A Public Health Priority
The Centers for Disease Control and Prevention (CDC) has a longstanding commitment
to developing and promoting evidence-based strategies to prevent or delay disease
and disability (1, 2). Significant among these strategies is support for self-management
of chronic diseases. About one-half of all U.S. adults have at least one chronic condition
(3) and over two-thirds of Medicare beneficiaries aged 65 years or older have two
or more chronic conditions (4). Given that the risk of developing a chronic disease
increases with advancing age (5), the dramatic aging of the U.S. population underscores
the importance of chronic disease self-management supports. Further, effective self
management of chronic conditions is essential to achieving a state of health, which
is proposed to reflect “the ability to adapt and to self manage” (6).
An effective approach to improve population health requires a strong focus on self-management.
CDC’s National Center for Chronic Disease Prevention and Health Promotion includes
among its four priorities efforts to help ensure that “communities support and clinics
refer patients to programs that improve management of chronic conditions” (7). Self-management
(e.g., what individuals and families do on a daily basis to feel better and pursue
the life they desire) (8) and self-management support (e.g., actions taken by others
to support individual self-management) (9) are critical strategies in meeting this
priority objective. The U.S. Department of Health and Human Services recognized the
importance of self-management support in its framework for addressing multiple chronic
conditions (MCC). One of the four goals of the framework is to “maximize the use of
proven self-care management and other services by individuals with MCC” (10).
Chronic disease self-management support occurs at the intersection of public health,
clinical healthcare delivery, social services, aging services networks, and other
community resources. In this commentary, we provide a public health perspective on
self-management support, identify examples of CDC investment in self-management support
activities, and discuss potential future directions. These examples are provided to
illustrate the breadth of CDC’s work in this area and are not designed to serve as
comprehensive list of CDC’s investment in self-management support.
An International Foundation for Understanding
Consistent with a public health perspective, we advance an expanded definition of
self-management support from the International Framework for Chronic Condition Self-Management
Support. This definition describes self-management support as a grouping of policies,
programs, services, and structures that extend across healthcare, social sectors,
and communities to support and improve the way individuals manage their chronic conditions
(11). The definition frames self-management support within a social-ecological perspective
underscoring individual, interpersonal, community, environmental, and systems levels
resources (12). This definition also embraces a life course perspective that attends
to individual autonomy and decision-making as well as role changes and other adaptations
to life events (13).
Self-management support takes many forms. It includes interventions such as the Chronic
Disease Self-Management Program (CDSMP) (14) and the falls prevention programs featured
in this special issue (15). It also includes supportive interactions between healthcare
providers and patients, proactive follow-up, and social and physical environments
that support healthy behaviors such as having safe places to exercise, access to healthy
foods, and social norms that combat stigma, promote social participation, and support
self-care behaviors (9).
Self-management support interventions are provided in a variety of formats (e.g.,
one-to-one, small groups, telephone, online/mobile, self-study); and in a variety
of settings (e.g., home, healthcare, worksite, community) (9, 12). Although the form
and formats vary, the goal of self-management support is consistent: to help individuals
and their personal support system acquire and maintain the knowledge, skills, and
confidence to do what they need to do to live as well as possible with their chronic
condition(s).
Advancing the Study and Application of Self-Management Support
The International Framework for Chronic Condition Self-Management Support identifies
seven key strategic directions to move self-management support forward in research,
policy, and practice at the local, regional, state, and national levels. These strategic
directions are to involve consumers, expand the reach and range of services, advance
evidence, improve effectiveness and appropriateness of services, strengthen inter-sector
linkages, foster multi-sector commitment and accountability, and build infrastructure.
Using this organizing structure (11), in Table 1, we highlight a few select but illustrative
examples of CDC’s contributions to the Framework’s seven strategic directions.
Table 1
Self-management support strategic directions: select CDC program examples.
