Self-management

Support
for people with long-term
conditions

November 2014

Internationally, self-management is recognised as one of the critical components in improving

health care for people with long-term conditions (LTCs) (Singh 2005; Zwar et al 2006; Tsai et al
2005). It is fundamental to the health and wellbeing of people with LTCs, and enables the health
system to make the best use of increasingly scarce resources.
For some, the term self-management is problematic, suggesting a focus on the self as an
individual at the expense of important social contexts; particularly family/whnau. In fact, selfmanagement theory takes a holistic view that is aware of the need to engage people with LTCs
within their wider social context. This is in keeping with Mori, Pacific and South Asian peoples
emphasis on interdependence rather than personal independence. Definitions of selfmanagement, self-management support and self-management education follow. Thereafter, this
document discusses the principles of self-management support, expected outcomes of selfmanagement programmes and the components of self-management support.
This document includes information on diabetes specific self-management requirements,
attached as Appendix 1.

Definition of self-management
Self-management refers to any way in which a person with an LTC manages their condition by
themselves. Learning and practising self-management is an ongoing process; it is not
accomplished in a singular step. Self-management is a continuum of learning experiences and
opportunities, and involves a person with an LTC and their family/whnau working in
collaboration with carers and health professionals. People with LTCs who are self-managing:
know their condition and its various treatment options
set goals and decide a care plan to achieve those goals, and review that care plan regularly
engage in activities that protect and promote their health
monitor and manage the symptoms and signs of their condition appropriately
manage their condition to reduce the impact on their physical functioning, emotions and

interpersonal relationships (adapted from Flinders Human Behaviour and Health Research
Unit 2006).

Self-management Support
for people with long-term conditions

Definition of self-management support

Self-management support refers to policies and people that may support the continuation of
self-management behaviours across the lifespan, but that are not specific to educational
processes (Canadian Diabetes Association Clinical Practice Guidelines Expert Committee 2013).

Definition of self-management education

Self-management education (SME) is defined as a systematic intervention that teaches a
person to actively participate in self-monitoring (of physiological processes) and/or decisionmaking (managing) relating to their condition/s. It recognises that patient-provider
collaboration and the enablement of problem-solving skills are crucial to the individuals ability
for sustained self-care.
Self-management education provides people with LTCs with the knowledge, skills and
motivation to make decisions, and increases their capacity and confidence to apply these skills
in daily life.
Providers of SME must individualise the content and skill-training components of SME
according to the types of LTC and recommended therapy, the individual patients ability,
potential barriers to achievement, the patients motivation for learning and change, the patients
culture, the patients literacy level, and available resources.
Both self-management support and SME can be provided for individuals and their
family/whnau or in a group setting.

Principles of self-management support

There is a wide range of self-management approaches; however, some overarching principles
apply:
a patient centred approach self-management support programmes should empower people

with LTCs to take a leading role in their care planning, (as they are able to) and support them
to work in partnership with their health care professionals to set goals and action plans
cultural relevance programmes should be culturally sensitive and appropriate for diverse

ethnic groups
systematic follow up primary care providers should undertake clinical assessment and

follow-up care
evaluation providers should undertake both qualitative and formal quantitative evaluation

of the programme.

Self-management Support for People with Long-term Conditions

Cultural relevance for Mori

Any self-management programme, and particularly group programmes, must be culturally
appropriate. People with LTCs should have access to self-management support that is relevant
to the ethnicity they identify with.
A programme underpinned by kaupapa Mori approaches enriches the environment for
effective learning by focusing on:
tinorangitiratanga self determination
taonga tuku iho cultural aspirations
ako Mori culturally preferred ways of learning
whnau the extended family members and their influence and support
kaupapa the collective philosophy of the members of the group (Smith and Reid 2000,

pp 911).

Expected outcomes of self-management

programmes
Self-management programmes should help people with LTCs to live longer, healthier, more
independent lives. They should also achieve the following outcomes:
people with LTCs work in partnership with their health care providers
people with LTCs share information with their health providers and make informed decisions

about their care

health providers support people with LTCs to navigate information, services and resources.

Components of self-management support

As well as providing advice to individual people about managing their LTCs, programmes
supporting patient self-management emphasise goal setting and problem solving skills. Such
programmes reinforce the individuals central role in managing their condition, with a key focus
on health providers responding to peoples questions and needs.
There are three essential components in self-management support programmes:
health literacy
behaviour change
the role of the health professional in supporting self-management.

These are discussed below.

Health literacy
Health literacy, from the patient perspective, is the cornerstone in enabling people to make
informed choices and take care of their own health. A person with health literacy has the ability
to obtain, process and understand basic health information and services, and can therefore
make appropriate health decisions (Ministry of Health 2010).

Self-management Support for People with Long-term Conditions

People with LTCs and individual health professionals on their own cannot address health
literacy. Health care providers such as district health boards and primary health organisations
play a critical role in supporting health professionals and people with LTC and their
families/whnau to develop health literacy.
Health literacy includes the ability to:
understand and interpret health information provided in written, spoken and digital form
understand instructions written on prescribed medicine containers and consent forms
understand a health professionals verbal advice and explanations
navigate complex health systems
communicate with health professionals, including by describing symptoms accurately and

asking relevant questions

find relevant information needed to make choices and decisions.

