Telehealth for Self-Manajement in Chronic Diseases.
COMPETITIVE AINEC RESEARCH AWARD
MANUSCRIPT
AINEC RESEARCH AWARD
TELEHEALTH FOR SELF MANAGEMENT IN CHRONIC DISEASES
Researchers:
Ns. Putu Oka Yuli Nurhesti, S.Kep., MM., M.Kep
NIDN.0530078001
Ns. Made Oka Ari Kamayani, S.Kep., M.Kep
NIDN. 001888018306
SCHOOL OF NURSING, FACULTY OF MEDICINE
UDAYANA UNIVERSITY
2015
ABSTRACT
TELEHEALTH FOR SELF MANAGEMENT IN CHRONIC DISEASES
Putu Oka Yuli Nurhesti, Made Oka Ari Kmayani
The development of information technology is getting better. It can help to improve the quality
of nursing care in patients with chronic disease. Innovation and social engineering in the field of
health care with the empowerment of patients and their families is one of information technology
products in the field of health to help patients perform the management of the chronic diseases.
Telehealth is a method to provide information related to self management in patients with
chronic disease with the help of communication tools and social media. Telehealth method goal
is to help patients with chronic diseases controlling the disease through self-management. The
models used in this study is the Chronic Care Model (CCM). The tool for measuring patient’s
self management is Patient Activation Measure (PAM).
This research is quasy experiment conducted in patients with chronic disease in Sanglah Hospital
Denpasar. The sampling technique used is purposive sampling with randomization to divided
respondents into control and treatment groups. Telehealth method was applied to perform
discharge planning for patients with chronic diseases who were treated at Sanglah Hospital. The
discharge follow-up conducted by telephone and short message twice a week for theree weeks.
Patient self-management assessed either in the control group or treatment with a questionnaire
translated instrument of PAM. The process of validity and reliability test performed by the test
content and back translation method.
The results show a significant difference between the self-management of patients with chronic
diseases who gets telehealth follow-up and with chronic disease patients who do not get
telehealth follow-up with an average PAM score of 75.6 ± 10.4 in the treatment group and 62.5
± 10.0 in the control group. The value of independent t-test with a 95% confidence level is
0.001. This value is smaller than 0.05
Telehealth can help patients with chronic diseases to improve self-management and active
involvement in the control of their chronic condition
Key words: chronic diseases, self management, telehealth
INTRODUCTION
Technological and social innovation in health care is one way to make the self
management of various chronic diseases. Adult nursing technology is growing rapidly in
many parts of the world, as part of the development of science and technology in general.
Countries in the world have started to do research on nursing technology use in the
prevention and management of disease. Indonesia as one of the developing countries
have not optimally developed technology of nursing in the prevention and management
of diseases, especially chronic diseases. Chronic disease is a condition in which an
individual suffering from a disease that is not curable but can be controlled. According to
WHO (2010), which includes chronic diseases are heart disease, stroke, Chronic
Obstructive Pulmonary Disease (COPD), cancer, hypertension, diabetes and kidney
disease. Chronic diseases have various influences on physical function, psychological,
economic, social and spiritual. The disease is generally followed by a variety of chronic
conditions such as pain, disability, and limitations of function as well as psychosocial
issues that influence the quality of life of patients (CDC, 2006). Chronic diseases require
the active participation of the patient and family for controlling and managing the disease
throughout the life.
Self-management is the dynamic, interactive, process where the patient is actively
involved in the control and management of the disease. Self-management refers to the
ability of individuals (patients) to work with families, communities, and health care
providers to manage the symptoms of the disease, therapy, lifestyle changes, and the
consequences of psychosocial, cultural and spiritual related disease conditions (Richard
& Shea, 2011), The use of medical technology and nursing in the treatment of patients
with chronic diseases is essential to help patients controlling the disease through selfmanagement. Telehealth is one way to facilitate patient self-management using the
nursing and medical information technology in the form of telephone, SMS and social
media use. According to Locsin, 2005, an important nursing technology was developed to
support the delivery of nursing care.
