Patient activation in long-term conditions: a systematic review of the effectiveness of self-management interventions for improving patient activation using the short-form Patient Activation Measure and an empirical study of the variables associated with patient activation and self-management in multiple sclerosis
Purpose: The systematic review explored whether self-management interventions improve patient activation in long-term conditions, and if any improvements are greater than the amount of change experienced by patients in usual care or active control conditions. It also aimed to determine if positive effects on activation are maintained at follow-up. The empirical study sought to explore relationships between patient activation, psychological factors (depression and valued living), perceived clinician empathy, perceived symptom severity, self-management and demographic variables. It also examined whether depression, valued living and perceived clinician empathy are unique predictors of activation, and if activation is a unique predictor of self-management for MS, when relevant confounding variables are controlled for. Methods: For the systematic review, a comprehensive search of multiple electronic databases was conducted to identify intervention research reporting on patient activation outcomes, as measured by the short-form Patient Activation Measure (PAM-13), in people with long-term conditions. For the empirical study, a cross-sectional survey of 118 people with MS explored patient activation, MS symptom severity, valued living, depression, perceived clinician empathy, self-management for MS and demographic factors. Correlation and hierarchical regression analyses were employed to explore relationships between variables. Results: Twenty-five studies were eligible for inclusion in the systematic review, reporting a wide range of long-term conditions. Twenty-one studies (10 RCTs; 1 non-randomised study; and 10 uncontrolled studies) found an improvement in patient activation at post-intervention. Nine studies reported a significantly greater improvement in activation in self-management conditions compared with usual care or an active control at post-intervention. In six out of eight studies, gains in patient activation were maintained in the intervention group at follow-up. However, in four of these six studies, patient activation in the control group also improved over time. Findings from the empirical study suggested that only valued living was a significant predictor of patient activation after controlling for demographic variables and MS symptom severity. Neither depression nor perceived clinician empathy significantly predicted activation. After controlling for valued living, depression and perceived clinician empathy, patient activation independently predicted 5.5% of variance in self-management for MS. Both activation and perceived clinician empathy were significant predictors of self-management for MS. Conclusions: Self-management interventions improve patient activation in long-term conditions compared with usual care or active control. Patient activation gains appear to be maintained longer-term; however, the impact of self-management interventions on activation is unclear due to increases in activation in control groups over time. Valued living is associated with patient activation in MS, while patient activation and perceived clinician empathy are associated with MS self-management. Self-management interventions targeting valued living and the patient-clinician relationship may be effective for addressing low levels of activation in some patients with MS.
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