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ComparEuEtdsWeb
QUESTION | |
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03. Should education, action-based, and emotional-based behavioural techniques vs. usual care be used for adult patients living with heart failure? | |
Population | adult patients living with heart failure |
Intervention | Action-based and emotional-based behavioural techniques See more |
Comparison | Usual Care |
Main outcomes | All cause admissions; All causes readmissions; Heart failure admissions; Heart failure readmissions; Mortality; Quality of life; Self-efficacy; |
Setting | European Union, outpatient care |
Perspective | Clinical recommendation- Population perspective |
Background | Heart failure (HF), a complex clinical syndrome, is considered a global pandemic with an increasing overall incidence and prevalence due to ageing of population (Savarese G et al., 2017). HF clinical practice guideline self-management strategies are recommended to increase quality of life and to reduce the risk of HF hospitalization and mortality. However, there are still gaps in the evidence especially regarding the comparative effectiveness and cost-effectiveness of the strategies, due to variations in study locations and time of occurrence and to suboptimal reporting of patient-relevant outcomes (ESC 2021, Jonkman NH et al., 2016, Takeda A et al., 2019). |
Conflict of interest |
This work was supported by the EU Horizon 2020 research and innovation programme (grant agreement no. 754936). The funder had no role in developing the protocol or obtaining the results for this study. |
ASSESSMENT | ||||||||||||||||||||||
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Priority of problem Is the problem a priority? |
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JUDGEMENT | RESEARCH EVIDENCE | |||||||||||||||||||||
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Heart failure (HF), a complex clinical syndrome, is considered a global pandemic with an increasing overall incidence and prevalence due to ageing of population (Savarese G et al., 2017). HF clinical practice guideline self-management strategies are recommended to increase quality of life and to reduce the risk of HF hospitalization and mortality. However, there are still gaps in the evidence especially regarding the comparative effectiveness and cost-effectiveness of the strategies, due to variations in study locations and time of occurrence and to suboptimal reporting of patient-relevant outcomes (ESC 2021, Jonkman NH et al., 2016, Takeda A et al., 2019). |
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Desirable Effects How substantial are the desirable anticipated effects? |
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JUDGEMENT | RESEARCH EVIDENCE | |||||||||||||||||||||
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View summary of findings of network meta-analysis
View summary of findings of component network meta-analysis |
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ADDITIONAL CONSIDERATIONS | ||||||||||||||||||||||
The guideline panel judged the desirable effects as large.
The SMI reduces mortality (large effect) and increases quality of life (small effect).
No data available for the rest of critical/important outcomes.
Proportion of direct evidence contributing to the final NMA estimate per outcome: All-cause admissions: 100% All-cause re-admissions: 100% Exercise capacity: 84% Heart failure admission: 100% Heart failure re-admission: 100% Mortality (All-cause) 100% Quality of life: 87% Self-efficacy: 100%
Component Network Meta-analysis: Mortality: the components with larger effects are education (E), action - based behavioural change techniques (AB), and emotional - based behavioural change techniques (EB). Quality of life: the component with largest effect is education (E)
Studies that inlcude this SMI: Gary-2010 - Cognitive behavioral therapy (CBT) based on Beck’s CBT model of depression - 12 face-to-face sessions, phone calls when needed; all individual - Duration 12 weeks - Expected patient (or carer) self-management behaviours: o Psychological management § Handling/managing emotions
Chen-2018e - Individualized rehabilitation programs, including home-based cardiac rehabilitation, diet education, and management of daily activity - 37 face-to-face sessions, 6 phone calls; all individual - Duration 3 months - Expected patient (or carer) self-management behaviours: o Lifestyle related behaviours § Doing physical activity o Clinical management § Condition-specific behaviours § Medication use and adherence § Physical management
Bekelman-2018 - Collaborative symptom care provided by a nurse and psychosocial care provided by a social worker, both of whom worked with the patients’ primary care clinicians and were supervised by a study primary care clinician, cardiologist, and palliative care physician - Face-to-face sessions (number unclear), 24 phone calls; all individual - Duration 6 months - Expected patient (or carer) self-management behaviours: o Lifestyle related behaviours § Eating behaviours § Doing physical activity o Clinical management § Condition-specific behaviours § Medication use and adherence § Early recognition of symptoms o Psychological management § Handling/managing emotions
Leventhal-2011 - Home visit by a heart failure nurse, followed by 17 telephone calls of decreasing frequency over 12 months, focusing on self-care. Calls from the HF nurse to primary care physicians communicated health concerns and identified goals of care. - 2 face-to-face sessions, 17 phone calls; all individual - Duration 12 months - Expected patient (or carer) self-management behaviours: o Lifestyle related behaviours § Eating behaviours § Doing physical activity o Clinical management § Condition-specific behaviours § Self-monitoring § Early recognition of symptoms § Asking for professional help or emergency care when needed o Working with healthcare and/or social care providers § Communication with health care and/or social care provider