Health professionals have a pivotal role in improving health literacy. Health professionals must
tailor their style of communication to individual people with LTCs (and their family/whnau).
Cultural competence and efforts to understand peoples health beliefs and preferences will
improve the quality of health interactions, and consequently health literacy.

Health behaviour change

Health literacy education needs to be complemented by programmes to support people to
change their health behaviour. There are five essential elements to changing health behaviour
within self-management programmes:
active involvement in problem solving, goal setting and written action plans
lifestyle changes, including diet, physical activity and smoking cessation
informed decision-making
medication management
stress management/positive mental health.

Health professionals should recognise and address the potential barriers to health behaviour
change, which will be different for each individual.

The role of health professionals in self-management support

Self-management requires health professionals to pose the following question, at every
encounter: What can we do (as health providers and a health system) to support, enable and
facilitate this person and their family and whnau to manage more effectively, safely and
appropriately at home?
A self-management approach requires behaviour change in health professionals as well as the
person and their families and whnau. It requires a collaborative approach to care planning
based on mutual respect and trust.
A health professional can contribute to and support behaviour change by:
supporting people with LTCs to set goals for themselves by providing information that helps

them make informed decisions

Self-management Support for People with Long-term Conditions

 encouraging people to participate actively in their self-management by acknowledging that

they are experts in their own lives

supporting people with LTCs to attend supported self-management groups, where they

available
advocating for the creation of self-management support groups, where they are currently not

available
ensuring that self-management is culturally appropriate
following up with people after their participation in self-management education

programmes, to optimise and support their learning

ensuring that initial self-management education is followed by regular updates and

opportunistic learning as required.

Primary health care providers in particular general practice teams play a particular role in
ensuring that people with LTCs can access self-management support. However, to provide
effective self-management support, nurses and general practitioners need to form part of a
wider multidisciplinary team. The level of engagement each person with an LTC has with such a
team will differ depending on the needs of that person.
Multidisciplinary teams can be made up of general practitioners or primary health care nurses,
Mori providers, Pacific providers, community pharmacists, community mental health workers,
allied health professionals and medical specialists.

References
Canadian Diabetes Association Clinical Practice Guidelines Expert Committee. 2013. Clinical
Practice Guidelines for the Prevention and Management of Diabetes in Canada. Canadian
Journal of Diabetes 37(suppl 1): S1S212.
Flinders Human Behaviour and Health Research Unit. 2006. The Flinders Program. URL:
www.flinders.edu.au/medicine/sites/fhbhru/self-management.cfm (accessed 14 September
2014).
Ministry of Health. 2010. Krero Mrama: Health Literacy and Mori. Wellington: Ministry of
Health.
Singh D. 2005 Transforming Chronic Care: Evidence for improving care for people with longterm conditions. Birmingham: Health Services Management Centre, The University of
Birmingham.
Smith LT, Reid P. 2000. Mori Research Development: Kaupapa Mori Principles and
Practices: A literature review. Wellington: Te Puni Kkiri.
Tsai A, Morton S, Mangione C, et al. 2005. A meta-analysis of interventions to improve care for
chronic illnesses. American Journal of Managed Care 11(8): 47888.

Self-management Support for People with Long-term Conditions

Zwar N, Harris M, Griffiths R, et al. 2006. A systematic review of chronic disease management.
Sydney: Australian Primary Health Care Research Institute, School of Public Health and
Community Medicine, University of New South Wales.

Appendix 1: Diabetes-specific self-management

support
This document addresses self-management for LTCs in general; however, some aspects of selfmanagement are specific to diabetes. Additionally, different types of diabetes, including type 1,
type 2 and gestational diabetes, are discreet conditions requiring different self-management
skills across the lifespan.
People with diabetes require specific information to make informed decisions on selfmanagement. This includes:
information on living with diabetes, including:

managing high and low blood glucose levels

diet, including managing carbohydrate, fat and sugar intake

the importance of regular physical exercise and how to adjust insulin and carbohydrate
accordingly

controlling diabetes before, during and after exercising

knowledge of diabetes-specific medications, including:

information about individual medications for managing a persons own diabetes

information about potential future medications

information on the risks of non-adherence to medicine schedules

awareness of diabetes-specific complications and how to prevent them, including:

cardiovascular disease, and the need for regular monitoring and lifestyle advice to
manage this risk

renal disease, and the need for regular monitoring to manage this risk

peripheral neuropathy, and the need to regularly undergo foot checks

retinopathy, and the need to regularly undergo retinal screening

depression, and the need for psychological support

sexual dysfunction

information on clinical parameters, including:

blood glucose levels (HbA1c)

blood pressure

blood lipid levels (cholesterol)

microalbuminuria.

Health providers should prioritise self-management support for the following groups:
people newly diagnosed with type 2 diabetes
people with diabetes failing to achieve clinical targets despite 612 months of trying
people with diabetes with persisting clinical issues (eg, hypoglycaemia or weight gain)

Self-management Support for People with Long-term Conditions

 people with diabetes who are at high risk of complications.

Dietary, exercise and lifestyle information can be suitable for inclusion in a programme created
for people with prediabetes; however, diabetes-specific self-management support content is not
appropriate for them.

Published in November 2014 by the Ministry of Health, PO Box 5013, Wellington 6145.
ISBN 978-0-478-42897-1 (online)
HP 6017

Self-management Support for People with Long-term Conditions