Thesis (Ph.D. (Health Sciences)) -- University of Limpopo, 2022 / Background: Cardio Vascular Diseases(CVD) are presently the main cause of high mortality rate around the world. In sub-Saharan Africa, CVDs contributes to about 13% of deaths, with 80% deaths being recorded from developing countries. Behavioural and metabolic risk factors contribute to high mortality rate related to development of CVD which self-management strategies and practices could effectively prevent. Objective: To explore and develop ―self-management strategies‖ to prevent the development of CVD among patients living with chronic conditions at Ga Molepo Area clinics in the Limpopo Province, South Africa. Methods: “A mixed method exploratory sequential design study was conducted in four primary health care settings in a rural setting.‖ A semi structured one-on-one interviews were conducted with 43 patients selected by non-probability homogenous purposive sampling for a qualitative strand. Qualitative findings that was obtained with thematic ―Tesch‘s open coding data analysis method guided the quantitative strand‖. A simple random sampling was used to sample 347 respondents for the quantitative strand.Descriptive statistics and chi-square were applied to analyze data from the quantitative strand. ``Results: The qualitative results revealed that there is different self management strategies used by patients living with hypertension and Diabetes Mellitus as risk factors of CVDs. The self-management strategies include engaging in physical activity, eating a healthy balanced diet, drinking a lot of water and adhering to treatment. The quantitative revealed majority of participants(74%) perform mild exercises with 26% performing moderate exercis.On the other hand 7% are having stress and depression and while 7% are smoking.`` Conclusions:The findings indicated that by adopting self-management strategies could be an effective way of preventing the development of CVD which complicates to hypertension and diabetic mellitus .Therefore are encouraged to adhere to strategies adhere to treat,healthy diet and perform mild exercises Recommendations Hence, the government needs to appoint CHW permanently to strengthen the guidelines on the prevention of CVD and also the risk factors that put the communities at risk of developing CVD. Communities need to adhere to preventative strategies ti order prevent CVD. / SPICES Project - (Scaling -up Packages of Interventions for CVD prevention in Europe and sub-Saharan)