Ojeda-2005 - Patient education, consultation with the cardiologist and monitoring in the Heart Failure Unit - 5 face-to-face sessions, phone calls when needed; all individual - Duration unclear - Expected patient (or carer) self-management behaviours: o Lifestyle related behaviours § Eating behaviours § Doing physical activity o Clinical management § Self-monitoring § Medication use and adherence § Early recognition of symptoms § Physical management
Paradis-2010 - Motivational interviewing (MI) based on the stages of change (MISC) intervention - 1 face-to-face session, 2 phone calls; all individual - Duration 1 month - Expected patient (or carer) self-management behaviours: o Lifestyle related behaviours § Eating behaviours § Doing physical activity § Alcohol consume, and other harmful consumptions, cessation or reduction o Clinical management § Self-monitoring § Medication use and adherence § Early recognition of symptoms
Park-2017 - Diaries to track daily weight, HF symptoms, and response to symptom changes - 1 face-to-face session, 2 phone calls; all individual - Duration 24 months - Expected patient (or carer) self-management behaviours: o Lifestyle related behaviours § Eating behaviours o Clinical management § Self-monitoring § Medication use and adherence § Early recognition of symptoms § Asking for professional help or emergency care when needed
Vaillant-Roussel-2016 - General practitioners were trained during a 2-day interactive workshop to provide a patient education program. - 2-day workshop for GPs; 6 individual face-to-face sessions - Duration 19 months - Expected patient (or carer) self-management behaviours: o Lifestyle related behaviours § Eating behaviours § Doing physical activity o Clinical management § Medication use and adherence § Early recognition of symptoms
Modeling estimations for long term consequences We used the COMPAR-EU heart failure (HF) model developed for the cost-effectiveness analysis to also inform about long-term health outcomes. Decision analytic models can provide valuable information for outcomes when empirical evidence is not available or is unfeasible (Trikalinos TA, 2009). The following events were estimated over a lifetime and informed by the NMA effect of each SMI on all-cause mortality and all-cause admission outcomes. We suggest cautious interpretation as the certainty of the evidence for those input parameters was low to very low across comparisons. Long-term model outcomes: - Life-Years (LY): 117 days of additional life per patient - Effect on the all-cause admission: reduction in hospital costs of 425 euros per patient. |
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Undesirable Effects How substantial are the undesirable anticipated effects? |
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View summary of findings of network meta-analysis
There are no undesirable effects observed. |
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ADDITIONAL CONSIDERATIONS | ||||||||||||||||||||||
The guideline panel judged the undesirable effects as trivial or marginal. |
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Certainty of the evidence What is the overall certainty of the evidence of effects? |
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ADDITIONAL CONSIDERATIONS | ||||||||||||||||||||||
The guideline panel has judged the certainty of the evidence as very low. |
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Values Is there important uncertainty about or variability in how much people value the main outcomes? |
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An overview of systematic reviews provided information about how patients value several of the outcomes of interest (critical/important) included in this clinical question:
References
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ADDITIONAL CONSIDERATIONS | ||||||||||||||||||||||
The guideline panel judged that there is probably no important uncertainty or variabilty y on how patients value the main outcomes.
The panel agreed that there is some variability on how patients value the outcomes, since preferences will vary based on patients' particular starting point, and their disease progression. The panel also noted, that the variability on how patients value the main outcomes, could also depend on the intensity of monitoring. |
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Balance of effects Does the balance between desirable and undesirable effects favor the intervention or the comparison? |
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ADDITIONAL CONSIDERATIONS | ||||||||||||||||||||||
The guideline panel judged that the balance of effects probably favours the intervention. This is due to the large desirable effects, the trivial undesirable effects, the probably no important uncertainty and variability on how patients value outcomes, as well as the very low certainty of evidence of effects. |
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Resources required How large are the resource requirements (costs)? |
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Estimated costs for the intervention across all types of self-management interventions (SMIs), as described in the included studies of the network meta-analysis, were on average 794 euros per patient, with a range from 85 to 2,045 euros. Please note that this average/range estimate has been based on ten cost estimates of SMIs for HF reported in publications. Furthermore, most of the SMIs were an element of a management program, which means that the other costs of the management program are not taken into account in the intervention costs.