According to WHO (2010) Chronic diseases cause 36 million (63%) deaths of 57
million deaths worldwide in 2008. Based on data from the Ministry of Health (2008), in
Indonesia the proportion of the numbers of deaths from chronic diseases increased from
41.7% in 1995 to 49.9% in 2001 and 59.5% in 2007. The problems in chronic diseases
affect individuals throughout their lives. This disease occurs in individuals early
adulthood, middle, and end with age and many individuals who suffer from more than
one chronic disease. Most chronic diseases have the same characteristics associated with
symptoms such as fatigue and pain that interferes with the activity of individuals in our
daily lives and demanding change individual lifestyles. Psychological and emotional
reaction to the disease can be depression, anger, anxiety and stress (Mart & Livneh, 2007;
Smeltzer, Bare, Hinkle, Cheever, 2010). Research Clarke & Currie, 2009 showed that
69% of patients with chronic diseases experience anxiety and depression.
Telehealth is a service using electronic technology to patients in the distance limitations.
Telehealth is a new method in nursing care. Telehealth include the use of websites, social
media, telephone, mobile phone and interactive video in providing care to patients (Lee,
Chen, Haiso 2007; Locsin, 2005).
LITERATURE REVIEW
Chronic disease is defined as a medical condition or health problems associated
with the symptoms or disability requiring long-term management. Part of this
management involves learning to live with this disease and disability that might occur,
and modify lifestyle to control the signs and symptoms. This disease can be suffered by
all age groups, socio-economic and cultural level. Examples of common chronic diseases:
chronic sinusitis, arthritis, hypertension, heart disease, chronic bronchitis, asthma,
diabetes, chronic kidney disease (Falvo, 2005; Smelthzer Bare, Hinkle, Cheever, 2010).
According to WHO (2005), which includes chronic diseases are heart disease, stroke,
respiratory disease, cancer and diabetes mellitus.
According Oeffinger, Mertens & Sklar, (2006), the cause of the growing number
of people with chronic diseases are: 1) The decline in the death rate from infectious
diseases for example measles, diphtheria, infections associated with HIV / AIDS, and
good management of various acute conditions such as trauma; 2) Lifestyle factors such as
smoking, chronic stress, and monotonous lifestyle that enhances the risk of chronic health
problems such as respiratory disease, hypertension, cardiovascular disease and obesity.
Although the signs and symptoms of chronic disease often appears first in adulthood but
the progression of the disease may have been started since the age of the children; 3)
Increased life expectancy as a result of advances in science and medical technology,
improved nutritional status, working conditions safer, and easier access to health
services; 4) Increased screening and diagnostic procedures so that early detection and
disease management can be done and improve yield management and treatment of
various chronic diseases
Barlow, Wright, Sheasby, Turner, & Hainsworth, (2002) based on the results of
review (in 28 diseases) find the components of self management in chronic disease
consists of information needs, medication management, symptom management,
management of psychosocial, lifestyle, social support, communication and others. The
increased understanding by clients, lowering disease recurrence and acute conditions
between the period of chronic illness. Lorig and Holman (2003) identified five basic
skills in self-management; 1) solve the problem: the ability to find solutions to maintain
the health of patients with chronic diseases; 2) make decisions: a part of problem-solving
skills, including knowledge for the management of symptoms and choose appropriate
treatments; 3) the use of resources: the ability of individuals with chronic illnesses
searching services and information while on the community to assist in the management
of the disease; 4) build partnerships with health personnel is very important to have this
ability to obtain more information on self-management; 5) the ability to take action:
individuals with chronic diseases are expected to have the ability to take action and
participate in self-management. This capability is based on self-efficacy theory of
Bandura, where every patient with chronic disease should have confidence in doing selfmanagement.