Rheumatoid arthritis (RA) is a chronic, progressive autoimmune disease causing inflammation of the synovium resulting in severe pain, joint disfigurement and disability as well as malaise, fatigue and a depressed immune system. Treatment consists of three broad phases; firstly, following diagnosis treatment is focussed on rapid reduction of pain and inflammation. Secondly, maintenance of quiescence is sought through medication. Finally, if disease activity remains high despite medication, escalation to anti-TNF α therapy is required to prevent permanent joint damage and disability. The primary course of treatment is prescription of disease modifying anti-rheumatic drugs (DMARDs) within 3 months of onset of symptoms. However, DMARDs can take 8-12 weeks to exhibit a noticeable benefit whereas unpleasant side effects can occur shortly after initiation. Also, DMARDs do not alleviate pain; therefore it is difficult for patients to attribute recovery to this medication. For these reasons, although it is imperative for future health and functioning to take DMARDs as prescribed, non-adherence is common at 30-50%. Non-adherence to treatment can be intentional, where a decision is made not to conform to the prescription, or unintentional which is often due to forgetting. To measure intentional non-adherence, a validated measure of adherence for rheumatoid arthritis was reduced through exploratory factor analysis from 19 items to 5 items by removing items that did not add to the explained variance of adherence. The CQR5 explained 53% of the variance in adherence and was shown to have a good fit to the data through confirmatory factor analysis. A discriminant function equation was generated that correctly identifies 88.5% of patients as high or low adherers and has high clinical utility due to the brevity for patients and unidimensionality for easy interpretation. The CQR5 was used throughout the programme of research to measure intentional non-adherence along with a separate measure of unintentional non-adherence. Four commonly used social cognition models of illness were measured in 227 RA patients to determine which had the best utility for predicting non-adherence to DMARDs. Patients were recruited to represent the three stages of illness including newly diagnosed, established on DMARD therapy and established with concurrent anti-TNF α therapy. Logistic regression analysis showed that the Self Regulatory Model best predicted intentional non-adherence as patients with perceptions of worse consequences of RA and longer disease duration were more likely to be highly adherent to DMARDs in cross-sectional analysis. In contrast, the Theory of Planned Behaviour better predicted patients who self-reported forgetting their DMARDs with patients with more confidence in being able to take their medications (Perceived Behavioural Control) being less likely to forget. 171 patients were successfully followed-up six months after baseline recruitment. The longitudinal results showed that the social cognition models differed for patients at different stages of the illness suggesting that their experience of living with rheumatoid arthritis influenced perceptions of their illness and medications. Newly diagnosed patients scored lower on factors measuring perceptions of disease chronicity and seriousness whereas patients that had escalated to anti-TNF α therapy scored higher on these factors. The newly diagnosed patients also showed more variability in the social cognition scores whereas the more established patients demonstrated stable models of illness. This supports Leventhal’s (1992) theory that illness representations will be regulated through integration of knowledge and experience of an illness. Structural equation modelling was used to establish the best predictors of intentional non-adherence at six month follow-up. In support of research in other chronic illnesses (Horne & Weinman, 2002; Niklas, Dunbar & Wild, 2010), the effect of perceptions of the consequences and chronicity of the illness on adherence are mediated by perceptions of the necessity of the medication. In addition, the impact of the emotional reaction to the illness on adherence to DMARDs is mediated by concerns about the medication. In addition, this study incorporated factors from the Theory of Planned Behaviour to explain medication adherence and found that the influence of friends and family impacts on the patient’s confidence to follow the prescription accurately which in turn as an effect on adherence to DMARDs. This large longitudinal study found that by combining factors from a number of social cognition models, it is possible to explain and predict intentional non-adherence and provides some evidence for best ways to intervene to improve adherence and prognosis. To provide a more comprehensive and clinically useful picture of non-adherence, a Cost of Illness study was carried which found that patients self-reporting low adherence to DMARDs also had significantly higher costs for this medication. This was caused by an increased incidence of Leflunamide prescribing for patients who often forget their medication and was maintained longitudinally. This association has not been previously reported in the literature and provides some evidence that non-adherence to DMARDs is having a concrete effect on the clinical management of patients. Finally, an SMS text message based reminder service designed to remind patients who self-report forgetting their medications was tested through a simulation study for the cost and likely benefit in health related quality of life using the health economic analysis of the longitudinal study and the results of a survey establishing the feasibility of implementing such a service in the rheumatology clinic. A sensitivity analysis testing the number of messages sent and the cost per message found that a reminder service for the sample of patients in this programme of research would cost between £1387.00 and £142.27 per year. This would equate to a cost per Quality Adjusted Life Year (QALY) gain of between £2889.58 and £296.40 by enabling patients to adhere more rigorously to their DMARD regimen. This programme of research is the first to test four commonly used social cognition models to predict adherence to DMARDs in a large, multi-centre longitudinal study of rheumatoid arthritis patients. Perceptions of the likely duration and consequences of the illness, as measured by the Illness Perceptions Questionnaire and the necessity of medications (measured by the Beliefs about Medications Questionnaire) along with self-efficacy (measured by the Theory of Planned Behaviour) explained 24% of the variance in intentional adherence over six months. The results show the importance of considering intentional and unintentional non-adherence separately as they appear to have different underlying mechanisms as well as patients in different phases of the illness as their experience influences their social cognition models of illness. A simple SMS based reminder service could act as a cue to action to reduce unintentional non-adherence whereas addressing issues surrounding maladaptive perceptions about the illness and the treatment could improve intentional non-adherence which has the potential to improve the prognosis and quality of life for patients as well as safe costs for the NHS.

Cystic Fibrosis, a life threatening autosomal recessive genetic disease, is characterized by a defective gene resulting in the production of thick mucus that obstructs the lungs and pancreas. CF requires intensive management performed at the home. An initial pilot study was performed to describe knowledge of CF related diabetes (CFRD) in adults with CF. The findings of this study, which demonstrated that adults with CF lacked sufficient knowledge about CFRD confirmed the need to explore additional factors of self-management guided by a theoretical framework. The second study presented in this dissertation used the Individual and Family Self-Management Theory (IFSMT) to describe context (condition-specific and individual and family factors) and process (self-efficacy and knowledge) and outcome (family self-management) variables for caregivers of children with CF. It also compared differences in context, process, and outcomes in caregivers based on socioeconomic status (Medicaid vs. private insurance), and explored correlations among context, process, and outcomes. Participants for this cross-sectional descriptive study were caregivers of individuals with CF who were under the age of 18 and diagnosed with CF for at least 9 months. Participants completed a demographic survey and questionnaires that included measures of perceived disease severity (VAS), depression (Patient Health Questionnaire), self-efficacy (Perceived Health Competence Scale, Mountain West Cystic Fibrosis Consortium Questionnaire), knowledge (CF Knowledge and Attitudes Questionnaire), and self management behaviors (Self-Management Behaviors Questionnaire) Additional information was collected on the children with CF and included demographic information as well as height/weight/BMI, pulmonary function test results, medication profile, and insurance status. Participants in this study were primarily female caregivers with high self-efficacy, and average knowledge. The children with CF in this study had moderate treatment complexity and normal/mild impairment in lung function. Deficits were noted in the areas of caregivers’ reproductive and genetic knowledge. This study found differences between Medicaid and private insurance groups related to knowledge. There were significant relationships between disease severity and CF specific self-efficacy and nutritional surveillance as well as general self-efficacy and respiratory surveillance. These findings confirmed that the IFMST would provide a consistent framework to guide future studies aimed at identifying factors that influence self-management behaviors of CF in patients and their caregivers.

