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

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

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

4. Many factors help or hinder individuals in their management tasks.

5. Management by Patient Family Involvement Clinical Expertise Work/School Support Community Awareness, Support & Action Community-Wide Environmental Control Measures Conducive Policies

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

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

8. 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

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

10. The elements of self-regulation we have identified are: observation judgment reaction: - expectation - efficacy

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

12. A Model of Self-Regulation

13. 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) Internal and External Factors

14. Use of Management Strategies Prevention Disease control Reactions (outcome expectations & self-efficacy) Judgments Observations Management Strategies

15. End Points Reaching personal goals Physiological status Functioning Health care use Perceptions of quality Reactions (outcome expectations & self-efficacy) Observations Judgments End Points

16. 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 Management Strategies 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 (outcome expectations & self-efficacy) Observations Judgments

17. 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

18. 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

19. 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.

20. * 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

21. * 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

22. * 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

23. 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

24. 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

25. Management Strategies The extent to which parents used the specific actions described.

26. Intrapersonal Factors Asthma knowledge/beliefs Awareness of treatment plan * Cronbach alpha =.82

27. External Factors Role models Social support Technical services * Cronbach alpha =.65 -.77

28. Outcomes Quality of life Severity of asthma in past year Hospitalizations ED visits Office visits

29. Baseline.175 (.000) Intrapersonal Factors External Factors Management Strategies Judgment Observations Confidence.021 (.026).015 (.042) Stable elements of Self-Regulation.535 (.000).357 (.000)

30. Follow-up 1.184 (.000) Intrapersonal Factors External Factors Management Strategies Judgment Observations Confidence.299 (.000).061 (.000) Stable elements of Self-Regulation.399 (.003).464 (.000)

31. Follow-up 2.126 (.000) Intrapersonal Factors External Factors Management Strategies Judgment Observations Confidence.191 (.000).251 (.000) Stable elements of Self-Regulation.447 (.000). 624 (.000)

32. Elements of Self-Regulation.126 (.000).184 (.000).175 (.000) BaselineFollow -up 1 Follow -up 2 Intrapersonal Factors Intrapersonal Factors Intrapersonal Factors External Factors Management Strategies Judgment Observations Confidence 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) External Factors External Factors Management Strategies Management Strategies Confidence & Outcome Expectations Judgment

33. Predictive Ability of Constructs

34. 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

35. Tentative Conclusions

36. Observation, judgment and reaction are interrelated and reciprocally reinforcing. Observation and judgment are directly associated with use of disease management strategies.

37. 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.

38. 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.

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

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

41. Specific Techniques May Enhance Self-Regulation Skills

42. Observation Diaries Record keeping Physiologic monitoring Practice

43. Judgment Setting criteria Rehearsing decision-making

44. Reaction Self-efficacy – realistic assessments – social support – role models

45. Reaction Outcome expectations –analysis of means-ends relationships –persuasive communicators –role models

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