Does improvement in self-management skills predict improvement in quality of life and depressive symptoms? A prospective study in patients with heart failure up to one year after self-management education.

BACKGROUND: Heart failure (HF) patient education aims to foster patients' self-management skills. These are assumed to bring about, in turn, improvements in distal outcomes such as quality of life. The purpose of this study was to test the hypothesis that change in self-reported self-management skills observed after participation in self-management education predicts changes in physical and mental quality of life and depressive symptoms up to one year thereafter. METHODS: The sample comprised 342 patients with chronic heart failure, treated in inpatient rehabilitation clinics, who received a heart failure self-management education program. Latent change modelling was used to analyze relationships between both short-term (during inpatient rehabilitation) and intermediate-term (after six months) changes in self-reported self-management skills and both intermediate-term and long-term (after twelve months) changes in physical and mental quality of life and depressive symptoms. RESULTS: Short-term changes in self-reported self-management skills predicted intermediate-term changes in mental quality of life and long-term changes in physical quality of life. Intermediate-term changes in self-reported self-management skills predicted long-term changes in all outcomes. CONCLUSIONS: These findings support the assumption that improvements in self-management skills may foster improvements in distal outcomes.

Evaluation of a self-management patient education program for patients with fibromyalgia syndrome: study protocol of a cluster randomized controlled trial.

BACKGROUND: Fibromyalgia syndrome (FMS) is a complex chronic condition that makes high demands on patients' self-management skills. Thus, patient education is considered an important component of multimodal therapy, although evidence regarding its effectiveness is scarce. The main objective of this study is to assess the effectiveness of an advanced self-management patient education program for patients with FMS as compared to usual care in the context of inpatient rehabilitation. METHODS/DESIGN: We conducted a multicenter cluster randomized controlled trial in 3 rehabilitation clinics. Clusters are groups of patients with FMS consecutively recruited within one week after admission. Patients of the intervention group receive the advanced multidisciplinary self-management patient education program (considering new knowledge on FMS, with a focus on transfer into everyday life), whereas patients in the control group receive standard patient education programs including information on FMS and coping with pain. A total of 566 patients are assessed at admission, at discharge and after 6 and 12 months, using patient reported questionnaires. Primary outcomes are patients' disease- and treatment-specific knowledge at discharge and self-management skills after 6 months. Secondary outcomes include satisfaction, attitudes and coping competences, health-promoting behavior, psychological distress, health impairment and participation. Treatment effects between groups are evaluated using multilevel regression analysis adjusting for baseline values. DISCUSSION: The study evaluates the effectiveness of a self-management patient education program for patients with FMS in the context of inpatient rehabilitation in a cluster randomized trial. Study results will show whether self-management patient education is beneficial for this group of patients. TRIAL REGISTRATION: German Clinical Trials Register, DRKS00008782 , Registered 8 July 2015.

Individual prevention courses for occupational skin diseases: changes in and relationships between proximal and distal outcomes.

BACKGROUND: To treat people with occupational contact dermatitis, the German Accident Prevention and Insurance Association in the Health and Welfare Services offers 2-day individual prevention (IP) seminars. OBJECTIVES: We investigated whether there are short-term and medium-term changes in proximal (e.g. behaviour) and distal (e.g. symptoms) outcomes after an IP seminar, whether changes in proximal outcomes are associated with changes in distal outcomes, and whether subgroups can be identified that benefit in particular. PATIENTS/MATERIALS/METHODS: In a prospective study, 502 participants of 85 IP courses completed the health education impact questionnaire (heiQ™) and skin symptom questionnaire (Skindex-29) at the start of the course, immediately thereafter, and after 6 months. Change was assessed according to standardized effect size. Regression techniques were used to analyse associations between proximal and distal outcomes. RESULTS: After 6 months, participants showed improved self-management skills and preventive behaviour, and less fear of job loss, disease-related symptoms, and emotional distress. Significant associations between proximal and distal outcomes were found. Participants who felt more limited by their skin disease showed greater effects. CONCLUSIONS: The results are consistent with the assumption that IP courses provide a range of benefits for people with occupational contact dermatitis. Changes in distal outcomes may be influenced by changes in proximal outcomes.

Measurement invariance across chronic conditions: a systematic review and an empirical investigation of the Health Education Impact Questionnaire (heiQ™).

BACKGROUND: To examine whether lack of measurement invariance (MI) influences mean comparisons among different disease groups, this paper provides (1) a systematic review of MI in generic constructs across chronic conditions and (2) an empirical analysis of MI in the Health Education Impact Questionnaire (heiQ™). METHODS: (1) We searched for studies of MI among different chronic conditions in online databases. (2) Multigroup confirmatory factor analyses were used to study MI among five chronic conditions (orthopedic condition, rheumatism, asthma, COPD, cancer) in the heiQ™ with N = 1404 rehabilitation inpatients. Impact on latent and composite mean differences was examined. RESULTS: (1) A total of 30 relevant studies suggested that about one in three items lacked MI. However, only four studies examined impact on latent mean differences. Scale means were only affected in one of these three studies. (2) Across the eight heiQ™ scales, seven scales had items with lack of MI in at least one disease group. However, in only two heiQ™ scales were some latent or composite mean differences affected. CONCLUSIONS: Lack of MI among disease groups is common and may have a relevant influence on mean comparisons when using generic instruments. Therefore, when comparing disease groups, tests of MI should be implemented. More studies of MI and according impact on mean differences in generic questionnaires are needed.

Evaluation of a self-management patient education program for patients with chronic heart failure undergoing inpatient cardiac rehabilitation: study protocol of a cluster randomized controlled trial.