Denna studie kombinerar enkätundersökning med kvalitativa intervjuer i syftet att identifiera och jämföra motivationsfaktorer för eget ledarskap i självstyrande organisationer kontra formella ledare. I studien ingår åtta respondenter från en självstyrande organisation och för att identifiera vilka drivkrafter och psykologiska behov dessa besitter genomfördes en enkätundersökning. Underlaget för studien baserar sig på MyNeeds, ett analysverktyg utvecklat från Self-Determination Theory. Utifrån denna teori har de identifierat sex psykologiska behov som ofta är omedvetna och genom verktyget kan mätas på individnivå. Analysresultatet från studien har därefter jämförts med data från en kontrollgrupp som tagits fram vid Malmö Universitet genom det samarbete som finns med MyNeeds. I syfte att närmare undersöka hur respondenterna själva ser på sitt ledarskap i en självstyrande organisation och vad de motiveras utav i sin befattning, genomfördes semistrukturerade intervjuer. Resultat av studien visar att det finns skillnader i hur drivkrafterna fördelar sig i jämförelse mellan respondenter och kontrollgrupp, studiens deltagare hade större benägenhet att drivas av ett behov av samhörighet än de formella ledarna som ingick i studiens jämförelseunderlag.

Bakgrund: Stomi innebär en konstgjord öppning på buken. Vanligaste orsakerna till att en person får stomi är kolorektal cancer, blåscancer, chrons sjukdom och ulcerös kolit. Den stomiopererade personens vardag påverkas ofta på grund av kroppsförändringar. Dessa kroppsförändringar innebär exempelvis nya hygienrutiner samt förlust av kroppsfunktion. Syfte: Att beskriva hur vuxna personer med stomi upplever sin vardag. Metod: Litteraturöversikt med induktiv ansats. Insamling av kvalitativa artiklar genom sökning i databaserna Cinahl och Medline. Sammanlagt användes nio vetenskapliga artiklar i litteraturöversiktens resultat. Artiklarna analyserades med hjälp av Fribergs tre-stegsmetod. Resultat: Tre huvudteman identifierades vilka var psykologiska aspekter, fysiska aspekter samt sociala aspekter. Under dessa framkom subteman som visade på att personer med stomi bland annat upplevde rädsla och oro i vardagen, begränsning i klädval samt aktiviteter. Resultatet visade även en påverkan i intima situationer. Slutsatser: Upplevelse av begränsning ses som vanligt förekommande hos stomiopererade personer och påverkar deras vardag. Stöd från sjuksköterska, familj samt vänner är betydelsefullt och kan hjälpa till att hantera situationen. / Background: Stoma is an artificial opening in the abdomen. Common reasons why a person might acquire stoma is colorectal cancer, bladder cancer, Crohn's disease and ulcerative colitis. The everyday life for a person with a stoma is often affected due to body changes. These body changes mean, for instance, new hygiene routines and loss of body function. Aim: To describe how adults with a stoma experience their everyday life. Method: Literature review with inductive approach. Qualitative articles were collected through searches in the databases Cinahl and Medline. In total, nine scientific articles were used as a result of the literature review. The articles were analyzed using Friberg´s three-step method. Result: Three main themes were identified; psychological aspects, physical aspects and social aspects. Under these main themes subthemes emerged that showed that people with a stoma among other experienced for instance fear and concern of everyday life, limited in choice of clothes and activities. The results also exposed an effect in intimate situations. Conclusion: Experience of limitation is common among persons with a stoma and affect their everyday life. Support from a nurse, family and friends are significant and can help the person with a stoma to manage the situation.

