Self-Management of Health

Patients with diabetes use an increasing number of self-management tools in their daily life. However, health institutions rarely use the data generated by these services mainly due to (1) the lack of data reliability, and (2) medical workers spending too much time extracting relevant information from the vast amount of data produced. This work is part of the FullFlow project, which focuses on self-collected health data sharing directly between patients' tools and EHRs. The main objective is to design and implement a prototype for extracting relevant information and documenting information gaps from self-collected health data by patients with type 1 diabetes using a context-aware approach. The module should permit (1) clinicians to assess the reliability of the data and to identify issues to discuss with their patients, and (2) patients to understand the implication their lifestyle has on their disease. The identification of context and the design of the system relied on (1) 2 w...

Healthcare systems in many developed countries are rapidly approaching a crisis point, due to an aging population, an increase of chronic diseases, healthcare costs consuming an increasing share of the government expenditure, and the dwindling pool of healthcare professionals. One solution to address these challenges is to empower health consumers to better manage their health. Consumer Health Informatics (CHI) applications can enable users to track their health status and to actively participate in treatment regimens and preventive strategies. However, in spite of their immense potential in empowering patient to take charge of their healthcare, many challenges remain in the design and use of CHI applications. In this study, we investigate the barriers that hinder effective usage of CHI applications for health self-management. Results indicate that the primary barriers to self-management via CHI applications resulted from privacy and security concerns and cost. The barriers to self-management identified in this study are amenable to novel CHI applications that could improve health outcomes.

Background: Limitations in mainstream medicine are apparent in patients with chronic health conditions who are not responding to conventional treatments. These limitations cost individuals, employers, the welfare system, society and the NHS millions each year. Previous research has recommended integrating Complementary and Alternative Medicine (CAM) with mainstream medicine to support patient health and wellbeing. However, there are information gaps for those who would be integral to this provision of CAM within the NHS.

Objective: To bridge information gaps by providing an insight into how CAM is provided within the context of the NHS, the strengths and challenges found in practice and the opportunities for furthering integrative healthcare in the UK.

Methodology: A systematic review collated quantitative and qualitative data from peer reviewed studies dated between 2011 and 2016 that examined the real-world use of CAM in the NHS. The studies were critically appraised for the quality of information and data was collated and organised into themes that addressed the research questions.

Results: 14 studies met the inclusion/exclusion criteria. 55 types of CAM were reported as used in the NHS for a wide range of health conditions. Strengths of CAM included positive health outcomes and potential cost-effectiveness. Weaknesses and challenges included the perception of CAM and the allocation of financial resources. Opportunities to overcome these limitations included raising awareness of CAM within the NHS, working with multidisciplinary teams and incorporating NHS modes of working into CAM practice.

Conclusion: CAM can support NHS professionals with promoting and enabling health, recovery and rehabilitation for patients. Resources, perspectives and awareness of CAM currently limit the extent of CAM provision in the NHS. There are opportunities offered within these studies to overcome these limitations, assimilating CAM not only into the healthcare service provision but into the modus operandi, language and culture of the NHS.

Author: Lise Dassieu

(article in French)
Title : Self-medication among drug users: from experiential knowledge to interaction with physicians

Abstract: Little is known in social science about illicit drug users’ perspective on the therapeutic dimension of substance use. Based on a qualitative study, this article examines drug users’ self-medication practices, and the attitude of general practitioners towards them. The availability of opioid substitution treatments on the black market allows people to use them to self-medicate heroin withdrawal symptoms. Drug users also use a wide range of substances in order to relieve common health problems
(e.g., flu, pain, or anxiety). Through self-experimentation and peer-to-peer exchange, they develop experiential knowledge about substances, created and transmitted within the social world of illicit drugs. But this knowledge is not always recognized as such by physicians who often interpret drug users’ self-medication practices as misuse or non-compliance.