Model analyses showed that over lifetime the total costs (without cost of the intervention) for the SMI were 7,042 euros higher compared to usual care. This cost increase was mainly the result of extending the life-expectancy.
References Trikalinos TA, Siebert U, Lau J. Decision-analytic modeling to evaluate benefits and harms of medical tests: uses and limitations. Med Decis Making. 2009 Sep-Oct;29(5):E22-9. Girling A, Lilford R, Cole A, Young T. Headroom approach to device development: current and future directions. Int J Technol Assess Health Care. 2015 Jan;31(5):331-8. |
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ADDITIONAL CONSIDERATIONS | ||||||||||||||||||||||
Despite the scarcity of data in available publications, and the important variability in the characteristics of self-monitoring interventions the panel considered that the resources required varies for this SMI.
Resource use and costing data for SMIs should be interpreted with caution. We could not provide cost for any specific type of SMI intervention, because in many publications detailed information needed to estimate the intervention cost was missing (for example number of sessions, average group size or duration of sessions). As an alternative, we searched for intervention cost estimates as presented by the authors of publications and used the average value as an estimate of the average costs of SMI programs for HF in general. |
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Certainty of evidence of required resources What is the certainty of the evidence of resource requirements (costs)? |
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ADDITIONAL CONSIDERATIONS | ||||||||||||||||||||||
The guideline panel agreed on a very low certainty of the evidence on this domain.
Resource use and costing data for SMIs should be interpreted with caution. We could not provide cost for any specific type of SMI intervention, because in many publications detailed information needed to estimate the intervention cost was missing (for example number of sessions, average group size or duration of sessions). As an alternative, we searched for intervention cost estimates as presented by the authors of publications and used the average value as an estimate of the average costs of SMI programs for HF in general. Further, the costs of the SMI, implementation of SMIs and HF management programs vary between countries and target group. |
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Cost-effectiveness Does the cost-effectiveness of the intervention favor the intervention or the comparison? |
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The table below shows the cost-effectiveness results for the SMI intervention. Costs and QALYs in this analysis were discounted at 3.5% annual rate.
NA: not applicable; QALY: quality adjusted life years; ICER: incremental cost-effectiveness ratio Explanations
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ADDITIONAL CONSIDERATIONS | ||||||||||||||||||||||
The guideline panel judged that the cost-effectiveness probably favors the intervention
There is a possibility that this specific SMI can be cost-effective, but this depends on the intervention costs of the particular intervention and the threshold used. The intervention is costs can be up to 2,075 with a threshold value of 20,000 euro/QALY and 5,374 euro maximum when a threshold value of 50,000 euro/QALY is used. Both cost estimates are above the observed range of cost estimates of SMI in the literature (average 793 euro, range: 65 to 2,045) (see research evidence for an explanation of headroom analysis). |
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Equity What would be the impact on health equity? |
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A US study on symptom diary use among patients living in a rural area reported that greater diary use was associated with longer all-cause survival (Park, 2017). Also, sedentary lifestyle was found to be significantly associated with all-cause mortality and less diary use. |
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ADDITIONAL CONSIDERATIONS | ||||||||||||||||||||||
The panel agreed that the impact on health equity varies, due to the variability across European countries on the levels of health literacy and socioeconomic status. Equity may be affected by geography and accessibility.
If implemented, tailored to culture and health literacy, it may increase equity. |
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Acceptability Is the intervention acceptable to key stakeholders? |
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JUDGEMENT | RESEARCH EVIDENCE | |||||||||||||||||||||
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The information below has been obtained through an overview of systematic reviews of contextual factors, as well as a scoping review and one overview of systematic reviews of values and preferences. It also includes considerations from a Delphi study that was conducted in COMPAR-EU that included the most important contextual factors for the implementation of components (e.g. groups, peers) of self-management interventions according to stakeholders.
References
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Feasibility Is the intervention feasible to implement? |
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JUDGEMENT | RESEARCH EVIDENCE | |||||||||||||||||||||
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The information below has been obtained through an overview of systematic reviews of contextual factors, as well as a scoping review and one overview of systematic reviews of values and preferences. It also includes considerations from a Delphi study that was conducted in COMPAR-EU that included the most important contextual factors for the implementation of components (e.g. groups,peers) of self-management interventions according to stakeholders.
References
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ADDITIONAL CONSIDERATIONS | ||||||||||||||||||||||
The guideline panel judged that the feasibility of implementing this type of SMI varies. Implementation may be difficult, depending on the context and the use of specific devices for monitoring, for example, online feedback could be more complicated to obtain in certain contexts. and may depend on resources availablity. Limited human resources, healthcare system coordination and transport services may complicate the implementation of this SMI. Usually, duration of follow-up was not provided in the studies.
