Mapping interventional components and behavior change techniques used to promote self-management in people with multimorbidity: a scoping review

Figures & data

Figure 1. Prisma diagram illustrating the flow of information through the different phases.

Table 1. Characteristics of included studies.

Author, Year, Country	Participants	Type of intervention	Target of intervention	Comparator^3	Theory mentioned in text
(Ahmadpanah et al., 2016), Iran	Hypertension & Depression N = 45	Metacognitive detached mindfulness therapy (MDM) or Stress management training (SMT)	Reducing high blood pressure, depression, and anxiety	UC +	Metacognitive detached mindfulness therapy (MDM), stress management principles (SMT), systematic desensitization (Wolpe 1958) attention training techniques (ATT) (Kang, Gruber, & Gray, 2013)
(Alexopoulos et al., 2013) United States	COPD & Depression N = 138	Personalised intervention for depression and COPD (PID-C)	Depression, adherence to rehabilitation and treatment	UC	Theory of reasoned action (TRA)
(Alexopoulos et al., 2016), United States	COPD & Depression N = 101	Problem Solving-Adherence (PSA) and personalized intervention (PID-C)	Depression, adherence to rehabilitation and treatment	PID-C vs. PSA	Problem- solving therapy (PST)
(Barker et al., 2018), Australia	MM (COPD, bronchiectasis, heart failure, coronary artery disease or ischemic heart disease and at least one other chronic condition, such as diabetes, hypertension, and cancer) N = 17	A multimorbidity rehabilitation program (exercise and education)	Improving exercise capacity, self-management, quality of life and reducing hospitalizations	UC	Multimorbidity rehabilitation
(Barley et al., 2014), United Kingdom	Heart Disease & Depression N = 81	Personalised care (PC)	Improving Self-management, reducing depression	UC	Self-efficacy (goal setting and action planning)
(Beckie et al., 2011), United Kingdom	Heart Disease & Depression N = 252	Behavior change plan (Informed by TTM)	Reducing depression	UC	Transtheoretical model (TTM) and Motivational Interviewing (MI)
(Behnammoghadam et al., 2015), Iran	Heart Disease & Depression N = 60	EMDR therapy	Reducing depression	UC +	EMDR therapy
(Berkman et al., 2003) United States	Heart Disease & Depression N = 2481	Psychoeducation and medication	Reducing depression and increasing social support	UC +	CBT, Social Learning Theory
(Bogner & de Vries, 2008), United States	Hypertension & Depression N = 64	Integrated care	Improving adherence to medication, increase BP control, and reduce depression	UC	Theory of reasoned action (TRA)
(Bogner & de Vries, 2010), United States	Diabetes & Depression N = 58	Integrated care	Improve medication adherence, glycaemic control and reduce depression	UC	Theory of reasoned action (TRA)
(Bogner et al., 2012), United States	Diabetes & Depression N = 180	Integrated care	Improve adherence to medication, glycaemic control and depression.	UC	Theory of reasoned action (TRA)
(Bogner et al., 2013) United States	Hypertension & Depression N = 60	Integrated care	Improve BP control and depressive symptoms.	UC	Theory of reasoned action (TRA)
(Cherrington et al., 2018), United States	Diabetes & Depression N = 360	Self-management support	Improving self-management (T2DM control, exercise, diet, stress management), reducing depressive symptoms and healthcare utilization)	UC +	Self-management support
(Clarke et al., 2019), Australia	Diabetes & Depression N = 723	Self-guided CBT	Improving work and social functioning (in T2DM), reducing depression	CG + Placebo control program (Healthy Lifestyles) with health and lifestyle information	CBT
(Coventry et al., 2015), United Kingdom	MM (diabetes and/or coronary heart disease, Depression) N = 387	Collaborative care	Reduce depressive symptoms and anxiety, increase self-management	UC	Collaborative care model, ABC model
(de Godoy & de Godoy, 2003), Brazil	COPD & Depression N = 30	Exercise, psychotherapy and education	Reduce depression and anxiety	CG + PT, Exercise, Education	Exercise, psychotherapy, and education
(de Groot et al., 2019), United States	Diabetes & Depression N = 140	Psychotherapy, exercise, and education	Reduce depression	UC or EX (Exercise only) or CBT + EX all offered the Dining with Diabetes nutrition education program	Beck’s model of cognitive therapy
(Dejesus et al., 2009) United States	Diabetes & Hypertension N = 54	Education and home BP self-monitoring	Improve self-management	UC	Chronic disease model
(Dekker et al., 2012), United States	Heart Disease & Depression N = 41	Brief cognitive therapy	Reduce depressive symptoms and negative thinking, improve QoL	UC	Beck’s model of cognitive therapy (CT)
