Self-management for chronic conditions in low- and middle-income countries: how can we know what works?

Self-management of chronic conditions is an approach to engaging people in their own health care. It places increased responsibility on the patient for monitoring their condition and their adherence to treatment. Wherever health systems are under resource strain, self-management is promoted as a means to increase patient investment in their treatment plan, thus improving treatment adherence and reducing use of costly services. Initiatives to support self-management have included text messaging reminders to monitor blood pressure or blood glucose, and community peer groups to support adherence to medications and lifestyle advice. More recently, the COVID-19 pandemic has further focused attention on self-management of chronic conditions, for example for vulnerable patients who are self-isolating.

Despite increased attention and resources devoted to self-management for chronic conditions, evidence of the effectiveness of self-management limited. This is particularly true in low- and middle-income countries, where self-management is proposed as one response to the challenges that accompany ageing populations, a rapidly increasing prevalence of non-communicable diseases and multi-morbidities, and rising health care costs.

One reason for this lack of evidence is the absence of a common understanding of what self-management means in different contexts, and a standard definition and tool for its measurement. While some work has been done to identify dimensions of self-management of chronic conditions in higher income settings, measures of this concept remain inconsistent. They have also been largely determined without input from all affected stakeholders in the health system. This is despite evidence that self-management is understood differently by health professionals and lay people. To characterise self-management programmes, to evaluate and compare their effectiveness over time and across settings, more work is required to develop tools for measuring self-management that can be adapted to different contexts.

There is also a lack of consensus on the goals of self-management. Most self-management support initiatives focus on an ultimate goal of improved disease outcomes, putting the onus on patients to better manage their own conditions. The impact of these initiatives is not inherently positive. The added responsibility put on patients can represent a burden for many of them, adding to the already significant workload of patient-hood. In many low- and middle-income countries, where health systems are often-fragmented and under-resourced and social support systems are weak, the patient workload may already be particularly heavy. Patients face the work of, for example, financing health care costs from household resources or traveling long distances to seek specialist care. For them, the added responsibility of self-management at home may present a burden rather than an opportunity for improved care.

Rather than a focus on disease control, self-management must instead be about supporting patients to “live well” with their conditions. To do so, any initiatives must not assume that all individuals have access to the same informational, social and psychological resources. Instead, they must be tailored to the varying needs, capacities and expectations of different patients.

 

Key references

1.  van Olmen J, Ku GM, Bermejo R, Kegels G, Hermann K, Van Damme W. The growing caseload of chronic life-long conditions calls for a move towards full self-management in low-income countries. Global Health 2011; 7: 38.
2. Nolte E, Merkur S, Anell A, editors. Achieving person-centred health systems: evidence, strategies and challenges. Cambridge: Cambridge University Press, 2020.
3. Boger E, Ellis J, Latter S, et al. Self-Management and Self-Management Support Outcomes: A Systematic Review and Mixed Research Synthesis of Stakeholder Views. PLoS One 2015; 10(7): e0130990.
4. May C, Eton DT, Boehmer KR, et al. Rethinking the patient: using Burden of Treatment Theory to understand the changing dynamics of illness. BMC Health Services Research 2014; 14 (1), (281).

 

  Tags:

chronic diseases, engagement, research, self-management