Part Three. What works: the evidence for action
Chapter Two. Review of effective interventions
Working successfully in resource-poor settings
The long list of health-care disciplines that ideally should be available for individuals with chronic diseases may appear to be unrealistic in resource-poor settings. It is possible, however, to provide some of the core skills from these disciplines in other ways (by training primary health-care workers in key elements of chronic disease management, for example). It may be possible to provide core aspects of effective health care that in more resourced settings would be provided by health professionals from several different disciplines.
Use of evidence-based decision support tools
The development and implementation of evidence-based treatment guidelines is fundamental to putting evidence into practice. Guidelines have been defined as "systematically developed statements (recommendations) to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances". They draw on the best research evidence available at the time. The production of an evidence-based guideline is a resource-intensive and time consuming process. Nonetheless, evidence-based guidelines are available for many chronic diseases (see, for example, http://www.guideline.gov), and guidance on adapting them to specific national or local circumstances has been described. Of course, guidelines only work if they are used appropriately.
The evidence suggests that the more specific and focused the approach to implementation, the more likely that practice will change in the direction recommended by a guideline. For example, simply providing information about the guideline is likely to have little impact, but linking the guideline to workshops or outreach training sessions and providing prompts within medical records are much more likely to change practice.
Support for patient self-management
Self-management for people with chronic disease is now widely recognized as a necessary part of treatment. Interventions that aim to improve the ability of patients and their carers to manage conditions can be highly effective and are an essential component of chronic disease care.
Spotlight: Chronic disease self-management in China
A chronic disease self-management programme was developed in Shanghai from 1999 to 2001. The programme was conducted by trained volunteer lay leaders and included exercise, the use of cognitive symptom-management techniques, nutrition, fatigue and sleep management, use of medications, management of fear, anger, and depression, communication with health professionals, problem-solving and decision-making.
The programme significantly improved participants’ health behaviour, confidence and health status, and reduced the number of hospitalizations after six months. The programme has been implemented in 13 communities and six districts of Shanghai, and is being replicated in other cities.