Strategic direction
Tactic
CDC program examples
a
Involve consumers
Community-based participatory research
CDC’s prevention research centers (PRC) use community-based participatory research
methods as a foundation for their research (16). Evidence-based intervention programs
such as Enhance Fitness (17) to increase physical activity among older adults and
PEARLs (18) to screen and treat depression among older adults were developed at PRCs
(http://www.cdc.gov/prc).
Audience research
CDC collaborated with the Arthritis Foundation to support qualitative and quantitative
market research that provided insights into the types of services people with arthritis
want to support their self-management efforts (Listening to Consumers: What do People
With Arthritis Want? A Focus Group Report to: The Centers for Disease Control and
Prevention (Arthritis Program) and the Arthritis Foundation. Unpublished report by
Fleishman Hillard, 2006; Receptivity to Existing and Potential Programs and Services
for People with Arthritis. A Report to the Arthritis Foundation. Unpublished report
by Fleishman Hillard, 2007).
CDC conducted audience research with people with various chronic conditions and determined
that non-disease specific, non-intervention specific messaging to increase the visibility
of self-management education would resonate with consumers and motivate them to seek
more information on specific interventions (Audience Research to Determine the Feasibility
of Developing a Marketing Campaign to Increase Visibility of Self-Management Education.
Unpublished report submitted to CDC by FHI 360, 2014). CDC is developing this type
of broad awareness campaign.
Expand reach and range of services
Tele-health
Emory University developed Project UPLIFT, an effective tele-health intervention delivered
by phone and Internet that helps adults with epilepsy and comorbid depression reduce
their depressive symptoms, and improve some well-being domains (19).
Self-study interventions
The University of North Carolina and Stanford University developed and evaluated The
Arthritis Toolkit that provides the content of the small group-delivered Arthritis
Self-Management Program (ASMP) in a mail-delivered, self-study format (20). Currently,
CDC is funding Stanford University to develop a self-study version of the Chronic
Disease Self-Management Program (CDSMP).
Online interventions
Stanford University
b
developed an online (virtual group) version of the ASMP (21), and national dissemination
a
is being pilot-tested by the Arthritis Foundation.
a
(http://www.arthritistoday.org/arthritis-self-management-program/).
The American Cancer Society pilot-tested a cancer-specific online version of the CDSMP,
titled Cancer: Thriving and Surviving, developed at Stanford University (https://cancer.selfmanage.org/survivor/hl/hlMain).
Emory University PRC developed and tested, WebEase (Epilepsy Awareness Support and
Education), an online program that is available on the national Epilepsy Foundation
web site (22).
Advance evidence
Meta-analysis
CDC conducted meta-analyses of 24 ASMP and 23 CDSMP studies that documented robust
improvements in health outcomes and health behaviors across multiple studies (23,
24).
Intervention research
PRCs, in collaboration with other universities, conducted effectiveness studies that
substantiated evidence-based community interventions such as the Arthritis Foundation
Exercise Program, Walk with Ease, Enhance Fitness, and First Steps to Active Health
(http://www.cdc.gov/arthritis/funded_science/completed/index.htm).
Improve effectiveness and appropriateness of services
Clinical-decision support tools
The University of Texas (Houston) PRC developed and tested MINDSET (Management Information
& Decision Support Epilepsy Tool), a tablet-based tool for inputting data on (1) seizures
(e.g., history, management); (2) medicine (e.g., barriers, side effects), and (3)
lifestyle (e.g., social support). The tool is designed to enhance patient-provider
communication and action planning to sustain or improve epilepsy self-management behaviors
(25).
Comparative effectiveness studies
The University of North Carolina PRC conducted a study of CDSMP and ASMP among people
with arthritis that documented the equivalence of these two interventions for people
with arthritis (26).
The University of Pittsburg PRC conducted a study of preventing falls among older
adults that compared 3 strategies: usual care, an education program, or an education-plus-exercise
program (http://www.caph.pitt.edu/wps/docs/falls/FP_AlbertfallsCDCpresentation9-25-11.pdf).
