Tackling Heart Disease Together or Alone: The Behavioural Science of Self-Management

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Heart disease is the leading killer in the U.S. and throughout most of Europe. People’s behaviour can protect and reduce risk of heart disease, and interventions to help people “self-manage” exist. But what is the best way to “self-manage”? A recent study shows that group programmes and self-directed programmes have remarkably different effects [1].

Self-management interventions exist for many health problems. They are notoriously difficult to define. One thorough definition is that it relates to activities undertaken by the person who has a “chronic” or “long-term” condition such as asthma, multiple sclerosis or arthritis. These activities include problem solving, decision making, resource utilization, the formation of a patient-provider partnership, action planning and self tailoring [2]. Interventions or programmes are designed around these activities to help support people to manage their own illness. The idea is that following attendance at a programme of some sort, the activities and skills learned will be continued to be used, thus improving health, maintaining fitness and/or quality of life and reducing the risk of future acute episodes of ill health. These interventions are popular for many reasons, including the relatively low cost to health service providers as interventions can be delivered by health-care professionals or by people with the relevant condition who have been trained, or a mixture of both. Self-management interventions also allow people with long-term conditions to be meet in a group with people with similar conditions. The experience of being in a group, knowing one is not alone and sharing stories is thought to play some part in the effectiveness of self-management interventions. But to what extent is this true?

Researchers at the University of Michigan explored the effect of the format of a self-management intervention for women with heart disease by comparing a “self-directed” programme to a “group” programme to a control group [1]. In the “self-directed” version, there was a single session with health educator followed by completing programme at home. The “group” programme consisted of 6 – 8 women meeting for around 2 hours once a week for six weeks. In the control condition, no intervention was presented. The aim was to investigate which intervention would most usefully effect symptom experience, health status and weight. To make the comparison of the “self-directed” and “group” interventions more equitable, the “self-directed” version included videos of group discussions to emulate the motivation and support that would be given in the “group” programme. Further, to ensure information was provided to all, the “self-directed” group also received telephone calls from a health educator.

The results revealed a remarkable difference. Eighteen months after the intervention, data were collected. For the “self-directed” intervention, cardiac symptoms such as chest pain and dizziness were reduced in number, frequency and impact. For the “group” intervention, weight loss and exercise capacity (in terms of how far a person can walk within a set time) were improved. This is despite the fact that the information and instructions provided in both programmes were the same.

So does this mean we should all join groups if we want to lose weight and exercise more but stay at home if we want to feel fewer symptoms? Not necessarily. This study, like all studies, has several limitations. Obviously, the women in the “self-directed” group were not observed, so we do not know to what extent they followed the intervention they were given. A diary record of what the women did could have been included in this study, but even that may not be an accurate picture of how well the intervention was followed. Another issue is that the women in the “group” may have experience a higher “dose” of the intervention – that is to say the they attended a meeting for approximately 2 hours per week, receiving a two hour “dose”. We do not know how much time the women in the “self-directed” intervention spent on their activities. Further, this study included a sample only of women who were white and high school educated. Therefore, we cannot say whether the same effect would be observed outside of this group of people. It would be interesting to see this issue investigated with other demographics, including men (who may be less amenable to group processes), different ethnic groups and educational levels.

What the results do suggest however is that being in a group may facilitate exercise and weight loss improvement for women with heart disease. But we still do not know how this occurs. A common problem in behavioural interventions, including self-management interventions, is that we simply do not know which bit of the intervention is working. The study suggests that the “group” part of the intervention is affecting how the intervention works. However, we do not know why. Is peer pressure a factor? Would these results be the same if we looked at people in relation to personality type? Would a shy, introverted sample show the same results?

There are many self-management interventions available today, in terms of both health service packages, “self-help” books and DVDs, information from health care professionals, charity groups and community organisations. Our health and its care is now a collaborative endeavour in which we are involved actively and with responsibility. Self-management is increasingly included in health policies. Researching and understanding whether such interventions work, which components work, what “dose” is needed and who they work for, is vital to our future health.

References

Clark et al. Heart disease management by women: does intervention format matter? Health Educ Behav. 2009 Apr;36(2):394-409. Epub 2007 Dec 15.
DOI: 10.1177/1090198107309458
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Lorig KR, Holman H. Self-management education: history, definition, outcomes, and mechanisms. Ann Behav Med. 2003 Aug;26(1):1-7.
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