(Denver et al., 2003), United Kingdom	Diabetes & Hypertension N = 120	Nurse-led HT clinic group	Improve management of uncontrolled HT	UC	Nurse-led HT clinic group
(Doyle et al., 2017), Australia	COPD & Depression N = 110	Telephone CBT	Reducing depression and anxiety and improving self-efficacy	UC + Active social control (befriending)	CBT, Befriending
(Dunbar et al., 2014), United States	Diabetes & Heart Disease N = 65	Education, counseling, self-management	Self-care and self-management (diet, medication, symptom monitoring, physical activity, and recognition of the interaction between self-management strategies for HF and DM)	UC +	Integrated theoretical framework to guide HF and DM self-care
(Dunbar et al., 2014), United States	Diabetes & Heart Disease N = 134	Integrated HF-T2DM Self-Care	Integrate and improve HF and DM self-care (diet, medications, self-monitoring, symptoms, and PA)	UC +	Integrated theoretical framework to guide HF and DM self-care
(Edelman et al., 2010) United States	Diabetes & Hypertension N = 239	Self-management and medical clinic education groups	Improve self-care and self-management	UC	Self-management model, Group medical clinics
(Edelman et al., 2015), United States	Diabetes & Hypertension N = 377	Tailored behavioral intervention	Improve self-management of comorbid T2DM and HT	UC +	Nurse led behavioral management
(Egede et al., 2018), United States	Diabetes & Depression N = 90	Reducing depression and anxiety and improving glycaemic control	Reducing depression and anxiety and improving glycaemic control	BAT via telemed at home vs. BAT in same room	Behavioral activation
(Fortin et al., 2016), Canada	MM (Diabetes, cardiovascular disease, COPD, asthma, tobacco smoking, obesity, hyperlipidaemia, Prediabetes) N = 332	Self-management support and health education	Improve chronic disease prevention and self-management of multimorbidity	CG + 3 months delayed intervention	Chronic disease prevention and management (CDPM)
(Freedland et al., 2009), United States	Heart Disease & Depression N = 123	CBT or Supportive stress management and medication	Reducing depression and improving HF self-care after surgery	UC	Cognitive behavior therapy (CBT), Stress management
(Freedland et al., 2015), United States	Heart Disease & Depression N = 158	CBT and tailored education (for HF)	Reduce depression and improve self-care in HF patients	UC	CBT and tailored education (for HF)
(Gary et al., 2010), United States	Heart Disease & Depression N = 74	CBT, exercise, CBT and exercise	Improving physical activity, reducing depression, and enhancing quality of life	CBT + Exercise vs CBT only vs Exercise only vs. UC	CBT (Beck's model of depression)
(Garvey et al., 2015), Ireland	MM (two or more chronic conditions, 43 conditions identified, most common: arthritis, congestive cardiac failure, diabetes, depression and hypertension) N = 50	Multimodal program: Fatigue management; healthy eating; maintaining physical activity, maintaining mental health; managing medications and communicating effectively with health professional	Improving activity participation, self-efficacy, self-management and quality of life	UC + Waiting list (invited to attend an OPTIMAL course following trial completion)	Adapted Stanford Chronic Disease Self-Management Program, Bandura's model of Self efficacy
(Glasgow et al., 2006), United States	Diabetes & Depression N = 335	Computer-assisted Self-management Intervention (focused on healthy eating and physical activity)	Improving diabetes self-management (by improving healthy eating and exercise)	UC	Chronic care model self-management framework, Motivational interviewing (MI) (Miller & Rollnick)
(Hochhalter et al., 2010), United States	MM (treated for at least two of following: arthritis, lung disease, heart disease, diabetes, hypertension, depression, and osteoporosis) N = 79	Patient engagement intervention or safety Group	Improve patients’ self-efficacy for managing multimorbidity	Group A: Intervention (Appointment - workshop + phone call) Group B: Safety (attention control - workshop + phone call) Group C: UC	Self-Determination Theory (SDT)
(Huang et al., 2016), Taiwan	Diabetes & Depression N = 61	Motivational enhancement therapy (MET) and CBT	Reduce depressive symptoms and increase quality of life	UC +	Theory of stress and coping (Lazarus and Folkman) modified by Miller & Rollnick's motivational principles
(Hynninen et al., 2010), Norway	COPD & Depression N = 51	CBT	Reduce anxiety and depression	UC +	CBT adapted by Stanley et al.)