Strengthen inter-sector linkages
Community-clinical linkages
CDC’s Heart Disease and Stroke Prevention Program is collaborating with the Vermont
Blue Print for Health to explore the use of community-health workers as part of the
primary care team to help assess patients’ needs and coordinate community-based support
services (27).
Linking public health and aging services networks
The Healthy Aging Research Network, a thematic network of the PRC Program, developed
and implemented a national research and dissemination agenda related to the public
health aspects of healthy aging (28).
Linking mental health and public health
The Managing Epilepsy Well Network, a thematic network of the PRC Program, includes
interdisciplinary teams of researchers who collaborate across mental health and epilepsy
sectors to develop and implement evidence-based self-management programs that target
both physical and mental health needs of people with epilepsy (29).
Linking multiple stakeholders
The Osteoarthritis Action Alliance, under the auspices of the Arthritis Foundation,
provides a forum for multiple organizations to work collaboratively to advance the
osteoarthritis public health agenda including increasing physical activity and fostering
self-management education (http://www.oaaction.org).
Foster multi-sector commitment and accountability
Strategic frameworks
The U.S. Department of Health and Human Services developed the document, The Multiple
Chronic Conditions: A Strategic Framework that outlines national strategies for improving
health and quality of life for individuals with multiple chronic conditions (MCC),
and cites the use of proven self-care management and other services by individuals
with MCC as one of its’ four strategic goals (10).
CDC staff participated in the development of the International Framework for Chronic
Condition Self-Management Support that highlights priority strategic directions to
advance the research, policy, and practice of self-management support (11).
National objectives
Healthy People 2020 includes objectives to increase participation in self-management
education among select chronic disease populations including people with arthritis
and diabetes (http://www.healthypeople.gov/2020/topicsobjectives2020/objectiveslist.aspx?topicId=3;
http://www.healthypeople.gov/2020/topicsobjectives2020/objectiveslist.aspx?topicId=8).
Convening stakeholders
CDC collaborated with the Arthritis Foundation to convene a broad stakeholder group
that developed Environmental and Policy Strategies to Increase Physical Activity among
People with Arthritis; this document recommends strategies for action in 6 sectors
including community, business, healthcare, transportation, parks and recreation, and
mass media (http://www.arthritis.org/files/documents/OA_Physical_Activity_Rpt_508_v1_TAG508.pdf).
Build infrastructure
Professional training opportunities
The Managing Epilepsy Well Network provided professional training that helped providers
better understand self-management strategies and how to implement at least three evidence-based
self-management programs (http://web1.sph.emory.edu/ManagingEpilepsyWell/index.php).
Capacity building
All 50 states receive CDC funding to support the delivery of diabetes self-management
education through consolidated chronic disease funding (http://www.cdc.gov/chronicdisease/about/statepubhealthactions-prevcd.htm).
Individual CDC programs focused on asthma, arthritis, diabetes, and heart disease
have supported at least 40 state health departments to disseminate CDSMP.
The National Association of County and City Health Officials, the National Recreation
and Parks Association, and the Y-USA are testing their ability to serve as national
delivery systems in disseminating self-management support interventions. http://naccho.org/topics/HPDP/chronicdisease/cdsmp.cfm;
http://c.ymcdn.com/sites/www.chronicdisease.org/resource/resmgr/Arthritis_Monthly_Reports/030513_ACHandoutDisseminatio.pdf).
Effective dissemination strategies
CDC collaborated with the National Association of Chronic Disease Directors to support
a multi-site evaluation of state health department approaches to dissemination of
evidence-based interventions. This evaluation documented the effectiveness of working
with multi-site delivery systems, embedding interventions into routine operations,
collaborating with other chronic disease programs and prioritizing the expansion of
reach (Strategic approaches to expanding the reach of evidence-based interventions:
results of a multi-state evaluation) (Unpublished report submitted to the National
Association of Chronic Disease Directors by Westat, 2012.) (http://www.cdc.gov/arthritis/publications/reports.htm).
aCDC funded these efforts unless otherwise noted.
bCDC provided partial funding.