***************************************************
La dimension thérapeutique que peut revêtir la prise de drogues aux yeux des usagers reste peu explorée en sciences sociales. À partir d’une enquête qualitative, cet article étudie les pratiques d’automédication des usagers de drogues, ainsi que l’attitude des médecins généralistes à leur égard. La disponibilité des traitements de substitution aux opiacés sur le marché noir permet aux usagers de les utiliser en automédication pour soulager les symptômes de manque. Ces derniers consomment aussi divers médicaments et drogues illicites lorsqu’ils doivent faire face à des problèmes de santé courants (grippe, douleur, angoisse, par exemple). Par le biais de l’auto-expérimentation et de l’échange entre pairs, ils développent des savoirs expérientiels sur les produits et leur maniement, constitués et transmis au sein du monde des drogues. Mais ces savoirs ne sont pas toujours reconnus comme tels par les médecins, qui interprètent souvent l’automédication des usagers de drogues comme un mésusage ou une inobservance du traitement.

Background: With the burden of chronic illness increasing globally, self-management is a crucial strategy in reducing healthcare costs and increasing patient quality of life. Low income and low health literacy are both associated with poorer health outcomes and higher rates of chronic disease. Thus, self-management represents an important healthcare strategy for these populations. The purpose of this study is to review self-management interventions in populations with low income or low health literacy and synthesize the efficacy of these interventions.
METHODS:

A systematic review of trials evaluating the efficacy of self-management interventions in populations with low income or low health literacy diagnosed with a chronic illness was conducted. Electronic databases were primarily searched to identify eligible studies. Data were extracted and efficacy summarized by self-management skills, outcomes, and content tailoring.
RESULTS:

23 studies were reviewed, with ten reporting an overall positive effect on at least one primary outcome. Effective interventions most often included problem-solving as well as taking action and/or resource utilization. A wide range of health-related outcomes were considered, were efficacious empowerment and disease-specific quality of life were found to be significant. The efficacy of interventions did not seem to vary by duration, format, or mode of delivery or whether these included individuals with low health literacy and/or low income. Tailoring did not seem to impact on efficacy.
DISCUSSION:

Findings suggest that self-management interventions in populations with low income or low health literacy are most effective when three to four self-management skills are utilized, particularly when problem-solving is targeted. Healthcare providers and researchers can use these findings to develop education strategies and tools for populations with low income or low health literacy to improve chronic illness self-management.

Objective:
The general medical health of individuals with serious mental illnesses is compromised relative to those without serious mental illnesses. To address this health disparity, numerous integrated care strategies are being employed from the system level to the level of individual patients. However, self-management of health care, a strategy considered an integral aspect of typical care, has been infrequently included in interventions for this population. Despite reservations about the capacity of those with serious mental illnesses to self-manage health care, a subset of new interventions focused on general medical health in this population has tested whether models including self-management strategies have empirical support. To understand whether these models are supported, the authors reviewed the evidence for self-management models.

Methods:
This systematic review examined collaborative and integrated care models that include self-management components for individuals with serious mental illnesses.

Results:
Across the 14 studies identified in this review, promising evidence was found that individuals with serious mental health issues can collaborate with health professionals or be trained to self-manage their health and health care. The evidence supports the use of mental health peers or professional staff to implement health care interventions. However, the substantial heterogeneity in study design, types of training, and examined outcomes limited conclusions about the comparative effectiveness of existing studies.

Conclusions:
This review found preliminary support that self-management interventions targeting the general medical health of those with serious mental illnesses are efficacious, but future work is needed to determine what elements of training or skills lead to the most salient changes.

Objectives: This article aims to elaborate chronotope disruption - a changed relation to time and space - as a sensitizing concept for understanding chronic illness narratives. Methods: Sixteen men and 16 women with Type 2 diabetes were purposefully sampled. Each was interviewed about his or her experience of diabetes self-management using the biographical-narrative interview method. Transcripts were inspected for key moments defined as emotionally laden stories relevant to the purpose of the research. We present dialogically inflected discursive analysis of exemplar extracts. Results: The analysis demonstrates how the concept of chronotope disruption helps identify, and understand, important aspects of patients’ chronic illness narratives. First, we investigate how medical advice can conflict with embodied experience and how progressive bodily deterioration can provoke a reevaluation of past illness (self-mis)management. Second, the increasing temporal and spatial intrusion of chronic illness into participants’ lives is examined. Finally, we focus on the masquerade of health as an attempt to manage, hide, or deny that one is physically challenged. Conclusions: Chronotope disruption offers a useful sensitizing concept for approaching chronic illness narratives and around which to organize analytical insights and to develop practice. Chronotope analysis fills an important gap in the science
through compensating current health sciences’ focus on rationality, cognition, and prospective time (prediction) with a patient-oriented focus on emotionality, embodiment, and retrospective time (nostalgia). Chronotope disruption could be used to develop practice by gaining empathic understanding of patients’ life-worlds and provides a tool to examine how new technologies change the way in which the chronically ill have “being” in the world.

