Implementation and Quantitative Evaluation of Chronic Disease Self-Management Programme in Shanghai, China: Randomized Controlled Trial. (Research)

Article excerpt

Introduction

Chronic diseases--mainly heart disease, stroke, cancer, and lung disease--are becoming leading causes of disability and premature death in China. Noncommunicable diseases accounted for 81% of total deaths in China in 1996 (1). Chronic disease is also a major health care cost for China. In 1994, direct treatment costs related to chronic disease were more than four hundred billion Yuan (2). In China, Shanghai has the heaviest burden of noncommunicable diseases, because it has the largest population and the largest ageing population. Prevention and management of chronic disease is an urgent primary health problem to be addressed in Shanghai. The inability of current major health care systems to deal with chronic conditions calls for prompt policy action and new approaches to people with chronic conditions. Self-management for people with chronic disease is now widely recognized as a necessary part of treatment.

Chronic disease self-management has been shown in the United States, Canada, and the United Kingdom to be useful in maintaining and improving patients' health behaviour and health status, while lowering health care utilization through improved self-management skills, "self-efficacy", and better communication between patients and health providers (3-6). The community-based generic self-management programme developed by Lorig et al. at Stanford University Patient Education Research Center--the Chronic Disease Self-Management Program (CDSMP)--is the most widely accepted self-management patient education programme worldwide, because it is designed to meet the needs of patients who have more than one chronic condition and is taught by trained lay leaders (3). The CDSMP is a community-based patient self-management education course. Several assumptions make this programme suitable for different kinds of patients (7): (1) people with chronic diseases have similar concerns and problems; (2) people with chronic conditions can learn to take responsibility for the day-to-day management of their disease(s) and the physical and emotional problems caused by their disease(s); (3) lay people with chronic conditions, when given a detailed leader's manual, can teach the CDSMP as effectively, if not more effectively, than health professionals; and (4) the process or way the CDSMP is taught is as important, if not more important, than the subject matter taught. The content and process of teaching the CDSMP course are based on self-efficacy theory (8, 9). Self-efficacy refers to people's beliefs in their abilities to perform specific behaviours, which is a key factor to behaviour change and health functioning (9). The courses incorporate strategies suggested by Bandura to enhance self-efficacy (10), including weekly action planning and feedback, modelling of behaviours and problem-solving by participants for one another, reinterpretation of symptoms, several different management techniques, group problem-solving, and individual decision-making. The leaders of the courses act more as facilitators than lecturers. The process is documented in a detailed protocol--the Chronic disease self-management leaders manual (11). Topics covered include: exercise; use of cognitive symptom management techniques; nutrition; fatigue and sleep management; use of community resources; use of medications; dealing with the emotions of fear, anger, and depression; communication with others, including health professionals; problem-solving; and decision-making. The content of the course was published as Living a healthy life with chronic conditions (12), which was used as a textbook for course participants.

To date, no research has tested whether CDSMP would be culturally acceptable for Chinese people and could benefit participants in China, or whether Chinese lay people could be trained to teach CDSMP courses as capably as professionals. This study examined the course's feasibility, benefits, and cultural sensitivity in Shanghai. …