous response regarding the
outcome variables of interest and prior
and current inhaled anti-inflammatory
medication use were controlled in each
model.
Measures
Observation
• look for early warning signs
• watch child when symptoms begin
• determine if symptoms are improving
• monitor child after giving medications
* Cronbach alpha = .77
Measures
Judgment
• decide to adjust medicine
• use criteria for changing dose or type of
medicine
• distinguish from non-harmful substances
potential triggers in environment
• assess changes made in the child’s
environment
* Cronbach alpha = .62
Measures
Reaction
• Self-efficacy or confidence to:
– prevent symptoms
– keep symptoms from getting worse
– stop symptoms without an MD visit
– take care of asthma in general
* Cronbach alpha = .70
Measures
Reaction - Outcome Expectations
• Agreement that specific actions produce
results:
– give prescription medicine when symptoms
appear
– staying calm and calming the child
– getting child to rest at onset of symptoms
– identifying environmental factors
Measures
Outcome Expectations, cont’d.
– removing child from source of symptoms
– giving medications preventively
– keeping child away from irritants/ allergies
– asking for help/advice
* Cronbach alpha = .80
Management Strategies
The extent to which parents used
the specific actions described.
Intrapersonal Factors
• Asthma knowledge/beliefs
• Awareness of treatment plan
* Cronbach alpha = .82
External Factors
• Role models
• Social support
• Technical services
* Cronbach alpha = .65 -.77
Outcomes
• Quality of life
• Severity of asthma in past year
• Hospitalizations
• ED visits
• Office visits
Stable elements of Self-Regulation
Intrapersonal
Factors
Baseline
Judgment
.021
(.026)
.535
(.000)
.175
(.000)
External
Factors
Observations
.357
(.000)
.015
(.042)
Confidence
Management
Strategies
Stable elements of Self-Regulation
Intrapersonal
Factors
Follow-up 1
Judgment
.299
(.000)
.399
(.003)
.184
(.000)
External
Factors
Observations
.464
(.000)
.061
(.000)
Confidence
Management
Strategies
Stable elements of Self-Regulation
Intrapersonal
Factors
Follow-up 2
Judgment
.191
(.000)
.447
(.000)
.126
(.000)
External
Factors
Observations
. 624
(.000)
.251
(.000)
Confidence
Management
Strategies
Elements of Self-Regulation
Intrapersonal
Factors
Intrapersonal
Factors
Judgment
.021
(.026)
.535
(.000)
.175
(.000)
Judgment
Judgment
External
External
Factors
Factors
Observations
.299
(.000)
.399
(.003)
.184
(.000)
Confidence
Baseline
.161
(.000)
.447
(.000)
.126
(.000)
Factors
.624
(.000)
.464
(.000)
Management
Strategies
External
.191
(.004)
Observations
Observations
.357
(.000)
.015
(.042)
Intrapersonal
Factors
Management
Strategies
Confidence &
Outcome
Expectations
Follow-up 1
.251
(.018)
Management
Strategies
Confidence &
Outcome
Expectations
Follow-up 2
Predictive Ability of
Constructs
Baseline to two years later
Intrapersonal
Factors
External
Factors
Management
Strategies
-.290
(.000)
-.969
(.011)
.537
(.036)
Quality of
Life
Severity
Hospitalization
Judgment
-.722
(.060)
Observations
Confidence
Baseline
ED Visit
-.524
(.003)
-.394
(.007)
Follow-up
Visit
Follow-up 2
Tentative Conclusions
• Observation, judgment and
reaction are interrelated and
reciprocally reinforcing.
• Observation and judgment are
directly associated with use of
disease management strategies.
• Disease management strategies may
indirectly influence outcomes by
sharpening skills of observation and
judgment.
• Intrapersonal factors, when measured
as knowledge, beliefs and feelings, are
less important in control of asthma
than having self-regulation skills.
• Health care use is influenced by the
ability to make judgments -- Quality
of life by observation.
• External factors, perhaps because
they enhance self-regulation, are
significant in reducing severity and
health care use.
The elements of self-regulation lend
themselves to interventions for
enhancing chronic disease
management.
Focusing on self-regulation rather
than on information seems
warranted for interventions.
Specific Techniques May
Enhance Self-Regulation Skills
Observation
• Diaries
• Record keeping
• Physiologic monitoring
• Practice
Judgment
• Setting criteria
• Rehearsing decision-making
Reaction
• Self-efficacy
– realistic assessments
– social support
– role models
Reaction
• Outcome expectations
–analysis of means-ends relationships
–persuasive communicators
–role models
Self-regulation holds promise for
enabling individuals to make
optimum their control of chronic
disease.