Background: Higher self-compassion is associated with mental and physical health benefits in both healthy and chronically-ill populations. The current study investigated the role of self-compassion in predicting depression, diabetes-specific distress, and HbA1c in diabetes patients.
Aims: To assess the specific operationalization of negative emotionality that best predicted HbA1c and to test whether self-compassion would buffer diabetes patients’ HbA1c against the negative effects of distress.
Methods: Diabetes patients (n = 110) completed measures assessing trait self-compassion, depression and diabetes-distress. HbA1c results were obtained through medical records.
Results: As expected, diabetes-specific distress was a better predictor of HbA1c than depression; self-compassion moderated the relationship between distress and HbA1c such that higher distress predicted higher HbA1c at lower levels of self-compassion, but not at higher levels of self-compassion.
Conclusions: In addition to further demonstrating the link between distress and metabolic outcomes, these findings suggest self-compassion might buffer patients from the negative metabolic consequences of diabetes distress.

Type 2 diabetes is a metabolic disorder characterized by chronically elevated blood glucose and high risk of comorbidities. In this article we report a metasynthesis of the 21st-Century qualitative research concerning the self-management of type 2 diabetes. We identified 38 relevant articles (sample size range 6 to 175), which were synthesized through a process of iterative reading and theory development. In this literature, authors argued and assumed that diabetes management is influenced by multiple, complex, competing factors, including interpersonal relations, gender, and sociocultural context. Conversely, self-management was sometimes construed as a facet of individual agency and was accepted uncritically, placing accountability for health with patients themselves. We conclude that a satisfactory account of diabetes care would pay attention to the “inner” world, while acknowledging the social and political conditions in which diabetes-related experiences unfold.

What the unique flavours of herbs can tell you about them and how they work. Discover herbal actions just by tasting them. Lost Knowledge on Herbal Energetics Everybody seems to be talking about herbal energetics lately. But what is it really? Modern day herbal alchemist Sajah Popham has drawn from a large breath of traditional and non-traditional studies around the world to examine and break down the medicinal relationship that herbs have with people. He stresses in his teachings to look at the whole plant in relationship to the whole person, whereby one may even apply the taste of herbs with the health conditions and emotional constitution of a person. In his book, master herbalist Matthew Woods explains that the subject of herbal energetics was found throughout the practise of western traditional medicine. He begins with a short history of the lost art of natural healing by remembering that "much of the herbal and nutritional marketplace apes conventional medicine". He emphasises the difference in approach between reductionist pharmacology and holistic herbalism. Cultures do tend to behave in the same way all over the world, but only express themselves in their own unique way. The rise of curiosity amongst modern day conscious, enlightened herbalists and foragers around the world has enticed a field of herbal study and approaches that have been long forgotten. And better still, a hugely understudied area of medicine as lifestyle in the awakening questions as to how well are we really doing? Brigitte Mars is another prominently rising star of the modern herbal community. Through her herbal walks, she teaches how tasting raw leaves without washing is allowing the earth to help the immune system. In this way the folk approach to medicine is very different from conventional biomedicine, which takes away the medicinal virtues of the entire plant to make a reductionist approach to learning what is metabolism of the plant. The vocabulary of energetics is a powerful tool to help understand the impact of the Natural philosophy behind these histories and interconnected communications. In order to demonstrate how the aroma and tastes of herbs work, visit our Recipes section for a real Taste of Herbs to start developing your own herbal energetics. But first, let's go briefly back to our roots…. Return of the Ancient Wisdoms In standardised pharmaceutical studies there is a strong focus on the biochemical aspect of herbs. The constituency of the plants used in conventional laboratories order for a plant to have a particular medicinal effect, whereas this is the opposite case in herbal energetics. It has been primarily ignored in industrial pharmacology. However before standard science and pharmaceuticals, Sajah Popham teaches us how to use the respiratory system of herbal energetics because this relates to looking at it from a completely new level of respiratory conditions. He calls this the way of the vital force or vital intelligence of the plant and person. The vitalist models can be pertained to sensorial human experiences, such as how we feel, smell, touch, see and experience the quality of life and food actions in any given environment. If we look through the history of traditional medicine, herbal practitioners of the past understood how the taste of herbs, such as