Studies' Interventions Gary-2010 - Cognitive behavioral therapy (CBT) based on Beck’s CBT model of depression - 12 face-to-face sessions, phone calls when needed; all individual - Duration 12 weeks - Expected patient (or carer) self-management behaviours: o Psychological management § Handling/managing emotions Bekelman-2018 - Collaborative symptom care provided by a nurse and psychosocial care provided by a social worker, both of whom worked with the patients’ primary care clinicians and were supervised by a study primary care clinician, cardiologist, and palliative care physician - Face-to-face sessions (number unclear), 24 phone calls; all individual - Duration 6 months - Expected patient (or carer) self-management behaviours: o Lifestyle related behaviours § Eating behaviours § Doing physical activity o Clinical management § Condition-specific behaviours § Medication use and adherence § Early recognition of symptoms o Psychological management § Handling/managing emotions Park-2017 - Diaries to track daily weight, HF symptoms, and response to symptom changes - 1 face-to-face session, 2 phone calls; all individual - Duration 24 months - Expected patient (or carer) self-management behaviours: o Lifestyle related behaviours § Eating behaviours o Clinical management § Self-monitoring § Medication use and adherence § Early recognition of symptoms § Asking for professional help or emergency care when needed Chen-2018e - Individualized rehabilitation programs, including home-based cardiac rehabilitation, diet education, and management of daily activity - 37 face-to-face sessions, 6 phone calls; all individual - Duration 3 months - Expected patient (or carer) self-management behaviours: o Lifestyle related behaviours § Doing physical activity o Clinical management § Condition-specific behaviours § Medication use and adherence § Physical management Leventhal-2011 - Home visit by a heart failure nurse, followed by 17 telephone calls of decreasing frequency over 12 months, focusing on self-care. Calls from the HF nurse to primary care physicians communicated health concerns and identified goals of care. - 2 face-to-face sessions, 17 phone calls; all individual - Duration 12 months - Expected patient (or carer) self-management behaviours: o Lifestyle related behaviours § Eating behaviours § Doing physical activity o Clinical management § Condition-specific behaviours § Self-monitoring § Early recognition of symptoms § Asking for professional help or emergency care when needed o Working with healthcare and/or social care providers § Communication with health care and/or social care provider Ojeda-2005 - Patient education, consultation with the cardiologist and monitoring in the Heart Failure Unit - 5 face-to-face sessions, phone calls when needed; all individual - Duration unclear - Expected patient (or carer) self-management behaviours: o Lifestyle related behaviours § Eating behaviours § Doing physical activity o Clinical management § Self-monitoring § Medication use and adherence § Early recognition of symptoms § Physical management Paradis-2010 - Motivational interviewing (MI) based on the stages of change (MISC) intervention - 1 face-to-face session, 2 phone calls; all individual - Duration 1 month - Expected patient (or carer) self-management behaviours: o Lifestyle related behaviours § Eating behaviours § Doing physical activity § Alcohol consume, and other harmful consumptions, cessation or reduction o Clinical management § Self-monitoring § Medication use and adherence § Early recognition of symptoms Vaillant-Roussel-2016 - General practitioners were trained during a 2-day interactive workshop to provide a patient education program. - 2-day workshop for GPs; 6 individual face-to-face sessions - Duration 19 months - Expected patient (or carer) self-management behaviours: o Lifestyle related behaviours § Eating behaviours § Doing physical activity o Clinical management § Medication use and adherence § Early recognition of symptoms |
TYPE OF RECOMMENDATION | ||||
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Strong recommendation against the intervention | Conditional recommendation against the intervention | Conditional recommendation for either the intervention or the comparison | Conditional recommendation for the intervention | Strong recommendation for the intervention |
CONCLUSIONS |
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Recommendation |
For patients with heart failure, the COMPAR-EU heart failure panel, suggests in favour of using Education, action-based (problem-solving and/or goal settings), and emotional-based (coaching, motivation, and stress management) behavioural techniques, rather than usual care (conditional, very low certainty of the evidence about the effects). |
Justification |
The COMPAR-EU heart failure panel made a conditional recommendation in favour of, Education, action-based (problem-solving and/or goal settings), and emotional-based (coaching, motivation, and stress management) behavioural techniques, rather than usual care, given a balance that probably favours the intervention (very low quality evidence of effects), the cost-effectiveness evaluation that favours either the intervention or usual care, and an intervention that is probably acceptable for main stakeholders. |
Subgroup considerations |
Effect of the intervention may differ according to the intensity and duration of the intervention. |
Implementation considerations |
When implementing SMI in general, the most important contextual factors to keep in mind are:
When implementing Education the most important contextual factors to keep in mind are:
When implementing action-based behavioural techniques (problem solving and/or goal setting), the most important contextual factors to keep in mind are:
When implementing Emotional-based behavioural techniques, the most important contextual factors to keep in mind are:
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Monitoring and evaluation |
Research priorities |
- Future studies should measure patient important outcomes, both critical and important (list below), have adequate sample size and follow-up, including after the intervention is finished. - Future studies should address also preferences and values of patients in relation to their self management, cost effectiveness and sub-categories of self-monitoring interventions. - Future studies should describe in detail the aspects of the intervention and evalute the long term effectiveness.