Self-management model has been developed to provide a frame of reference in
providing self-management techniques in patients with chronic disease. Chronic Care
Model (CCM) is a model that is evidence based integrated of health knowledge by
prevention, treatments, diagnosis, monitoring and controlling chronic diseases in order to
achieve outcomes related to optimal quality of life for patients with chronic diseases
(Epping-Jordan et al 2004). This model considers that self-management can improve
clinical and functional outcomes of patients, disease management through productive
interaction between information providers, liveliness and readiness of patients, health
professionals proactive team with the support of a good information system.
According to Harvey, (2006); Popoola, (2005) some of the factors that influence
self-management in individuals with chronic diseases have been identified: 1)
Demographic factors: These factors include socioeconomic and cultural status; 2) clinical
factors: morbidity, mortality and the degree of complexity of the clinical condition of the
patient; 3) system: these factors include the quality of the relationship and
communication with health care providers. Measurement of the ability of selfmanagement of patients with chronic disease can be done with a variety of measuring
instruments, including the Patient Activation Measure (PAM), which is a measurement
tool to assess the knowledge, confidence levels and the ability of the patient in selfmanagement. This instrument consists of 22 questions grouped into three components,
namely: believe in the importance of active involvement, confidence and knowledge of
actions related to self-management, the act of self-management, the ability to maintain
self-management in conditions of stress (Hibbard & Tusler, 2007; Lieberman, 2003). ,
According to The Picker Institute Europe, 2005, interpretation PAM score is as
follows: Stage 1: the trust of patients to the importance of the roles, PAM score of 47.0 or
less; Stage 2: the confidence and knowledge to take action PAM score of 47.1 - 55.1;
Stage 3: take action PAM score of 55.2 - 67.0; Stage 4: keep doing self management even
under stress or pressure PAM score of 67.1 or more.
Telehealth is the use of information technology in providing health care to
patients. Telehealth may include the use of information technology by various health
professionals including doctors and nurses. Information technology in the field of nursing
is an information technology that integrates nursing science, computer science, and
information science to manage and communicate data, information, and knowledge in
nursing practice. Nursing informatics facilitates the integration of data, information, and
knowledge to support clients, nurses, and other health care providers (Moscato et al.
2007; Fitzner & Moss, 2013).
According to Hughes (2001), Dumitriu (2014) there are some skills that need to
be mastered by nurses when performing the method: 1) Skill interpersonal
communication: effective communication of nurses and patients affected by various
factors. Nurse client relationship must be developed well in order to be able to
communicate care-related diseases. Negative attitudes that emerged from the nurse and
the patient can be a barrier to effective communication between nurses and patients; 2)
Skill of collaboration: the ability to collaborate in a team of nurses to patients, families
and other health professionals will support the implementation of telenursing and ensure
adequate flow of information to the patient; 3) Clinical skill assessment: a nurse who do
clinical telenursing are required to have the ability to recognize various emotional
changes, physical changes that occurs in patients to provide effective treatment for acute
conditions; 4) Skill related to information technology: the nurse who did telenursing must
have a mind and an open attitude towards the development of information technology.
Self-management with telenursing method is a method that integrates the concept
of self-management with the help of technology onformasi and carried out by nurses.
This method is widely used in helping patients with chronic diseases to the management
of the disease through lifestyle changes. Chronic disease with a variety of characteristics
such not curable condition, require control throughout a patient's life, there is a period
between the acute and chronic conditions that need the stress management and social
support .
Research conducted by Nilsson (2009) on the use of SMS to medication
adherence in chronic disease patients in the district perawa in Sweden, shows there is
increased confidence in nurses and patient adherence to therapy protocols. Research
conducted by Solomon (2008), Knight & Shea (2014) showed that there was significant
relationship between self-management, patient characteristics and the use of technology.
Telenursing increasing the capability of nurses to provide a variety of information related
to self management in patients with chronic diseases such as; nutrient management,
protocol therapy, social support and stress management.
RESEARCH METHODS
This research is quasy experimental to analyze differences in the ability of selfmanagement in the group of patients with chronic disease given telehealth method
(treatment group) and the group of patients with chronic diseases are not given telehealth
method (the control group). Telehealth method does is combined telephone and SMS.