Introduction: One of the factors which increase the rehabilitation efficacy and accelerate the convalescence and return to society of the patients after myocardial infarction may be the self-care attitude. Therefore it seems justifiable to seek such factors which will affect the self-care level. Self-estimation belongs to the most important determinants of coping efficacy and undertaking health behaviours. Considering that health behaviours may be treated as a behavioural manifestation of
the self-care attitude, it is probable that the correlation between the self-image and self-care attitude appears to be strong.
Aim: The aim of the research was determination of the strength of the correlation between the level of self-image and selfcare attitude as well as the care types in patients after myocardial infarction. Methods: The study involved 127 persons who had myocardial infarction for the first time and did not undergo any other severe concomitant illnesses. The study covered 28 women and 99 men aged from 39 to 81, with the average age 57.74. The study consisted in completing the KTS questionnaire measuring the self-care level and OS questionnaire measuring the self-image level. The results were analysed statistically
and discussed. Results: Analysis of the levels of self-care and self-image in patients after myocardial infarction showed a strong correlation between those variables at the 0.01 significance level. It is a linear correlation which means that the higher the self-image level, the higher the self-care level. This rule applies to each of the care dimensions, i.e. responsibility, involvement and future perspective as well as each of the types of self-care.
Conclusions: The research indicated a strong correlation between the self-care level and types and the self-image level in those who underwent myocardial infarction. It appeared that the higher the self-image level after myocardial infarction, the higher the self-care level and the fuller
the self-care. Therefore the self-acceptance level should be increased in the patient, because in the case of those who underwent myocardial infarction it is extremely important for development of the self-care attitude. A change in the self-image from negative into positive may be directly translated into an increase in the self-care level.

Background: Sleep problems exist for up to 30% of young people, and increase in the case of those with chronic pain. Because exclusive pharmacological management of sleep problems for children with pain is contraindicated, the development of appropriate non-pharmacological sleep interventions is a significant, largely unmet, need. Purpose: This study examined whether the application of a standardized hand self-shiatsu (HSS) intervention within a population of young people with chronic pain would be associated with improved objectively and subjectively measured sleep. Setting: The Pain Management Clinic of the Stollery Children’s Hospital Hospital, a large tertiary care centre in Edmonton, Alberta and the University of Alberta. Research Design: Sixteen young adults, aged 17 to 27, were recruited for a case series study. The intervention involved participants self-applying a standardized hand shiatsu protocol. Participants wore an actigraph for one week at baseline before learning the...

Objectives: To explore how self-management support
(SMS) is considered and conceptualised by Clinical
Commissioning Groups (CCGs) and whether this is
reflected in strategic planning and commissioning.
SMS is an essential element of long-term condition
(LTC) management and CCGs are responsible for
commissioning services that are coordinated,
integrated and link into patient’s everyday lives. This
focus provides a good test and exemplar for how
commissioners communicate with their local
population to find out what they need.
Design: A multisite, quasi-ethnographic exploration
of 9 CCGs.
Setting: National Health Service (NHS) CCGs in
southern England, representing varied socioeconomic
status, practice sizes and rural and urban areas.
Data collection/analysis: Content analysis of CCG
forward plans for mention of SMS. Semistructured
interviews with commissioners (n=10) explored
understanding of SMS and analysed thematically.
The practice of commissioning explored through the
observations of Service User Researchers (n=5)
attending Governing Body meetings (n=10, 30 hours).
Results: Observations illuminate the relative absence
of SMS and gateways to active engagement with
patient and public voices. Content analysis of plans
point to tensions between local aspirations and those
identified by NHS England for empowering patients by
enhancing SMS services (‘person-centred’, whole
systems). Interview data highlight disparities in the
process of translating the forward plans into practice.
Commissioners reference SMS as a priority yet details
of local initiatives are notably absent with austerity
(cost-containment) and nationally measured biomedical
outcomes taking precedence.
Conclusions: Commissioners conceptualise locally
sensitive SMS as a means to improve health and
reduce service use, but structural and financial
constraints result in prioritisation of nationally driven
outcome measures and payments relating to
biomedical targets. Ultimately, there is little evidence of
local needs driving SMS in CCGs. CCGs need to focus
more on early strategic planning of lay involvement to
provide an avenue for genuine engagement, so that
support can be provided for communities and
individuals in a way people will engage with.