Self-management interventions enhance the health self-management techniques and physical and psychological health outcomes among people with long-term health conditions (LTHCs). Few individuals from South Asian backgrounds attended the pilot phase of one such intervention: the Expert Patients Programme (EPP), a community-based self-management course. This raised concerns about exacerbating health inequalities. South Asian people have increased prevalence and severity of certain musculoskeletal conditions, yet little is known about their experiences of living with and self-managing these. This research aimed to rectify these omissions, by describing Punjabi Sikh women's experiences of living with and self-managing arthritis, and identifying barriers and facilitators to EPP. Three studies explored White and Punjabi Sikh EPP tutors‟ experiences of delivering EPP to South Asian attendees, and Punjabi Sikh women's experiences of living with and self-managing arthritis, both before and after they attended a Punjabi-language EPP. White and Punjabi Sikh tutors' sometimes dichotomous experiences of delivering EPP to South Asians, captured barriers to South Asian people's attendance, engagement and self-management. Facilitators identified included the need for sensitive tailoring of the Course, involving the Punjabi Sikh community. The Punjabi Sikh women's vibrant experiential accounts revealed the detrimental psychological and physical consequences that arthritis had upon their lives. Highly versatile in their proactive arthritis self-management prior to attending EPP, participants' refined techniques encompassed combinations of medication and Indian remedies, empowered by their religious and spiritual values. Following EPP attendance, the participants reported psychological and physical improvements in their arthritis. Thus, this Study established Punjabi Sikh 4 Abstract women's inherent acceptance of the concept of self-management, and, notwithstanding its current limitations, the likely appropriateness of EPP. Every Study represents a novel contribution to knowledge. Meaningful engagement with Punjabi Sikh community-members may produce a culturally-competent intervention that could better improve this group's physical and psychological outcomes, thus addressing one small area of health inequalities.

Background: Chronic kidney disease (CKD) affects approximately 26 million individuals in the United States and is a top priority in the objectives for Healthy People 2020. Despite efforts to improve awareness, discussion of CKD is often minimal or ineffective in the primary care setting. This leads to a lack of patient awareness and knowledge of self-care skills to prevent or slow progression of the disease. A lack of communication of has been attributed to the provider's lack of confidence and knowledge to discuss CKD and to avoid unnecessary stress. Purpose: The purpose of the DNP project is to provide a systematic review of patient-provider communication processes used to influence self-management or behavioral change in primary care and propose a tool to enhance communication and slow progression of CKD. Methods: A systematic review was conducted following the method guidelines of the Cochrane Collaboration. Six electronic databases were searched. Inclusion criteria were adult humans, primary research studies, systematic and literature reviews, focus on communication of self-management or behavioral change strategies, primary outcomes of improving self-management and/or patient outcomes and availability of full-text online or by request. Outcomes: Of the 5765 articles initially identified, 28 studies met inclusion criteria. The studies revealed a lack of evidence directed towards CKD and communication was not directly addressed in a majority of the studies. Interventions most successful in improving patient outcomes were individualized, elicited collaboration or interaction with the patient and provider, were motivational or encouraging and aided in barrier identification and problem solving. A communication tool was developed from the evidence in order to stimulate more meaningful conversation between the patient and provider.

In the UK angina affects 2 million people (BHF, 2010b) and unfortunately secondary prevention interventions such as Cardiac Rehabilitation (CR) are not widely available for this population (NACR, 2011). This doctoral research project examined the effectiveness and feasibility of an alternative intervention for this population; CR delivered via the internet. The programme was interactive and comprised personalised goal setting orientated around exercise, diet, emotions, and smoking with support available through an online email link or synchronised chat room. A randomised controlled trial (RCT) and semi-structured interviews were used to evaluate the intervention. Primary care patients with angina were randomised to either an intervention group (n=48) or to a control group that did not receive any intervention other than treatment as usual (n=47). Outcome measures were taken at baseline, 6 week and 6 month follow ups. The primary outcome measure was daily steps (measured objectively using Sensewear Pro 3® accelerometer technology). Secondary outcome measures included daily energy expenditure (EE), daily duration of sedentary activity (DDSA), daily duration of moderate activity (DDMA), daily duration of vigorous activity (DDVA), weight, diastolic blood pressure (DBP), systolic blood pressure (SBP), body fat %, fat intake, fibre intake, anxiety, depression, self-efficacy, and health related quality of life (HRQOL). At the 6 week follow up the intervention group had greater improvements than the control group in daily steps, daily EE, DDSA, DDMA, weight, self-efficacy, emotional quality of life and frequency of angina symptoms. In addition, at the 6 month follow up there were significantly greater improvements in anxiety, and frequency of angina symptoms among the intervention group compared to the control group. Semi-structured interviews were also conducted with a subsample of intervention group participants at the 6 week follow up (n=16). Themes resulting from these interviews indicated a high level of programme acceptability and feasibility; ‘self reported improvements’ and ‘programme facilitators’. However, the theme labelled ‘programme barriers’ illustrated intervention related challenges which should be taken into account when delivering the programme. Overall the study demonstrated that a new web based CR programme was effective at improving lifestyle related cardiac risk factors for a primary care angina population in both the short-term (significantly improved daily steps, DDSA, DDMA, weight, self-efficacy, emotional QOL and frequency of angina) and medium-term (significantly improved anxiety, and frequency of angina). These findings on the whole suggest that the programme could be offered to a primary care angina population who are not routinely included within conventional CR. However, there is a need to consider the factors described to affect engagement of the programme; family and work commitments, bad weather, older age, receiving the programme late in angina diagnosis and levels of self-motivation.