The study population was patients with chronic diseases who were treated at Sanglah
Hospital in Denpasar. The sampling technique used was purposive sampling. The
inclusion criteria for patients suffering from chronic diseases are diagnosed and treated
for at least 3 days in Sanglah Hospital in Denpasar. Documentation of data specified
sample size of 60 respondents, which was divided into the 30 respondents to the control
group and 30 responders to the treatment group. Processing of the data in the study
include the steps of: editing, coding, and cleaning. Data analysis is done by Man Whitney
test because of the results of the Shapiro Wilk normality test showed the data were not
normally distributed. The confidence level used is 95% and the value of significance =
0.05.
RESEARCH PROCESS
This study began with the preparation, implementation and final. Preparation is
done by applying the test of ethics and conduct trials, asking application letter and permit
research to the research and development Sanglah Hospital, Faculty of Medicine,
University of Udayana. Randomization was performed to include respondents who met
the inclusion criteria into control and treatment groups according to the return from the
hospital. Patients given inform concern then performed 3 times a week telephone and
SMS for 3 weeks. Phones given to the treatment by the investigator (nurse) and in
cooperation with the treating physician resident. After 3 weeks of either the control or the
treatment group was given questionnaires to assess PAM Score. There were 3 patients in
the treatment group dropped out due to a decrease in health conditions and 5 respondents
in the control group whose address is hard to find and a decrease in health conditions.
Researchers have considered the ethical principles in performing any action or
intervention in this study and all activities performed on a patient using the clear
informed consent. Before the study began made ethical ethics clearance through a test
conducted by the research ethics committee FK unud / Sanglah Hospital in Denpasar, so
this study considering the ethical principles like beneficence, Respect for human dignity,
Justice.
RESULT
The age of patients suffering from chronic diseases are above 30 years and in both
groups of patients with highest number of patients is in the age range 31- 40 years,
although in the treatment group as well as large number of respondents in the age range
71-80 years. Falvo, (2005); Smelthzer Bare, Hinkle, Cheever, (2010), state that chronic
diseases can be suffered by all age groups socioeconomic and cultural level. According
Oeffinger, Mertens & Sklar, (2006), the epidemiological transition has changed the
course of various chronic diseases, where chronic diseases appear at an increasingly
young age due to various causes including lifestyle factors. In the control group of
chronic disease affects more men than women are respectively 16 cases (53.3%) and 14
cases (46.7%). The results of this research together with research conducted by Ndraha,
Rinaldi, Hernando and Santosa (2010 ) conducted in Koja Hospital Jakarta, where the
number of patients with chronic diseases more men than women are 30 (54.5%) men and
25 (45.5%) women. The number of patients in the treatment group more women than
men, respectively 13 men (43.3%) and 17 women (56.7%). According to Smeltzer, Bare,
Hinkle, Cheever (2010), a chronic disease can occur at any age and gender.
Most types of chronic disease suffered by patients in the case group were not done
telehealth is CKD with the number 4 (13.3%), while in patients who do not do telehealth
approach most types of chronic disease is cancer the number and frequency of 4 (13.3%),
According to WHO (2010), ten most common chronic disease in 2009 based on data
from inpatient hospitals in Indonesia are cancer, stroke, chronic kidney disease, heart
disease, and the rest is a combination of various diseases. According to Clarke & Currie,
(2009), the emergence of chronic disease will be followed by the emergence of other
chronic diseases in the same individual, so many individuals are not only suffered with
one type of chronic disease. In this research can be seen there are patients who suffer
from more than one chronic disease, it is likely due to a chronic disease is a
predisposition of the other chronic diseases, for example diabetes mellitus predisposes to
the appearance of hypertension, CKD and stroke due to increased blood viscosity due to
high levels of glucose blood.