Background: Systemic lupus erythematosus (SLE) is a chronic multisystem autoimmune disease that predominately affects women (90%) during their childbearing years. Pregnancy complications in women with SLE exceed that of the general population. Women with
systemic lupus erythematosus (SLE) have fewer children on average than other women. This research aimed to analyse the perspectives of individuals with SLE in Ireland towards pregnancy. Methods: The research involved 23 semi-structured interviews with participants from Lupus groups in Ireland using multiple case study analysis. Results: Two key findings emerged in the qualitative
interviews: reluctance towards becoming pregnant, and not conceiving again post-diagnosis. Conclusions: This paper through analysis of qualitative findings highlights the need for psychosocial education and awareness in the clinical management of SLE and pregnancy. Patient counselling should be available for all possible issues that may arise both for the individual with SLE (risk of disease flares and pregnancy complications) and the foetus (risk of neonatal lupus syndromes and learning difficulties). There is a necessity for education  in optimal disease control with safe medications during pregnancy.

To assess the effectiveness of self-management support interventions in men with long-term conditions. A quantitative systematic review with meta-analysis. The Cochrane Database of Systematic Reviews was searched to identify published reviews of self-management support interventions. Relevant reviews were screened to identify randomised controlled trials (RCTs) of self-management support interventions conducted in men alone, or which analysed the effects of interventions by sex. Data on relevant outcomes, patient populations, intervention type and study quality were extracted. Quality appraisal was conducted using the Cochrane Risk of Bias Tool. Meta-analysis was conducted to compare the effects of interventions in men, women, and mixed-sex sub-groups. 40 RCTs of self-management support interventions in men, and 20 eligible RCTs where an analysis by sex was reported, were included in the review. Meta-analysis suggested that physical activity, education, and peer support-based interv...

Self-management is an established, effective approach to controlling asthma, recommended in guidelines. However, promotion, uptake and use among patients and health-care professionals remain low. Many barriers and facilitators to effective self-management have been reported, and views and beliefs of patients and health care professionals have been explored in qualitative studies. We conducted a systematic review and thematic synthesis of qualitative research into self-management in patients, carers and health care professionals regarding self-management of asthma, to identify perceived barriers and facilitators associated with reduced effectiveness of asthma self-management interventions. Electronic databases and guidelines were searched systematically for qualitative literature that explored factors relevant to facilitators and barriers to uptake, adherence, or outcomes of self-management in patients with asthma. Thematic synthesis of the 56 included studies identified 11 themes: (1) partnership between patient and health care professional; (2) issues around medication; (3) education about asthma and its management; (4) health beliefs; (5) self-management interventions; (6) co-morbidities (7) mood disorders and anxiety; (8) social support; (9) non-pharmacological methods; (10) access to healthcare; (11) professional factors. From this, perceived barriers and facilitators were identified at the level of individuals with asthma (and carers), and health-care professionals. Future work addressing the concerns and beliefs of adults, adolescents and children (and carers) with asthma, effective communication and partnership, tailored support and education (including for ethnic minorities and at risk groups), and telehealthcare may improve how self-management is recommended by professionals and used by patients. Ultimately, this may achieve better outcomes for people with asthma.

