Self-Regulation in Chronic Disease

1. Self-Regulation in Chronic Disease Noreen M. Clark, Ph.D. March 23, 2002

2. The day to day manager of chronic disease is the patient. Under best circumstance the physician provides guidelines for effective at home management.

3. Most chronic diseases are variable and an individual must exercise a significant degree of judgment regarding management.

4. Many factors help or hinder individuals in their management tasks.

5. Management by Patient Family Involvement Clinical Expertise Work/School Support Community Awareness, Support & Action Community-Wide Environmental Control Measures Conducive Policies

6. Self-regulation is the means by which people learn how to manage disease utilizing internal resources and external factors.

7. Self-regulation is a dimension of social cognitive theory - a comprehensive explanation of human behavior.

8. a) its constituents or elements b) how these are integrated into a model c) how they predict outcomes related to chronic disease management Our research group has been examining three aspects of self-regulation:

9. Patient efforts to manage asthma and heart disease serve as the context for studying self-regulation.

10. observation judgment reaction: The elements of self-regulation we have identified are: • - expectation • - efficacy

11. These elements are very useful constructs because means to improve one’s capacities are evident within them.

12. A Model of Self-Regulation

13. Intrapersonal Factors • Knowledge • Attitudes • Feelings • Beliefs Reactions(outcome expectations & self-efficacy) Judgments • External Factors • Role models • Technical advice and service • Social support • Money and material resources Observations Internal and External Factors

14. Management Strategies • Use of Management • Strategies • Prevention • Disease control Reactions (outcome expectations & self-efficacy) Judgments Observations

15. End Points • Reaching personal goals • Physiological status • Functioning • Health care use • Perceptions of quality Reactions (outcome expectations & self-efficacy) Judgments Observations End Points

16. End Points • Reaching personal goals • Physiological status • Functioning • Health care use • Perceptions of quality Reactions(outcome expectations & self-efficacy) Judgments Observations • Intrapersonal • Factors • Knowledge • Attitudes • Feelings • Beliefs Judgments Reactions (outcome expectations & self-efficacy) • External Factors • Role models • Technical advice and service • Social support • Money and material resources Observations Elements of Self-Regulation Reactions (outcome expectations & self-efficacy) • Use of Management • Strategies • Prevention • Disease control Judgments Observations

17. stability predictive ability We have conducted a number of studies to examine the elements of self-regulation (observation, judgment, reaction) as presented in this model:

18. N=637 families in Michigan and New York Data Collection: Baseline 6 months 1 year later A Study of Parent Management of a Child’s Asthma

19. 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. Data Analysis

20. Observation look for early warning signs watch child when symptoms begin determine if symptoms are improving monitor child after giving medications Measures * Cronbach alpha = .77

21. 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 Measures * Cronbach alpha = .62

22. 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 Measures * Cronbach alpha = .70

23. 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

24. Outcome Expectations, cont’d. removing child from source of symptoms giving medications preventively keeping child away from irritants/ allergies asking for help/advice Measures * Cronbach alpha = .80

25. The extent to which parents used the specific actions described. Management Strategies

26. Asthma knowledge/beliefs Awareness of treatment plan Intrapersonal Factors * Cronbach alpha = .82

27. Role models Social support Technical services External Factors * Cronbach alpha = .65 -.77

28. Quality of life Severity of asthma in past year Hospitalizations ED visits Office visits Outcomes

29. Stable elements of Self-Regulation Intrapersonal Factors Baseline Judgment External Factors .535 (.000) .175 (.000) .021 (.026) Observations .357 (.000) Management Strategies .015 (.042) Confidence

30. Stable elements of Self-Regulation Intrapersonal Factors Follow-up 1 Judgment External Factors .399 (.003) .184 (.000) .299 (.000) Observations .464 (.000) Management Strategies .061 (.000) Confidence

31. Stable elements of Self-Regulation Intrapersonal Factors Follow-up 2 Judgment External Factors .447 (.000) .126 (.000) .191 (.000) Observations . 624 (.000) Management Strategies .251 (.000) Confidence

32. Elements of Self-Regulation Intrapersonal Intrapersonal Intrapersonal Factors Factors Factors Judgment Judgment Judgment External Factors External Factors External Factors .191 .021 .535 .175 .399 .184 .447 .126 .299 (.026) (.004) (.000) (.000) (.003) (.000) (.000) (.000) (.000) Observations Observations Observations .624 .357 .464 (.000) (.000) (.000) Management Strategies Management Strategies Management Strategies .015 .161 .251 (.042) (.000) (.018) Confidence & Outcome Expectations Confidence & Outcome Expectations Confidence Baseline Follow-up 1 Follow-up 2

33. Predictive Ability of Constructs

34. Baseline to two years later Intrapersonal Factors Quality of -.290 External (.000) Life Factors -.969 (.011) Management Severity Strategies .537 (.036) Hospitalization Judgment -.722 (.060) ED Visit Observations -.524 (.003) Follow-up -.394 Confidence (.007) Visit Follow-up 2 Baseline

35. Tentative Conclusions

36. Observation, judgment and reaction are interrelated and reciprocally reinforcing. Observation and judgment are directly associated with use of disease management strategies.

37. 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.

38. 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.

39. The elements of self-regulation lend themselves to interventions for enhancing chronic disease management.

40. Focusing on self-regulation rather than on information seems warranted for interventions.

41. Specific Techniques May Enhance Self-Regulation Skills

42. Diaries Record keeping Physiologic monitoring Practice Observation

43. Setting criteria Rehearsing decision-making Judgment

44. Self-efficacy realistic assessments social support role models Reaction

45. Outcome expectations analysis of means-ends relationships persuasive communicators role models Reaction

46. Self-regulation holds promise for enabling individuals to make optimum their control of chronic disease.