Self-management education for rehabilitation inpatients: A cluster-randomized controlled trial

https://doi.org/10.1016/j.pec.2018.03.027Get rights and content

Highlights

  • Patient education is part of medical rehabilitation for various chronic diseases.

  • Self-management skills to foster health behavior change are crucial.

  • Effects of generic self-management modules aiming self-tailored goals are unclear.

  • A generic group program showed effects on self-regulatory outcomes in short-term.

  • Interventions should be developed to increase sustainability of effects.

Abstract

Objective

To evaluate generic self-management modules (SelMa) as an adjunct to disease-specific educational programs during inpatient medical rehabilitation.

Methods

A bi-center cluster-randomized controlled trial with 698 patients with coronary artery disease, metabolic syndrome, or inflammatory bowel disease was conducted. We compared two versions of SelMa, a group with 3 h or a lecture with 1 h, respectively, in addition to disease-related patient education, to usual care (only disease-related education). SelMa aims at providing skills that may help implementing health behavior. The primary outcomes were goal setting and behavior planning at discharge and goal attainment and health behavior at 6- and 12-months follow-up. Secondary outcomes included motivation, knowledge and self-management competences.

Results

At discharge, SelMa group, but not SelMa lecture, proved superior to usual care regarding goal setting (p = 0.007, d = 0.26), but not behavior planning (p = 0.37, d = 0.09). Significant effects were also observed on several secondary outcomes. At later follow-up, however, no effects on primary outcomes emerged. Participants’ satisfaction was higher in the group than the lecture format.

Conclusions

These short modules did not succeed in improving self-management skills in the long-term.

Practice implications

A self-management group may foster self-management skills in short term. Interventions should be developed to increase sustainability of effects.

Introduction

Patient education conveyed by disease-specific self-management programs are targeting disease-related knowledge, self-management skills and health behavior to reduce the impact of disease and foster health-related quality of life [[1], [2]]. Self-management requires a dynamic and continuous process of self-regulation performed by the individual deemed responsible for his/her health management [[1], [3]]. Self-management patient education comprises a number of behavior change approaches, such as providing information, encouragement, and skill training enabling patients to take an active role in their treatment [2]. Behavior change techniques with regard to changing health behavior have been systematized by Michie and Colleagues [4]. Systematic reviews and meta-analyses provide evidence for the effectiveness of self-management programs, but the effects vary depending on conditions and outcomes [[5], [6], [7], [8], [9]]. Due to the diversity of included interventions, information on the most effective means of delivery, educational approaches and techniques is incomplete.

In Germany, patient education is a mandatory part of (inpatient) medical rehabilitation for patients with chronic somatic diseases. Previous trials showed the superior efficacy of interactive patient-centered disease-specific group programs with regard to illness-knowledge and self-management outcomes [[10], [11], [12]]. Furthermore, theory-based interventions addressing self-regulatory variables, like planning, showed favorable effects on physical activity [[13], [14], [15]]. Additionally, plan enactment, a significant proximal outcome, was positively associated with later physical activity [16]. However, many programs are still predominantly providing knowledge or disease-related skills and lack a strong focus on behavior change techniques to foster health behavior change maintained after inpatient rehabilitation. Moreover, many programs are lecture based, provided in larger group settings and lack patient-oriented didactics [17]. Generic self-management modules promoting general self-management skills for taking action regardless of any specific disease and addressing self-tailored health behavior goals are not available so far. We therefore developed such generic self-management modules (SelMa) for use in inpatient rehabilitation. In the realm of health behavior change, we used evidence-based effective techniques [[18], [19]], self-tailoring [3] and the Health Action Process Approach [[20], [21]] as a theoretical framework. In consideration of applicability in routine care, we developed two SelMa interventions: a group program and a single lecture.

In this study, we evaluated the effects of both interventions employed in addition to disease-specific patient education as compared with usual care in inpatient rehabilitation. Usual care includes disease-specific patient education, among others. We hypothesized that the SelMa interventions are superior to usual care regarding goal setting and planning in short-term, as well as goal attainment and health behavior in medium-/long-term (primary outcomes). In addition, we expected superior effectiveness of the new interventions regarding motivation, knowledge and several self-management competences (secondary outcomes). We also explored differences in intervention satisfaction between the two self-management interventions.

Section snippets

Design and procedure

This study was a bi-center cluster-randomized controlled trial in inpatient rehabilitation centers in Germany. Clusters were patient education groups that comprise patients recruited within one week after commencement of inpatient rehabilitation. Clusters were randomly assigned to the three study groups using a computer-generated list of random numbers. Randomization was performed by a scientific assistant at the university research institute (central randomization per phone) guarantying

Sample characteristics

Table 1 presents the sociodemographic and clinical characteristics of participants by study group. The initial sample comprised N = 698 rehabilitants. Participants’ mean age was 50 years (SD = 10.2), 55% were male, and 76% reported to live with a partner. The sample mostly consisted of employed persons (87%), with 87% salaried employees and 9% blue-collar workers. About 51% had inflammatory bowel disease, and 49% cardiac rehabilitation. There were no systematic differences among the study

Discussion

In this cluster-randomized controlled trial we evaluated the effectiveness of two short generic self-management modules (SelMa group, SelMa lecture) as compared to usual care (including disease-specific patient education) in patients with inflammatory bowel disease or cardiac disease undergoing inpatient medical rehabilitation.

The SelMa group showed a significant, but small effect on one primary outcome, patients‘ goal setting at discharge. However, there were no effects on goal attainment and

Confirm of interests

The authors confirm that there is no conflict of interest.

“I confirm all patient/personal identifiers have been removed or disguised so the patient/person(s) described are not identifiable and cannot be identified through the details of the story.”

Funding

This work was supported by the German Statutory Pension Insurance Scheme [grant number: 8011 – 106 – 31/31.110].

Acknowledgements

We thank the participating patients and therapeutic teams from the Rehabilitation Centre Bayerisch Gmain and the Rehabilitation Centre Mölln.

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