Abstract
Over the past two decades, self-management programmes for chronic obstructive pulmonary disease (COPD) have been developed, tested and refined. Ranging from something as straightforward as an action plan for treating exacerbations 1,2 to comprehensive regimes of supervised education and exercise training from a multidisciplinary team, 3,4 self-management programmes have taken various guises and reported mixed success in their impact on patient outcomes. 5 The study described by Turner et al. 6 highlights two novel features of their self-management intervention which differentiates it from many other self-management programmes for COPD that have been published to date.
Firstly, the authors demonstrate a clear understanding of the theoretical framework that underpins the intervention. 6 The self-management programme that Turner et al. described is based on social learning theory, which was originally published by Albert Bandura in the 1970s. 7 Social learning theory dictates that behaviour is a cognitive process, which is acquired through observation and imitation of the behaviours we see around us. Not only do we learn from observing behaviour but also its consequences. Achieving, and furthermore maintaining behaviour change, is a fundamental goal of self-management intervention, and it remains a considerable challenge; therefore, it seems worthwhile to explore and investigate theories, laid down in psychology literature, which may enhance it. The co-creating health intervention described by Turner et al. 6 is a combined lay-led and health care professional-led programme. The presence of the lay tutor and their experience in self-management behaviours provides a platform for patients on the programme to observe in ‘real life’ the behavioural changes we want them to learn, as well as to listen to verbal accounts from the lay tutor directly. This lends patients the opportunity to model their behaviour on that of the lay tutor, and, according to social learning theory, thereby potentially optimizes the prospect of behaviour change. Although as yet we do not understand the added value of developing a self-management intervention on behaviour change theory, this is a novel approach in many self-management programmes in COPD.
The second unique feature of this study is the selection of outcome measures, in particular, the primary outcome of patient activation. Patient activation encompasses the requirements for individuals to be informed managers of their own health care and includes appropriate skills and knowledge of their disease, their health beliefs and motivation. 8 The concept of patient activation is seldom reported as an outcome in the COPD self-management literature. Figure 1(a) illustrates that there can be a process from delivery of the self-management intervention, which is required to improve knowledge, skills, health beliefs and motivation (core components of activation), this in turn might influence behaviour, and the result of the behaviour change drives the desired outcome. Many self-management programmes in COPD do not measure steps two or three (Figure 1(b)) and instead only measure the final outcome, for example, hospital admission or health status. However, in the event the outcome is not achieved, without measuring either activation or behaviour, we cannot understand at what stage of this process the intervention fails. Also, this assumes that if the final outcome does not change, that the intervention was not useful, which may not be the case. Figure 1 demonstrates that the link between the intervention and the outcome is not straightforward, and indeed, this model is complicated further when we consider additional social, environmental and psychological influences on behaviour. Measuring activation or any of its components, however, is the first step in establishing whether the intervention does what it aims to do and how behaviour change and outcomes may be initiated. Establishing not only if self-management interventions work but also understanding the processes in how they work is of importance for taking the field forward.
Process of behaviour change.
Amidst recent scepticism about the efficacy of self-management for COPD due to several negative and potentially harmful studies, there is a need to have a more comprehensive understanding of the processes that happen when patients are undergoing these interventions and the wider impact they have. The novel approaches taken in this study take us a step forward in achieving this.