In past decades, chronic diseases have become a salient social, political and healthcare issue. Empowerment, autonomy and self-management have been defined as medical priorities for the therapeutic support and healthcare of people living with chronic disease. The ways people cope with chronic disease require heterogeneous knowledge, including lay and medical notions and skills, and interactions with a large variety of healthcare professionals and other supporting actors (relatives, friends, patients, etc.). Thus, the complexity of chronic care implies a delegation of part of the medical tasks to patients, in order to enable them to undertake by themselves effective self-care and, in so doing, to improve their quality of life. Indeed, patients' self-management of chronic diseases and their relationship with healthcare practitioners rely more and more on the use of various tools which are expected to be driven by evidence-based knowledge in order to enhance efficient and effective care and self-care. This situation needs an accurate understanding on how techniques and tools do or not contribute to this effective self-care. In this increasingly widespread situation, knowledge translation appears to be inseparable from practices, whose understanding requires the analysis of activities in which actors are involved and tools that mediate their activity in chronic (self-)care management. A sharp focus upon practices, contexts of use and tools could thus produce a better understanding of the production, transmission, transformation and negotiation of knowledge between the actors involved in the management of chronic diseases. This interdisciplinary conference aims at crossing concepts and empirical research on the processes through which knowledge translation takes place in the self-management of chronic diseases, with a specific scrutiny of the expected and actual functions of the tools and the context in which translation occurs, on the one hand, and of the difficulties and negotiations that people living with a chronic disease face in gaining autonomy, on the other hand. For this purpose, the conference brings together scholars working within different disciplines as well as healthcare practitioners, designers of medical devices and policy makers, i.e. actors who contribute to the ongoing reflection on these salient issues.

Background: Understanding of COPD and uptake of evidence-based healthcare by patients is suboptimal in primary care, particularly in the context of multi-morbidity. This innovative study aims to empower primary care COPD patients with co-morbidities by improving their disease knowledge and self-efficacy by piloting a practice nurse-delivered, tailored self-management programme in Sydney, Australia.

Methods: Potential COPD patients with co-morbidities were recruited from participating general practices. Following an initial needs assessment, the self-management programme is being tailored by trained practice nurses and delivered to patients in subsequent one-to-one sessions. The programme, based on constructs from the Health Belief Model, involves active engagement of patients with strategies aimed at enhancing their COPD knowledge, self-management capacity and skills in prioritisating multiple chronic conditions. Primary outcome of the study is assessment of patient knowledge, skills and self-management capacity of multiple chronic conditions using the Patient Activation Measure (PAM). Secondary outcome measures include COPD Knowledge Questionnaire, COPD Assessment Test, Multi-morbidity Illness Perceptions Scale, Morisky Medication Adherence Scale and accuracy of inhaler technique.

Findings: The study is currently in the phase of intervention delivery and follow-up. The average PAM score from baseline data of 49 participants (24 male and 25 female, mean age: 69.2) was 57.67, indicating lack of confidence and skill to modify health behaviour. Impact of the programme will be tested by comparing pre and post-test outcome measures after six months’ follow-up. Feasibility and sustainability will be evaluated by qualitative feedback from participating clinicians.

Implications: There has been good uptake of the programme by participating nurses following training workshops conducted by the researchers. We have faced challenges in practice recruitment and patient retention, mainly due to their co-morbidities. A first of its kind, our study could lead to improved long-term health outcomes, healthcare utilisation and patient-provider relationships. The study also broadens the practice nurse’s role in patient empowerment, which is vital given the surge in multi-morbidity worldwide.

