**2. Self-Management training: Overview**

stroke [11-15]. Many of these patients suffer persistent pain episodes, poor general health, sleep disturbance, impaired social role functioning, activity restriction, and reduced ability to self-

As Lewin [28,29] and others [30] have argued, angina seems to have a disproportionately severe impact on one's self-perceived health status relative to other chronic illnesses. Extensive work in the field to date has shown that negative emotional states, such as anxiety and depression, are well-documented corollaries of CSA. For example, as part of a larger clinical trial, Ketterer et al. [31] (n= 196) examined the psychological profile of patients with stable CAD, angina symptoms during daily activities, and positive exercise stress tests. Anxiety and depression were strongly associated with recent angina, as well as angina in the presence of ischemia invoked by treadmill testing. Gravely-Witte et al. [32] found similar results in a prospective study of 121 patients following surgical and percutaneous revascularization procedures. Angina symptoms were predictive of higher levels of depression and lower levels

The central role of emotional distress in CSA may be explained, in part, by the fact that angina sufferers tend to hold erroneous and maladaptive beliefs about their condition. In Wynn's widely cited observational study (1967) [30], 23% of post-myocardial infarction patients (n=400) reported being anxious due to the misconception that each angina episode reflected further damage to the heart. In 40% of cases, failure to return to work was attributed to fear of immanent death [30]. Since the time of Wynn's seminal work, multiple studies have shown that CSA patients routinely interpret their angina symptoms as 'mini heart attacks' [19,22-24, 30,33]. Consequently, many patients adopt sedentary lifestyles, relinquish their normal routines, and/or retire early as means to avoid angina attacks [19,22-24,34,35]. Unfortunately, out of concern, family members, peers [17,19,36], and health care professionals [37] alike often reinforce such maladaptive coping behaviours which can evoke unintentional deconditioning as well as reductions in coronary blood flow, sheer stress, and impetus for healthy collateral

Considering the high prevalence and major negative psychological impact of CSA, the cost implications are significant. The total costs associated with CSA management in the United States have been estimated to exceed 15 billion dollars per annum [1]. In the United Kingdom, the direct cost of chronic angina in 2000, including prescriptions, repeated emergency depart‐ ment visits and other hospital admissions, outpatient referrals, and procedures, was estimated at ₤669,000,000, accounting for 1.3% of the total National Health Service expenditure [39]. At the patient level, a Canadian study [40] estimated the mean cost RFA-related disability (2003 – 2005) from a societal perspective including direct out-of-pocket costs to patients, indirect costs expressed as forgone income and leisure time, and system-related costs paid by public and private insurers. The total estimated annualized cost of CSA per patient was \$19,209 [40]. In recent years, increasing attention has been given to angina self-management training [SMT] interventions as a means to offset the societal burden of CSA. These interventions are multimodal educational packages that employ learning materials and cognitive-behavioural strategies to achieve changes in knowledge and behaviour for effective disease self-manage‐ ment [41]. This chapter provides a brief overview of the concept of self-management and discussion of background theory, key elements of intervention structure and process, as well

care [16-27].

220 Current Trends in Atherogenesis

of emotional and social functioning [32].

coronary vessel formation [38].

Self-management training emerged as a priority for health systems in the 1980's and 90's, following a surge of population-based research on the prevalence of chronic illness in the 1960's and 70's [42]. The realization of the global prevalence of divergent chronic illnesses, without cure, led to major critiques of standard health care delivery models as too poorly integrated and siloed to address the consequences of chronic illness and related therapies [42]. Similarly, traditional patient education models have been critiqued as lacking adequate scope and complexity to address an ageing population, multiple co-morbidities, and the complex needs of individuals who must manage their chronic illnesses daily [42]. Traditional acute care models and related patient education focus on diagnosis and cure, technological interventions, and the imparting of specific disease-related information to inexperienced patients who act as passive recipients of health teaching. Within this paradigm, the health care professional is understood to be the knowledgeable, experienced authority on the patient's care priorities [42-44]. Thus, a fundamental premise of traditional models of care is that patient compliance with specific direction and principles taught will lead to improved health behaviours and outcomes [42-44].

In contrast, SMT interventions espouse the tenets of Wagner et al.'s Chronic Care Model (CCM) [45]. According to the CCM, chronic disease management refers to a system of health care that supports individuals with chronic illness to remain as healthy and independent as possible. The process of disease management is conceptualized as patient-centered, with health care professionals, the health care system, and the community at large collaborating with the patient to facilitate optimum health and well-being. Implicit within the CCM is the concept that patients should be well-informed about their illness, and should be active participants in their care [45].

