The concept of self-management

Self-management is a dynamic, interactive process by which individuals seek to meet their everyday social, emotional, psychological and physical needs (Chambers et al., 2015; Eikelenboom, Van Lieshout, Wensing, Smeele, & Jacobs, 2013). The term was originally used to refer to active participation in treatment (Creer, Renne, & Christian, 1976). Since then, it has been used widely to describe how a person engages in the day- to-day management of a long-term and/or chronic condition (Lorig, Ritter, Pifer, & Werner, 2014).

The fundamental skills for self-management identified by Lorig and Holman (2003) include problem-solving, decision-making, resource utilisation, the formulation of a patient-provider partnership, action planning, and self-tailoring. Coventry et al. (2014) identify capacity, responsibility and motivation as the requirements for effective self- management. Although it includes significant others, community and health care professionals in practice, the overall concept acknowledges the person as self- determining and respects the expertise they bring to the management of their condition

(Lorig & Holman, 2003). However, the lack of a standard definition of self-management and different interpretations of the scope and potential of self-management may result in some confusion in the health professional, whose role, purpose and responsibility are unclear, as they balance a duty of care with efforts to promote self-management (Holm & Severinsson, 2014a). Notwithstanding this challenge, optimal self-management requires that people participate actively and effectively in their own health care on an ongoing basis (Chambers et al., 2015).

The principles of self-management have been applied successfully to manage a range of chronic conditions, including diabetes (Lorig et al., 2016), heart disease (Jaarsma, Cameron, Riegel, & Stromberg, 2017), asthma (Pinnock et al., 2015), chronic pain (Damush et al., 2016) and depression (Chambers et al., 2015). Underpinned by the constructs of self-efficacy and self-determination, self-management is most often recognised as a form of patient empowerment (Ellis et al., 2017; Raven, 2015). Processes of self-management concern the ways in which people can realise and sustain their well- being, even when their resources decline (Musekamp et al., 2016; Schuurmans et al., 2005). Often a life-long task, elements of self-management are frequently attached to health promotion and patient education programs, particularly for chronic illness (Lorig et al., 2014). In a qualitative study of the self-management of longer-term depression, Chambers et al. (2015) reported that self-management was more than a process of neutralising loss, as it reflected the ability to look ahead and invest in resources which contributed to well-being in the long run. Examples of appropriate resources include engaging in good health behaviour and maintaining positive social relationships (Chambers et al., 2015).

From a health system perspective, the main benefits that may be derived from improved self-management of chronic illness include long-term cost savings through reduced health complications and more efficient health service utilisation (Fisher et al., 2017). Consequently, health care policy in developed countries is focusing increasingly on promoting the self-management of long-term health conditions (Ellis et al., 2017; Fisher et al., 2017). Given that depression is often recurring and chronic, self-management

appears to be a promising approach by which the person may achieve the highest level of functioning and the lowest level of symptoms (Chambers et al., 2015; Houle et al., 2013).

The nature of depression requires specific interventions that transfer knowledge and skills to the person, to equip them to maintain their well-being (Houle et al., 2013). Turner et al. (2015) found that a co-produced management program improved psychosocial outcomes for people living with depression. Improved knowledge about depression and the use of appropriate self-management strategies resulted in significant improvements in health status and health-related quality of life (Turner et al., 2015). Similar results were reported in a cluster randomised controlled trial on the implementation of a self- management intervention for participants with depression (Zimmermann et al., 2016). Study participants reported improved motivation to engage in self-help and help-seeking behaviour, and an enhanced sense of self-efficacy and empowerment (Zimmermann et al., 2016). A wide range of strategies identified by Van Grieken et al. (2013) to self- manage depression included taking a proactive attitude towards depression and treatment, explaining depression to others, remaining engaged in social activities and giving attention to oneself. These findings align with the recovery approach in mental health,46 which involves people making sense of their experiences in a way that allows them to maintain a sense of personal efficacy or control (Chambers et al., 2015; Turner et al., 2015). In addition, each of these studies highlighted the need for health professionals to encourage individuals to take active roles in self-managing their mental and physical health (Chambers et al., 2015; Turner et al., 2015; Van Grieken et al., 2013; Zimmermann et al., 2016). The extent to which health professionals understand the individual’s needs and illness representations is associated with self-management behaviour (McSharry, Bishop, Moss-Morris, & Kendrick, 2013). Indeed, self-management forms part of a complex process of understanding and managing health (McSharry et al., 2013). The need for health professionals to recognise and address the complexities of ageing with depression has been identified, particularly in considering the individual’s personal, social and environmental circumstances (Cruwys et al., 2013).

46 _{A recovery approach is a process and an outcome that emphasises empowerment, autonomy, choice and hope. It represents “a} personal journey toward a new and valued sense of identity, role and purpose together with an understanding and accepting of mental illness” (Department of Health, 2009, p. 26).

Despite broad acceptance for the effectiveness of self-management for chronic conditions, there is some criticism of the increasing expectation on individuals to self- manage chronic conditions (Brijnath & Antoniades, 2016; Redman, 2007). Redman (2007), for example, questioned whether the push towards self-management placed unreasonable responsibility on the older adult with depression. In a study into the association of a disease management program and health behaviours, self-management ability and quality of life, Cramm and Nieboer (2015) found that a focus on clinical and functional outcomes did little to improve participants’ overall quality of life and well- being. Although participants’ health behaviours and physical quality of life improved, broader self-management abilities or mental quality of life were not maintained (Cramm & Nieboer, 2015). An additional concern is that much of the evidence in favour of self- management focuses on people with a single chronic disease, whereas older adults frequently experience multiple comorbidities (Rijken, Jones, Heijmans, & Dixon, 2008). Self-management studies have been conducted on people who have had a stroke (Boger, Demain, & Latter, 2013), experienced kidney disease (Washington et al., 2016) or are living with dementia (Martin, Turner, Wallace, & Bradbury, 2013). However, the self- management of co-morbid mental and physical conditions, particularly in older age, is more challenging (Musekamp et al., 2016; Stanhope & Henwood, 2014) and requires that individuals and health professionals share common values and beliefs about the illness and treatment approaches, including self-management (Holm & Severinsson, 2014a).