B. Background and Significance We focus our discussion on three aspects of self-management research that provide the primary rationale for inclusion of this Core: theoretical, measurement, cultural, and health literacy issues in self-management;the need for biobehavioral approaches;and the role of informatics in self-management support. B1. Theoretical, Measurement, Cultural, and Health Literacy Issues in Self-Management A number of methodological weaknesses have been identified in self-management research, which we describe briefly here and in the Design, Methods, Biostatistics, and Economic Analysis Core. [1-4] In a review of self-management interventions for three chronic illnesses (type 2 diabetes, arthritis, asthma), the authors noted the inadequate descriptions of the theoretical underpinnings, recommending more precise articulation of the rationale """"""""if we are to establish which theoretical approach is most valuable for which illnesses."""""""" (p. 1530) [3] In a second review, Jack et al.[2] qualitatively re-examined 8 studies on community-based diabetes self-management from a published systematic review [5] and concluded that the theoretical frameworks were inadequate to explain the complex pathways that produce health outcomes. Consistent with the CEBP framework (the Chronic Care Model), the authors proposed a contextual framework that encourages targeting of multiple levels of influence - individual, family, organizational, community, and policy. Taken together, these critical reviews identify the need for more explicitly-developed theoretical frameworks to improve understanding of self-management behavior and to predict under what circumstances a self-management intervention is likely to produce the desired outcome. B2. The Need for Biobehavioral Approaches The need for biobehavioral approaches in self-management is widely acknowledged and reflected in NINR's Strategic Plan and in its funding portfolio. [24] Indeed, a hallmark of nursing science is its application of biobehavioral approaches to key phenomena of interest to nursing such as dyspnea, heart failure, pain, menopause, adherence, and glycemic control. [9, 25-32] However, to date, many self-management studies have been limited to only behavioral or biological approaches and even fewer have addressed the emerging genomic data that may be of great relevance to certain conditions to tailor self-management interventions. Moreover, there is increasing recognition of the critical role that environmental factors play in an individual's ability to change their behavior, e.g., lack of safe outdoor spaces for exercise and of the significant relationship between mental health conditions such as depression and self-management behaviors. [33-35] Consequently, it is vital to increase biobehavioral research capacity to improve self-management approaches and outcomes and better predict which individuals are most likely to benefit from a particular self-management intervention. B3. Potential Roles for Informatics in Self-Management Support The potential for informatics as an enhancer of self-management support (information, education, reminders, email, social support, etc.) has been well-documented over the last decade. [36-41] Nurse scientists have substantially contributed to this body of literature since the 1980's. Brennan has documented the efficacy of multi-faceted self-management interventions across a number of studies in a variety of populations during the last two decades. [42-50] Most recently, she has turned her attention to defining personal health records, a key component of our Nation's emerging strategic framework for a national information infrastructure, [20] in a manner that facilitates self-management. [51-53] She will provide her expertise on this latter topic as a consultant to Currie's CEBP project in this submission. Another example is Lorig et al., who conducted an RCT of an Internet version of a Chronic Disease Management Program as compared to usual care and documented significantly better health status in the experimental group. [54] Ruland (CEBP External Advisory Board) directs a program of research on health information technologies to improve shared decision making and patient-provider communication in health care. A primary focus of this work is symptom management strategies in cancer. [55-58] In more recent years, increasing numbers of nurse investigators have integrated web-based strategies into self-management programs. [59-61] Less frequently implemented and evaluated are self-management support systems that monitor laboratory and physiologic data as well as deliver multi-faceted self-management interventions via the Internet. [62] Further research is needed to address the biobehavioral outcomes of informatics-based self-management interventions and to design intervention studies that optimize the use of information technology to systematically gather relevant biological and physiologic data.
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