Aim: To describe the evaluation of the NBN enabled telehealth pilot of Feros Care’s My Health Clinic at Home (MHCAH which involves daily vital-sign monitoring which is triaged by a telehealth nurse and video-conferencing.
Methods: A mixed methods, prospective, uncontrolled study design was used to capture learning on the processes of implementation and the impact of the project on clients. Data sources included surveys with service users and providers, pre-post test clinical data, audit data, documentary evidence from meetings and interviews and focus groups. 
Results: Overall, 181 of 200 clients recruited to the trial between April 2013 and June 2014 were included in the evaluation. Most clients (64%) self-referred into the pilot with the goals of monitoring their own health (68%) and identifying problems before they became serious (65%).Clients reported that as a result of participating in MHCAH, they better understood their vital sign monitoring (48%) and consequently: could better manage their own health (48%); were better informed (44%) and more confident (25%) to discuss their health with their doctor. Clients also reported making medication changes (17%), positive dietary changes (34%); and increased their physical activity (33%). Overall, client self-rated general health improved (mean improvement 0.303, SD= 0.80, 95% CI 0.16 – 0.45, 118 df, p=0.000), with more participants reporting that their health is “excellent” or “very good” health at the end of the trial. Clients also reported making fewer doctor visits (24%), which was supported by the comparative data at baseline and discharge (p=0.000); fewer visits to the emergency department at the local hospital (p=0.021) and fewer non-local hospital admissions (p=0.000) compared with the preceding year. There was no significant reduction in local hospital admissions (p=0.171). All health practitioner engagement was poor despite a willingness of clients to video-conference with a range of services. Cost was a barrier to most clients continuing to use MHCAH. Few clients were willing to pay more than $10 per week to use MHCAH, whereas the weekly cost of providing the service is $111.76.
Conclusions: While a causal link cannot be demonstrated, the findings suggest that MHCAH empowers clients to better understand and manage their own health, and may be associated with improved health outcomes and reduced service use. Having regular, daily access to a telehealth nurse reassured clients, and triggered changes to services and behaviour that are likely to have influenced outcomes. The ongoing costs of MHCAH appear high, however if the potential benefits demonstrated by this trial are realised, then the downstream savings could substantially outweigh these.

Introduction: Asthma self-regulation interventions help to improve awareness about asthma care and help reinforce positive behavioral
patterns. Management of asthma should not only target symptom control, but also bring about an improvement in Quality of Life (QOL).
Depression is an important co-morbidity in urban teens with asthma but its impact on the effectiveness of educational interventions is not
known.
Methods: The web-based, Puff City asthma management program was developed using tailoring to provide individualized education
related to asthma self-regulation and management, and also to impact negative behaviors that could affect asthma related outcomes. This
program was evaluated with a randomized controlled trial conducted in teenagers from grades 9-11 of six Detroit public high schools. The
intervention group received 4 sessions of web-based tailored messages, while the control group was given generic web-based asthma
education. Assessment of asthma symptoms, depression, and QOL measurements were done through online baseline questionnaires for
teens and a telephone baseline survey for caregivers. Outcomes such as functional status and QOL were assessed based on follow up at 12
months.
Results: Of the 422 teens enrolled, 355 had complete teen and caregiver data for analysis (170 treatment and 185 controls). Prevalence of
depression by randomization assignment was similar for teens (treatment vs. control = 29.4 vs. 24.9%, respectively, p=0.34) and caregivers
(12.4 vs. 13.5%, p=0.75). Analysis was stratified by teen depression at baseline, adjusting for potential confounders using logistic
regression. Depression did not seem to influence intervention effectiveness for functional status, i.e., most adjusted Odds Ratios indicated
intervention benefit regardless of depression status. However, for QOL, intervention benefit seemed to differ by depression status. Among
teens who were depressed, treatment vs. control QOL scores overall, and specifically for the domains related to activities, symptoms, and
emotional functioning respectively, were 4.5 vs. 4.1 (p=0.09), 3.8 vs. 3.7 (p=0.95), 4.7 vs. 4.1 (p=0.078), and 4.9 vs. 4.4 (p=0.010), indicating
intervention benefit for QOL among depressed students. No difference by treatment assignment was noted in QOL for teens without
report of depressive symptoms at baseline.
Conclusions: Results suggest that effect of an asthma self-regulation intervention on QOL can differ by depression
status, in that the intervention effect was greater in teens who met study criteria for depression at baseline compared to
those that did not. Further assessment of self-management educational interventions for asthma should look at how
co-morbidities may alter the intervention effect.

Self-management is an established, effective approach to controlling asthma, recommended in guidelines. However, promotion, uptake and use among patients and health-care professionals remain low. Many barriers and facilitators to effective self-management have been reported, and views and beliefs of patients and health care professionals have been explored in qualitative studies. We conducted a systematic review and thematic synthesis of qualitative research into self-management in patients, carers and health care professionals regarding self-management of asthma, to identify perceived barriers and facilitators associated with reduced effectiveness of asthma self-management interventions. Electronic databases and guidelines were searched systematically for qualitative literature that explored factors relevant to facilitators and barriers to uptake, adherence, or outcomes of self-management in patients with asthma. Thematic synthesis of the 56 included studies identified 11 themes: (...