(Jang et al., 2018), Korea	Heart Disease & Depression N = 44	Mindfulness-based art therapy (MBAT)	Reduce depression, trait anxiety, anger and anger expression	UC [Waiting list control (received MBAT afterwards)]	Kabat-Zinn's mindfulness meditation (MBSR,) Monti's Mindfulness-based art therapy (MBAT) and Self-regulation theory
(Kasteleyn et al., 2016), Netherlands	Diabetes & Heart Disease N = 161	Self-management support, motivational interviewing	Improve self-management, self-efficacy and wellbeing, reducing distress	UC + Attention control, 1 telephone consultation	Leventhal’s Common-Sense Model of self-regulation (CSM), Bandura’s Social Cognitive Theory, Motivational interviewing
(Kunik et al., 2008), United States	COPD & Depression N = 238	CBT	Reduce anxiety and depression	Education group	CBT
(Lamers et al., 2010), Netherlands	COPD & Depression N = 187	Minimal Psychological Intervention (MPI)	Reducing depression and anxiety, and improving quality of life	UC	CBT and self-management
(Lamers et al., 2011), Netherlands	Diabetes & Depression N = 208	Minimal Psychological Intervention (MPI)	Reducing depression and improving quality of life	UC	CBT and self-management
(Landman et al., 2013), Netherlands	Diabetes & Hypertension N = 48	Biofeedback	Lowering blood pressure	CG [visually identical device guiding users to a breathing frequency of approximately 14 breaths/min]	Biofeedback
(Liu et al., 2019), China	COPD & Depression N = 60	Reduce depression and improve the quality of life	Reduce depression and improve the quality of life	UC +	Music Therapy
(Logan et al., 2012), Canada	Diabetes & Hypertension N = 110	Telemonitoring Self-Care Support System	Improve blood pressure control and self-care	UC	Telemonitoring Self-Care Support System
(Logtenberg et al., 2007), Netherlands	Diabetes & Hypertension N = 30	Device-guided breathing (Resperate)	Change in mean daytime ambulatory BP	UC +	Device-guided breathing (Resperate)
(Long et al., 2015), China	Diabetes & Depression N = 100	Group counseling	Reduce depression, improve treatment compliance and blood sugar control	UC +	Cognitive-behavioral group counseling, group dynamics
(Ludman et al., 2013), United States	MM (Depression, Diabetes and/or coronary heart disease) N = 214	TEAM care (self-management support, monitoring disease and pharmacotherapy)	Improving self-care-efficacy and confidence to maintain lifestyle changes (diet and exercise), reducing depression	UC	Collaborative care, Social Cognitive Theory, Self-management support
(Lundgren et al., 2016), Sweden	Heart Disease & Depression N = 50	Internet-Based Cognitive Behavioral Therapy (ICBT)	Reduce depression and anxiety and improve quality of life	CG +	CBT
(Lutes et al., 2018), United States	Diabetes & Depression N = 139	Collaborative care	Reducing depression and diabetes distress, improving self-care (diet, physical activity, smoking, foot care)	UC + educational materials	CBT, Problem-solving Therapy (PST), Collaborative care model
(Lynch et al., 2014), United States	Diabetes & Hypertension N = 61	Self-management intervention- Lifestyle Improvement through Food and Exercise (LIFE)	Improve self-management (diet, physical activity, and glycaemic control)	CG	Information processing model for food choice, self-management
(Moral et al., 2015), Spain	MM (mean of 5 chronic conditions/patient: hypertension and diabetes -the most prevalent) N = 154	Motivational Interviewing	To promote adherence to treatment in people treated by polypharmacy	UC	Motivational Interviewing (MI)
(Nie et al., 2019) China	Heart Disease & Depression N = 284	Education and lifestyle improving program (IPEL)	Reducing anxiety and depression, improving lifestyle (healthy diet, physical activity, and smoking cessation)	UC	Multicare intervention
(Norlund et al., 2018), Sweden	Heart Disease & Depression N = 239	Internet-Based Cognitive Behavioral Therapy (ICBT)	Reducing depression and anxiety	TAU	CBT
(O'Moore et al., 2018), Australia	Osteoarthritis & Depression N = 69	ICBT Sadness Program	Reducing depression	UC	CBT
(O'Neil et al., 2014), Australia	Heart Disease & Depression N = 121	Reducing depression, improving self-management	Reducing depression, improving self-management	UC	CBT
(Onyechi et al., 2016), Nigeria	Diabetes & Depression N = 80	Cognitive behavioral coaching	Reducing depression	UC	Cognitive Behavioral Coaching for Depression Manual (CBCDM)