The emphasis of SMT, therefore, is the role of the patient as an active player engaged in preventive and therapeutic health activities in partnership with health care professionals [46]. At the crux of such partnerships are patients' everyday problems as a result if living with chronic illnesses. As D'Zurilla [47] Lorig and Holman [44], and others [46] have argued, effective SMT is fundamentally problem-oriented. A common starting ground for SMT interventions in practice is identification, crystallization, and prioritization of patients' chief concerns [44-47]. Care is generally taken during this process to harmonize perspectives through deliberative discussion—as health care professionals will often conceptualize the issues in terms of diagnosis and/or risk factor modification, whereas patients will think in practical terms about the day-to-day difficulties their illnesses present [19,48]. The problem list generated dictates the direction and scope of intervention for each patient [44-48].

Along with collaborative problem identification, additional key elements of SMT, which are typical [45,48,49], include a) *targeted goal setting:* identifying meaningful, realistic goals in the context of patient priorities and preferences, b) *self-reflection:* sharing of feelings to provide opportunities for discussion about the personal meaning of chronic illness and difficult emotional responses, c) *mini-lectures and supplemental reading/workbooks*: providing opportuni‐ ties for brief information sharing about relevant educational content in accessible language and formats, d) *brainstorming and problem solving*: facilitating discussion of the potential benefits of various self-management strategies such as safe exercise, sound nutrition, energy conser‐ vation and pacing, identifying and reframing negative self-talk, etc., e) *regular action plan‐ ning:* learning the process of setting incremental positive behaviour change, and f) *selfmonitoring, accountability, and feedback:* reporting back to peers or counsellors about individual progress and obtaining constructive feedback.

disease self-management is not simply a question of knowing what to do; the process requires incremental increases in one's perceived capacity to organize and integrate cognitive, social and behavioural skills to meet a variety of aims in managing illness from day to day [52-54]. Under the direction of Kate Lorig, the Stanford Patient Education Research Centre has been a world leader in the application of self-efficacy theory to chronic disease SMT research and implementation [55]. Lorig et al.s' seminal work, the Arthritis Self-Management Program (ASMP)—developed in 1978 and funded by the National Institutes of Health—has been widely disseminated through national arthritis societies on three continents [56-61]. Multiple process evaluations and randomized-controlled trials (RCTs) of the ASMP [56-61], and its prevalent, generic adaptation, the Chronic Disease Self-Management Program (CDSMP) [62-71] (devel‐ oped in 1996), have shown that participation in a standardized SMT program results in significantly improved levels of self-efficacy for those with chronic pain and other chronic diseases. In the ASMP evaluations, improved self-efficacy was found consistently to mediate sustained significant changes in HRQL, knowledge, pain, depression and disability. Reduc‐ tions in health care costs up to 4 years post intervention, without formal reinforcement of program content, have also been found [60,61]. Similarly, self-efficacy enhancement in the CDSMP trials has repeatedly demonstrated significant improvements in exercise, cognitive symptom management, communication with physicians, self-reported general health, health distress, fatigue, disability, and role and social functioning. Participants have also spent significantly fewer days in hospital; sustained outcome improvements have been demonstrat‐

Self-Management Training for Chronic Stable Angina: Theory, Process, and Outcomes

http://dx.doi.org/10.5772/54635

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Both the ASMP [56-61] and CDSMP [62-71] employ a standardized 6-week, community-based format, Sessions are delivered in 2-hour sessions weekly for small groups of approximately 12 to 15 patients. As preeminent models of SMT, the ASMP and CDMSP programs have consis‐ tently supported [72] the following major precepts of Self-Efficacy Theory—summarized by Lorig et al. [73], (p. 5-6)—as principal drivers of effective chronic disease self-management: **•** The strength of people's belief in their ability to achieve certain outcomes reliably predicts

**•** Perceived self efficacy can be enhanced via performance mastery, modeling, reinterpreta‐

**•** Enhanced self-efficacy belief leads to lasting improvements in behaviour, motivation,

Angina-specific SMT programs emerged in the early 1990s [74-76] and have been documented as recently as 2012 [82]. The majority of RCT evidence to date includes individual counseling or small-group interventions (i.e. 6-15 patients) employing varying combinations of educa‐ tional materials on CAD and medications, risk factor identification and modification, planned exercise/physical activity, and cognitive-behavioural techniques targeted at lifestyle and

ed up to three years post-intervention [62-71].

tion of symptoms, and social persuasion.

thinking patterns, and emotional well-being.

**4. Self-management training: Angina-specific models**

motivation and behaviour.

Self-management training programs have been delivered in a variety of formats including individual counseling, small group sessions, or individual and group-based approaches in combination. Programs that engage either health care professional facilitators or lay peer leaders have been shown to be effective, as have programs that use these delivery methods in combination [46,48,49]. Regardless of format, most established SMT interventions offer a range of self-management techniques for participant rehearsal and uptake over the course of several days or weeks [44-49]; typical settings for program delivery include clinical outpatient settings and community centres.