Through funded research and other mechanisms, CDC and its partners have employed a
variety of strategies to involve consumers by using applied community-based participatory
strategies in developing evidence-based programs and audience research. To expand
the range and reach of services, CDC supports the development, evaluation, and dissemination
of a variety of small group, tele-health, self-study, and online self-management support
tools. To advance evidence, CDC investigators conduct systematic reviews of the literature
and CDC funds applied prevention research to establish or strengthen the evidence-base
of programs and policies. To improve the effectiveness and appropriateness of services,
CDC supports comparative effectiveness studies and research designed to develop and
test clinical-decision support tools. In terms of efforts to strengthen inter-sector
linkages, CDC supports community-clinical collaborations and makes linkages across
public health sectors. CDC also helps to foster multi-sector commitment and accountability
through the development of new frameworks and guidelines. Finally, CDC invests in
building infrastructure to deliver self-management support intervention programs at
the national, state, and local levels systems initiatives.
Sustaining Self-Management Support: Gaps and Opportunities
The need to advance efforts in self-management support is well recognized in the public
health arena. However, challenges remain and several research questions are yet unanswered.
Such questions include how to identify the essential elements of an intervention,
how to best target effective interventions to specific audiences, and how to determine
the effect of self-management support on critical public health outcomes and biometric
measures such as hemoglobin A1c and blood pressure. Additional comparative effectiveness
and cost effectiveness research studies of self-management support interventions are
necessary. Importantly, selected papers in this special issue will help address these
issues.
If self-management support interventions are to achieve their potential for public
health impact, they need to be integrated into comprehensive chronic disease management
strategies at the national, state, and local levels, and across sectors. Given the
large and diverse population of people living with chronic conditions, engagement
of multiple organizations across various sectors is required to reach those in need.
Ideally, self-management support will become an integral element of clinical care
standards of care (30), part of the routine menu of services offered by a variety
of community agencies, and an essential component of community chronic disease control
efforts. Finally, sustaining self-management support will require the infrastructure
as well as multi-sectoral resources to reach people where they live, learn, work,
and engage with their family and community. Creative financing mechanisms will need
to be developed or expanded to ensure wide availability of evidence-based self-management
support.
The Centers for Disease Control and Prevention is supporting a wide variety of self-management
support activities across multiple strategic directions. CDC supported activities
exemplify a comprehensive view of self-management support that encompasses both health-enhancing
individual behaviors and physical and social environmental contexts that influence
self-management behaviors. To advance self-management support, several important areas
of research need to be conducted, broad-based organizational engagement needs to occur,
and delivery capacity infrastructure and financing mechanisms need to be established
or expanded. Despite these challenges, it remains essential to create self-management
support services and environmental supports that allow people to live well with their
chronic condition.
Conflict of Interest Statement
The authors declare that the research was conducted in the absence of any commercial
or financial relationships that could be construed as a potential conflict of interest.
This paper is included in the Research Topic, “Evidence-Based Programming for Older
Adults.” This Research Topic received partial funding from multiple government and
private organizations/agencies; however, the views, findings, and conclusions in these
articles are those of the authors and do not necessarily represent the official position
of these organizations/agencies. All papers published in the Research Topic received
peer review from members of the Frontiers in Public Health (Public Health Education
and Promotion section) panel of Review Editors. Because this Research Topic represents
work closely associated with a nationwide evidence-based movement in the US, many
of the authors and/or Review Editors may have worked together previously in some fashion.
Review Editors were purposively selected based on their expertise with evaluation
and/or evidence-based programming for older adults. Review Editors were independent
of named authors on any given article published in this volume.