(Ose et al., 2019), Germany	MM (Diabetes and at least two other severe chronic comorbidities) N = 495	Care management program	Improving self-management and self-care (diet, exercise, self-monitoring of blood glucose and foot care)	UC	Care management, Primary Care Network (PCN)
(Parswani et al., 2013), New Zealand	Heart Disease & Depression N = 30	MBSR	Reduce anxiety and depression	TAU + health education session	Mindfulness meditation (Jon Kabat-Zinn, Segal et al.)
(Penckofer et al., 2012), United States	Diabetes & Depression N = 74	Psychoeducation (SWEEP program) CBT and education	Reduce depression, anxiety and anger and improve quality of life	UC +	CBT, ‘Reality Management Approach for Persons with Depression’ (Munoz et al.)
(Pibernik-Okanovic et al., 2015), Croatia	Diabetes & Depression N = 209	Psychoeducation, Physical exercise, enhanced UC	Reducing depression, improving diabetes distress, self-management and quality of life	Group A: CBT + Self-help manual. Group B: Exercise (same interval and duration as CBT) Group C: Enhanced treatment as usual	CBT
(Piette et al., 2011), United States	Diabetes & Depression N = 291	Telephone-delivered CBT program	Improve management of depressive symptoms, physical activity levels, and diabetes-related outcomes	UC +	CBT
(Rachmani et al., 2002), Israel	Diabetes & Hypertension N = 141	Patient Participation Program	Improve self-management, self-monitoring, and disease control	UC	Intensive therapy, self-management
(Renn et al., 2018), United States	COPD & Depression N = 175	Brief CBT (Psychoeducation, chronic disease self-management, goal setting, behavioral activation, cognitive restructuring, relaxation, and coping with physical health symptoms)	Reduce illness intrusiveness and improve self-management	EUC (enhanced usual care)	CBT
(Richards et al., 2018), United Kingdom	Heart Disease & Depression N = 29	EPC (enhanced psychological care)	Reduce depression and anxiety, mortality and morbidity and improve quality of life	UC	Enhanced psychological care, rehabilitation
(Safren et al., 2014), United States	Diabetes & Depression N = 87	Enhanced treatment as usual, CBT	Reduce depression, improve adherence and glycaemic control	UC +	CBT, Motivational interviewing (MI)
(Salisbury et al., 2018), United Kingdom	MM (at least three types of chronic condition) N = 1546	Patient-centred care model (3D approach)	Improve patient-cantered care, self-care, and quality of life	UC	Patient-centred care model (3D approach)
(Schneider et al., 2016), United States	Diabetes & Depression N = 29	Behavioral Activation and Exercise	Increasing exercise level and exercise enjoyment	Enhanced Usual Care + Depression treatment referrals were also provided. Participants received information available from the ADA on nutrition, exercise, and glucose monitoring	Behavioral Activation (BA)
(Shen et al., 2018), China	Heart Disease & Depression N = 60	Psychological Intervention Program	Improving mental state, reducing stress and negative coping styles	UC	Comprehensive psychological intervention (cognitive therapy; relaxation therapy, emotional support)
(Taveira et al., 2011), United States	Diabetes & Depression N = 88	Psychoeducation (Pharmacist-Led Group Medical Appointments), Shared medical appointments (SMAs)	Reducing depression, improving self-care and self-care competence	UC	Psychoeducation (Pharmacist-Led Group Medical Appointments), Shared medical appointments (SMAs)
(Turner et al., 2014), Australia	Heart Disease & Depression N = 42	ICBT	Decreasing depression, increasing self- efficacy, improve health perceptions and behavior change (physical activity, diet, medication adherence, and smoking cessation)	UC	CBT and motivational interviewing (MI)
(Wakefield et al., 2011), United States	Diabetes & Hypertension N = 302	Home telehealth device and nurse care management	Improve self-care (diet, exercise, smoking cessation, foot care, advice for sick days, medication, weight management, preventive care)	High-intensity vs low-intensity vs UC	Care management
(Wu et al., 2012) Australia	Heart Disease & Depression N = 30	Peer CDSMP (self-management)	Improving knowledge, self-efficacy, and self-care behavior	UC +	Bandura’s theory of self-management (Bandura, 1977, 2004)
(Yoo et al., 2009), Korea, Republic of	Diabetes & Hypertension N = 123	Ubiquitous Chronic Disease Care (UCDC) system (self-management)	Improving self-management	UC	Chronic Disease Care

Figure 2. Presence of single conditions in the 72 studies.

Figure 3. Types of interventions according to the most common clusters of conditions.

Figure 4. Frequency of primary outcomes.

Figure 5. BCTs sorted by frequency.

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