Critical outcomes
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REFERENCES SUMMARY |
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Summary of findings of network meta-analysis
COMPAR-EU Isof Web
Summary of findings of component network meta-analysis
COMPONENT NETWORK META-ANALYSIS (sensitivity analysis)
Outcome | Components’ effect (95% Confidence Interval) | CNMA effect (95% Confidence Interval) | ||
E | AB | EB | ||
Mortality | 0,95 (0,79 to 1,14) | 0,85 (0,72 to 1,01) | 0,85 (0,70 to 1,02) | 0,68 (0,56 to 0,83) |
Quality of life | 0.58 (0.25 to 0.91) | -0,06 (-0,33 to 0,20) | -0,05 (-0,33 to 0,233) | 0,47 (0,11 to 0,83) |
Components' definition:
E: Education; AB action-based behavioural techniques; EB emotional-based behavioural techniques
Components
Education (E)
Education (E)
Sharing information. This form of support consists in sharing of information about self-management topics like coping with symptoms, diet, exercise, medication, information about what other people are doing, and information about the disease itself, or about any other relevant aspects that could lead to improved self-management, and ultimately better health. This information can be told or distributed in printed materials like a folder or workbook, or via website or DVD.
Examples: Educational session on healthy eating for people with obesity, provision of a printed leaflet on the importance of foot care in diabetes, or a link to a website with information on chronic obstructive pulmonary disease care.
Action-based behavioural change techniques (AB)
Action-based behavioural change techniques (AB)
There are different action-based behavioural change techniques:
Enhancing problem-solving skills. This technique consists in teaching on how to analyse factors that influence your behaviour and provide you or help you to develop strategies to reduce or overcome barriers and/or support facilitators (e.g., not eating unhealthy foods when you feel depressed). Strategies include anticipation, self-treatment, resource utilization, and problem management. Ideally, there should be an initial plan, but this is not a requisite.
Example: Identification and attenuation of environmental barriers (e.g., no gym in the neighbourhood when one want to exercise) and facilitators (e.g., someone who keeps you company during exercise) to everyday physical activities.
Goal setting and action planning. This technique consists in encouraging you to set one or more achievable goals based on your needs and preferences. These goals may be behaviours (e.g., a consuming a healthy meal three times a day) or outcomes (e.g., less pain) and can be used as a starting point. The process usually involves the formulation of a detailed action plan, specifying what you would do and at least when and/or where you will do it. It could also include an assessment of your behaviours with your health care provider and a discussion of goals and the writing up of agreed-on action plans, including plans for emergency situations.
Examples of goals: achieving a daily walking distance of 2 km or a weight loss of some kilograms in x months with diet and exercise.
Emotional-based change techniques (EB)
Emotional-based change techniques (EB)
There are different emotional-based behavioural change techniques:
Stress and/or emotional management. This technique consists in helping you to understand the role of stress and emotions and teaching them to use different coping strategies to manage, for example, stress and painful emotions caused by your disease.
Examples: Mindfulness, exercise, stretching, listening to music, deep breathing, or meditation.
Coaching and motivational interviewing. This kind of support helps you to change behaviours by looking what’s important to you, and then offering support, taking into account your needs and preferences. One provider (healthcare professional, peer or lay person) is usually your coach. Motivational interviewing and counselling are included, as well as collaborative conversations with a practitioner, helping with motivation and commitment, minimizing resistance, and resolve ambivalence to change.
Examples: coaching sessions led by a nurse to ease the transition from hospital to home, or rehabilitation programs using coaching methods.
Individual sessions
A single person receives the self-management support. Examples: self-guided actions (without the participation of any other person) during a clinical visit or within the context of a support or educational session
Face-to-face
Self-management support delivered in a face-to-face encounter between the providers and patients and/or caregivers.