Bakgrund: Diabetes typ 2 är en endokrin sjukdom och är en av de största folksjukdomarna i världen. Förhöjda blodsockervärden gör att både små och stora blodkärl tar skada och detta leder till olika komplikationer såsom hjärtinfarkt, stroke och njurskador. Med hjälp av viktnedgång, kostreglering, regelbundet fysisk aktivitet och övervakning av blodglukosnivåerna kan risken för komplikationer förebyggas. Genom att förebygga komplikationer kan livskvaliteten främja patientens dagliga liv. En del av diabetesvården består av egenvårdsprogram där patienten får stöd och rådgivning att hantera sin diabetes. Syfte: Denna litteraturstudie syftar till att studera vilka faktorer i egenvårdsprogram som främjar livskvaliteten hos patienter med diabetes typ 2. Metod: Litteraturstudie, artiklarna söktes i databaserna CINAHL, PubMed och Web of Science. 14 kvantitativa artiklar inkluderades. Resultat: Resultatet visade att information, individuell målsättning och uppföljning var viktiga faktorer i egenvårdsprogrammen för att främja livskvaliteten hos patienter med diabetes typ 2. Slutsats: Att leva med diabetes typ 2 kräver noggrannhet och planering i det dagliga livet. Egenvårdsprogram kan minska risken för komplikationer där följsamhet till egenvården främjas och livskvaliteten gynnas. / Background: Type 2 diabetes is an endocrine disorder and one of the major diseases in the world. Increase in blood sugar levels allows both small and large blood vessels are damaged and this leads to various complications such as heart attack, stroke and kidney damage. Using weight loss, diet control, regular physical activity, and monitoring of blood glucose levels, the risk of complications can be prevent. Preventing complications can promote the quality of life and improve the patient's daily life. In the diabetes care, self- management programs are a part where patients receives support and advice to manage their diabetes. Aim: Important factors in self-management programs that promote the quality of life for patients with diabetes type 2. Method: A literature review, the articles were searched in the databases CINAHL, PubMed and Web of Science. 14 quantitative articles were included. Results: The results showed that information, individual goal setting and follow-up where the key factors in self-care programs for promoting the quality of life in patients with diabetes type 2. Conclusion: Living with type 2 diabetes require precision and planning of daily life. Selfmanagement programs can reduce the risk of complications where adherence to self-care promotion and to promote quality of life.

Heart failure is a chronic illness requiring self-management to prolong individual lifespan while improving quality of life. The intent of this doctoral project was to conduct a quality improvement (QI) program focused on systematically educating patients about a two gram sodium diet, by using an educational pamphlet, provider-based patient-centered teaching, and follow up during the transition period between hospital discharge and first outpatient visit. This QI project provided systematic education for newly diagnosed heart failure patients to increase knowledge about a two gram sodium diet and facilitate translation of knowledge into self-management. The QI project used the plan, do, study, act model and was implemented by the Heart Failure Educator at Banner University Medical Center-Tucson. Patients were given the Sodium Restriction Questionnaire, to determine baseline knowledge and behavior, then educated on a two gram sodium diet and given a pamphlet with the same information for home reference. At home, patients were expected to document daily sodium intake and weight and received a phone call twice a week to obtain these values. Twice a week, patients received visual feedback to illustrate their self-management from a graph that represented personal sodium and weight values. After two weeks the same questionnaire was given to determine possible improvement. The average pre assessment questionnaire score was 19 and the average post assessment score was 21.2, showing an average improvement score of 2.2. All five patients, 100%, consumed less sodium and ingested less than two grams during the second week of monitoring sodium intake and daily weight compared to week one. Three patients, 60%, had lower average daily weight during week two by three to five pounds compared to week one. On average the patients consumed 307.18 milligrams less sodium and weighed 2.56 pounds less during week two. Results suggest that educating patients on a two gram sodium diet and providing transitional support from hospital to home, using individualized graphs and patient recording of daily sodium intake and weight, improved self-management behavior and knowledge as evidenced by improved average weight and sodium consumption and an average two point increase on the post assessment questionnaire.