Chronic Disease Self-Management Support: Public Health Perspectives

1 Arthritis Program, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA, USA 2 Healthy Aging Program, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA, USA 3 Rollins School of Public Health, Emory University, Atlanta, GA, USA 4 Epilepsy Program, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA, USA *Correspondence: tob9@cdc.gov


A PUBLIC HEALTH PRIORITY
The Centers for Disease Control and Prevention (CDC) has a longstanding commitment to developing and promoting evidence-based strategies to prevent or delay disease and disability (1,2). Significant among these strategies is support for self-management of chronic diseases. About one-half of all U.S. adults have at least one chronic condition (3) and over two-thirds of Medicare beneficiaries aged 65 years or older have two or more chronic conditions (4). Given that the risk of developing a chronic disease increases with advancing age (5), the dramatic aging of the U.S. population underscores the importance of chronic disease self-management supports. Further, effective self management of chronic conditions is essential to achieving a state of health, which is proposed to reflect "the ability to adapt and to self manage" (6).
An effective approach to improve population health requires a strong focus on self-management. CDC's National Center for Chronic Disease Prevention and Health Promotion includes among its four priorities efforts to help ensure that "communities support and clinics refer patients to programs that improve management of chronic conditions" (7). Self-management (e.g., what individuals and families do on a daily basis to feel better and pursue the life they desire) (8) and self-management support (e.g., actions taken by others to support individual self-management) (9) are critical strategies in meeting this priority objective. The U.S. Department of Health and Human Services recognized the importance of self-management support in its framework for addressing multiple chronic conditions (MCC). One of the four goals of the framework is to "maximize the use of proven self-care management and other services by individuals with MCC" (10).
Chronic disease self-management support occurs at the intersection of public health, clinical healthcare delivery, social services, aging services networks, and other community resources. In this commentary, we provide a public health perspective on self-management support, identify examples of CDC investment in selfmanagement support activities, and discuss potential future directions. These examples are provided to illustrate the breadth of CDC's work in this area and are not designed to serve as comprehensive list of CDC's investment in self-management support.

AN INTERNATIONAL FOUNDATION FOR UNDERSTANDING
Consistent with a public health perspective, we advance an expanded definition of self-management support from the International Framework for Chronic Condition Self-Management Support. This definition describes self-management support as a grouping of policies, programs, services, and structures that extend across healthcare, social sectors, and communities to support and improve the way individuals manage their chronic conditions (11). The definition frames self-management support within a social-ecological perspective underscoring individual, interpersonal, community, environmental, and systems levels resources (12). This definition also embraces a life course perspective that attends to individual autonomy and decision-making as well as role changes and other adaptations to life events (13).
Self-management support takes many forms. It includes interventions such as the Chronic Disease Self-Management Program (CDSMP) (14) and the falls prevention programs featured in this special issue (15). It also includes supportive interactions between healthcare providers and patients, proactive follow-up, and social and physical environments that support healthy behaviors such as having safe places to exercise, access to healthy foods, and social norms that combat stigma, promote social participation, and support self-care behaviors (9).
Self-management support interventions are provided in a variety of formats (e.g., one-to-one, small groups, telephone, online/mobile, self-study); and in a variety of settings (e.g., home, healthcare, worksite, community) (9,12). Although the form and formats vary, the goal of selfmanagement support is consistent: to help individuals and their personal support system acquire and maintain the knowledge, skills, and confidence to do what they need to do to live as well as possible with their chronic condition(s).

ADVANCING THE STUDY AND APPLICATION OF SELF-MANAGEMENT SUPPORT
The International Framework for Chronic Condition Self-Management Support www.frontiersin.org phone and Internet that helps adults with epilepsy and comorbid depression reduce their depressive symptoms, and improve some well-being domains (19).

Self-study interventions The University of North Carolina and Stanford University developed and evaluated The Arthritis
Toolkit that provides the content of the small group-delivered Arthritis Self-Management Program (ASMP) in a mail-delivered, self-study format (20). Currently, CDC is funding Stanford University to develop a self-study version of the Chronic Disease Self-Management Program (CDSMP).   (1) seizures (e.g., history, management); (2) medicine (e.g., barriers, side effects), and (3) lifestyle (e.g., social support). The tool is designed to enhance patient-provider communication and action planning to sustain or improve epilepsy self-management behaviors (25).   identifies seven key strategic directions to move self-management support forward in research, policy, and practice at the local, regional, state, and national levels. These strategic directions are to involve consumers, expand the reach and range of services, advance evidence, improve effectiveness and appropriateness of services, strengthen inter-sector linkages, foster multi-sector commitment and accountability, and build infrastructure. Using this organizing structure (11), in Table 1, we highlight a few select but illustrative examples of CDC's contributions to the Framework's seven strategic directions. Through funded research and other mechanisms, CDC and its partners have employed a variety of strategies to involve consumers by using applied communitybased participatory strategies in developing evidence-based programs and audience research. To expand the range and reach of services, CDC supports the development, evaluation, and dissemination of a variety of small group, tele-health, selfstudy, and online self-management support tools. To advance evidence, CDC investigators conduct systematic reviews of the literature and CDC funds applied prevention research to establish or strengthen the evidence-base of programs and policies. To improve the effectiveness and appropriateness of services, CDC supports comparative effectiveness studies and research designed to develop and test clinicaldecision support tools. In terms of efforts to strengthen inter-sector linkages, CDC supports community-clinical collaborations and makes linkages across public health sectors. CDC also helps to foster multi-sector commitment and accountability through the development of new frameworks and guidelines. Finally, CDC invests in building infrastructure to deliver selfmanagement support intervention programs at the national, state, and local levels systems initiatives.

SUSTAINING SELF-MANAGEMENT SUPPORT: GAPS AND OPPORTUNITIES
The need to advance efforts in selfmanagement support is well recognized in the public health arena. However, challenges remain and several research questions are yet unanswered. Such questions include how to identify the essential elements of an intervention, how to best target effective interventions to specific audiences, and how to determine the effect of self-management support on critical public health outcomes and biometric measures such as hemoglobin A1c and blood pressure. Additional comparative effectiveness and cost effectiveness research studies of self-management support interventions are necessary. Importantly, selected papers in this special issue will help address these issues.
If self-management support interventions are to achieve their potential for public health impact, they need to be integrated into comprehensive chronic disease management strategies at the national, state, and local levels, and across sectors. Given the large and diverse population of people living with chronic conditions, engagement of multiple organizations across various sectors is required to reach those in need. Ideally, self-management support will become an integral element of clinical care standards of care (30), part of the routine menu of services offered by a variety of community agencies, and an essential component of community chronic disease control efforts. Finally, sustaining self-management support will require the infrastructure as well as multisectoral resources to reach people where they live, learn, work, and engage with their family and community. Creative financing mechanisms will need to be developed or expanded to ensure wide availability of evidence-based self-management support.
The Centers for Disease Control and Prevention is supporting a wide variety of self-management support activities across multiple strategic directions. CDC supported activities exemplify a comprehensive view of self-management support that encompasses both health-enhancing individual behaviors and physical and social environmental contexts that influence self-management behaviors. To advance self-management support, several important areas of research need to be conducted, broad-based organizational engagement needs to occur, and delivery capacity infrastructure and financing mechanisms need to be established or expanded. Despite these challenges, it remains essential to create self-management support services and environmental supports that allow people to live well with their chronic condition.

ACKNOWLEDGMENTS
The findings and conclusions in this commentary are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.