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

Self-Regulation in Chronic Disease

Noreen M. Clark, Ph.D.March 23, 2002

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

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

Many factors help or hinder individuals in their management tasks.

Management by Management by PatientPatient

Family InvolvementFamily Involvement

Clinical ExpertiseClinical Expertise

Work/School SupportWork/School Support

Community Awareness, Support & ActionCommunity Awareness, Support & Action

Community-Wide Environmental Control MeasuresCommunity-Wide Environmental Control Measures

Conducive PoliciesConducive Policies

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

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

Our research group has been examining three aspects of self-regulation:a) its constituents or elements

b) how these are integrated into a model

c) how they predict outcomes related to chronic disease management

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

The elements of self-regulation we have identified are:

• observation• judgment• reaction:

- expectation - efficacy

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

A Model of Self-Regulation

Intrapersonal Factors • Knowledge• Attitudes• Feelings• Beliefs

External Factors• Role models

• Technical advice and service• Social support

• Money and material resources

Judgments

Observations

Reactions (outcomeexpectations

& self-efficacy)

Internal and External Factors

Use of ManagementStrategies• Prevention

• Disease control

Reactions (outcome

expectations& self-efficacy)

Judgments

Observations

Management Strategies

End Points• Reaching personal goals

• Physiological status• Functioning

• Health care use• Perceptions of quality

Reactions (outcomeexpectations

& self-efficacy)

Observations

Judgments

End Points

Elements of Self-Regulation

Intrapersonal Factors

• Knowledge• Attitudes• Feelings• Beliefs

External Factors• Role models

• Technical advice and service• Social support

• Money and material resources

Judgments

Observations

Reactions (outcome

expectations& self-efficacy)

Use of ManagementStrategies

• Prevention

• Disease control

Reactions (outcome

expectations& self-efficacy)

Judgments

Observations

End Points• Reaching personal goals

• Physiological status• Functioning

• Health care use• Perceptions of quality

Reactions (outcomeexpectations

& self-efficacy)

Observations

Judgments

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

A Study of Parent Management

of a Child’s Asthma• N=637 families in Michigan

and New York• Data Collection:

– Baseline– 6 months– 1 year later

Data Analysis• 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.

* Cronbach alpha = .77

Measures

Observation• look for early warning signs• watch child when symptoms begin• determine if symptoms are

improving• monitor child after giving

medications

* Cronbach alpha = .62

Measures

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

* Cronbach alpha = .70

Measures

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

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

Outcome Expectations, cont’d.

– removing child from source of symptoms

– giving medications preventively– keeping child away from irritants/

allergies– asking for help/advice

* Cronbach alpha = .80

Management Strategies

The extent to which parents used the specific actions described.

Intrapersonal Factors

• Asthma knowledge/beliefs• Awareness of treatment plan

* Cronbach alpha = .82

External Factors

• Role models• Social support• Technical services

* Cronbach alpha = .65 -.77

Outcomes

• Quality of life• Severity of asthma in past year• Hospitalizations• ED visits• Office visits

Baseline

.175(.000)

IntrapersonalFactors

External Factors

ManagementStrategies

Judgment

Observations

Confidence

.021(.026)

.015(.042)

Stable elements of Self-Regulation

.535 (.000)

.357(.000)

Follow-up 1

.184(.000)

IntrapersonalFactors

External Factors

ManagementStrategies

Judgment

Observations

Confidence

.299(.000)

.061(.000)

Stable elements of Self-Regulation

.399 (.003)

.464(.000)

Follow-up 2

.126(.000)

IntrapersonalFactors

External Factors

ManagementStrategies

Judgment

Observations

Confidence

.191(.000)

.251(.000)

Stable elements of Self-Regulation

.447 (.000)

. 624(.000)

Elements of Self-Regulation

.126 (.000)

.184 (.000)

.175 (.000)

Baseline Follow-up 1 Follow-up 2

Intrapersonal Factors

Intrapersonal Factors

Intrapersonal Factors

ExternalFactors

ManagementStrategies

Judgment Judgment

Observations

Confidence

Observations Observations

Confidence & Outcome

Expectations

.021 (.026)

.535 (.000)

.299 (.000)

.399 (.003)

.191 (.004)

.447 (.000)

.251

.624

(.018)

(.000)

.161 (.000)

.464 (.000)

.015 (.042)

.357 (.000)

ExternalFactors

ExternalFactors

ManagementStrategies

ManagementStrategies

Confidence & Outcome

Expectations

Judgment

Predictive Ability of Constructs

Quality of Life

Severity

Hospitalization

ED Visit

Follow-up Visit

Baseline Follow-up 2

External Factors

Management Strategies

Judgment

Observations

Confidence

Intrapersonal Factors

-.722 (.060)

-.524 (.003)

-.394 (.007)

.537 (.036)

-.290 (.000)

-.969(.011)

Baseline to two years later

Tentative Conclusions

• Observation, judgment and reaction are interrelated and reciprocally reinforcing.

• Observation and judgment are directly associated with use of disease management strategies.

• 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.

• 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.

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

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

Specific Techniques May Enhance Self-Regulation

Skills

Observation

• Diaries• Record keeping• Physiologic monitoring• Practice

Judgment

• Setting criteria• Rehearsing decision-making

Reaction

• Self-efficacy– realistic assessments– social support– role models

Reaction

• Outcome expectations–analysis of means-ends relationships

–persuasive communicators–role models

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