BACKGROUND: Chronic heart failure requires a complex treatment regimen on a life-long basis. Therefore, self-care/self-management is an essential part of successful treatment and comprehensive patient education is warranted. However, specific information on program features and educational strategies enhancing treatment success is lacking. This trial aims to evaluate a patient-oriented and theory-based self-management educational group program as compared to usual care education during inpatient cardiac rehabilitation in Germany. METHODS/DESIGN: The study is a multicenter cluster randomized controlled trial in four cardiac rehabilitation clinics. Clusters are patient education groups that comprise HF patients recruited within 2 weeks after commencement of inpatient cardiac rehabilitation. Cluster randomization was chosen for pragmatic reasons, i.e. to ensure a sufficient number of eligible patients to build large-enough educational groups and to prevent contamination by interaction of patients from different treatment allocations during rehabilitation. Rehabilitants with chronic systolic heart failure (n = 540) will be consecutively recruited for the study at the beginning of inpatient rehabilitation. Data will be assessed at admission, at discharge and after 6 and 12 months using patient questionnaires. In the intervention condition, patients receive the new patient-oriented self-management educational program, whereas in the control condition, patients receive a short lecture-based educational program (usual care). The primary outcome is patients' self-reported self-management competence. Secondary outcomes include behavioral determinants and self-management health behavior (symptom monitoring, physical activity, medication adherence), health-related quality of life, and treatment satisfaction. Treatment effects will be evaluated separately for each follow-up time point using multilevel regression analysis, and adjusting for baseline values. DISCUSSION: This study evaluates the effectiveness of a comprehensive self-management educational program by a cluster randomized trial within inpatient cardiac rehabilitation in Germany. Furthermore, subgroup-related treatment effects will be explored. Study results will contribute to a better understanding of both the effectiveness and mechanisms of a self-management group program as part of cardiac rehabilitation. TRIAL REGISTRATION: German Clinical Trials Register: DRKS00004841; WHO International Clinical Trials: = DRKS00004841.

Assessment of proximal outcomes of self-management programs: translation and psychometric evaluation of a German version of the Health Education Impact Questionnaire (heiQ™).

PURPOSE: This paper describes the translation, cultural adaption, and psychometric evaluation of a German version of the Health Education Impact Questionnaire (heiQ™), a widely used generic instrument assessing a wide range of proximal outcomes of self-management programs. METHODS: The translation was carried out according to international standards and included forward and backward translations. Comprehensibility and content validity were tested using cognitive interviews with 10 rehabilitation inpatients. Psychometric properties were examined in rehabilitation inpatients (n = 1,202) with a range of chronic conditions. Factorial validity was assessed using confirmatory factor analysis; concurrent validity was explored by correlations with comparator scales. RESULTS: The items of the German heiQ™ were well understood by rehabilitation inpatients. The structure of the eight heiQ™ scales was replicated after minor adjustment. heiQ™ scales had higher correlations with comparator scales with similar constructs, particularly mental health concepts than with physical health. Moreover, all heiQ™ scales differentiated between individuals across different levels of depression. CONCLUSION: The German heiQ™ is comprehensible for German-speaking patients suffering from different types of chronic conditions; it assesses relevant outcomes of self-management programs in a reliable and valid manner. Further studies involving its practical application are warranted.

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

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.

Improved self-management skills predict improvements in quality of life and depression in patients with chronic disorders.

OBJECTIVE: Self-management programs aim to improve patients' skills to manage their chronic condition in everyday life. Improvement in self-management is assumed to bring about improvements in more distal outcomes, such as quality of life. This study aimed to test the hypothesis that changes in self-reported self-management skills observed after participation in self-management programs predict changes in both quality of life and depressive symptoms three months later. METHODS: Using latent change modeling, the relationship between changes in latent variables over three time points (start and end of rehabilitation, after three months) was analysed. The sample comprised 580 patients with different chronic conditions treated in inpatient rehabilitation clinics. The influence of additional predictor variables (age, sex, perceived social support) and type of disorder as a moderator variable was also tested. RESULTS: Changes in self-reported self-management skills after rehabilitation predicted changes in both quality of life and depressive symptoms at the end of rehabilitation and the 3 months follow-up. These relationships remained significant after the inclusion of other predictor variables and were similar across disorders. CONCLUSION: The findings provide support for the hypothesis that improvements in proximal outcomes of self-management programs may foster improvements in distal outcomes. Further studies should investigate treatment mechanisms.

The impact of a self-management patient education program for patients with chronic heart failure undergoing inpatient cardiac rehabilitation.

OBJECTIVE: To evaluate a patient-centred self-management educational group program for patients with chronic systolic heart failure as compared to usual care education during inpatient cardiac rehabilitation. METHODS: A multicentre cluster randomized controlled trial of 475 patients was conducted. In the intervention condition, patients received the new self-management educational group program whereas in the control condition, patients received a short lecture-based educational program (usual care). The primary outcome was patients' self-reported self-management competence. Secondary outcomes included self-management health behaviour, health-related quality of life, and treatment satisfaction. Patients completed self-reported outcome measures at admission, discharge, and after 6 and 12 months. RESULTS: There was a significant small between-group intervention effect on certain dimension of patients' self-management competence (self-monitoring and insight) in short term (p<0.05). Furthermore, significant small effects were observed for treatment satisfaction at discharge as well as symptom monitoring after 6 months (p<0.05) and by trend on symptom monitoring and physical activity after 12 months. CONCLUSIONS: The patient-centred self-management program might be more effective in certain self-management outcomes than a usual care education in both short-term and long-term periods. PRACTICE IMPLICATIONS: Therefore, such programs may be considered for dissemination within cardiac rehabilitation.