Self-management level with a score of PAM, most respondents in the group that
did not do telehalth are at stage 3 is taking action with PAM score of 55.2 - 67.0. At this
stage the patient is able to take action if there are conditions that occur related acute
illness, for example subtracts the current salt intake is known to increase blood pressure
in patients with hypertension. In patients with chronic disease self-management level
given telehealth with PAM scores, the majority of respondents were in stage 4 is still
perform self management even under stress or pressure PAM score of 67.1 or more. At
this stage the patient remains capable of controlling the disease is continuously
consistently in various situations. Hypertensive patients remains a diet low in salt even
though her blood pressure was stable or under pressure from a variety of social situations.
This research was supported by the results of research conducted Solomon (2008) where
the use of information technology can improve the ability of self-management in patients
with chronic disease. Results of other studies that support this research which scores
menilaib PAM used for self management in patients with chronic disease carried Greene
and Hibbard (2012); Hibbard et al (2005), by providing information over the telephone
and audiovisual in society who are at risk of chronic disease suggests there is an increase
PAM scores for screening the disease in an individual.
According to Harvey, (2006); Popoola, (2005) some of the factors that influence
self-management in individuals with chronic diseases have been identified, namely:
Demographic factors: These factors include socioeconomic status and cultural, Clinical
factors: morbidity, mortality and the degree of complexity of the clinical conditions of
patients, Factor system: factor This includes the quality of the relationship and
communication with health care providers. This study uses a system factor of effective
communication between patients and health provider to provide information on patients
with chronic diseases of various patients with the necessary control and social support
expected.
Patients with chronic disease in the majority Sanglah Hospital has been able to
obtain sufficient information on how to control the chronic diseases suffered. Current
technological developments help patients to learn about the activities that can be done
related chronic diseases suffered. Provision of information carried on pasein helping
patients to remain continous controlling the chronic diseases.
Mann Whitney test results demonstrate the value of p = 0.001 where the value is
smaller than 0.05 so there is a significant different of (significant) self management in
patients with chronic disease were given telehalth by phone and SMS and chronic disease
patients who were not given telehealth. Results of this research together with research
conducted by McCabe et al (2014), in which there is an increase in self-management
knowledge, and ability to support rehabilitation in patients with chronic lung disease after
being given information about the management of the disease. Research of Chiang et al
(2012) showed that there is an increased ability of stress management, family
involvement and confidence in patients with chronic disease given telehealth method that
given as a follow-up after discharge of patients from hospital. Research Sharma and
Clark (2014) suggests that telehealth service delivery with support of nurses who provide
care to patients with chronic diseases as a new method in the delivery of nursing care.
According Dabb et al (2013) of the patients and families are the main systems that
help individuals with chronic disease to manage themselves to controlling the disease.
Effective self-management requires the active involvement of patients to make lifestyle
changes and remain consistent to do so even in a stable condition or under a certain
pressure. Acording to Russel (2012) nursing technology capable of supporting the
provision of nursing care to be effective and efficient as well as making an important
decision in nursing to improve the various outcomes in the treatment of patients with
chronic diseases.
Patients with chronic diseases were treated at Sanglah Hospital in Denpasar, most
have suffered from chronic diseases over 2 years. Knowledge about the illness is quite
good. The desire to control the disease have consistently not been so good in patients
with chronic disease were not given telehealth, where the average value of PAM is 62.6.
Patients with chronic diseases are given methods of telehealth has knowledge as well as
the desire to consistently control the chronic disease experienced by the average value of
PAM 75.5. Almost all patients with chronic diseases very cooperative receive calls and
SMS answer from researchers. Many questions they asked and they want to get
information about the illness. This is probably because the patients who went to Sanglah
Hospital is the referral of patients who have long exposed about the disease. Besides,
discharge planning have been started by the nurses and doctors who deal even though the
information provided there is not yet optimal according to the needs of the patient.
CONCLUSIONS AND SUGGESTIONS
Based on the results of research and discussion of the influence of telehealth on
self-management methods in patients with chronic disease can be concluded that PAM
scores of patients with chronic diseases are given telehelath higher compared to patients
who were not given telehealth kronim. Analysis by Mann Whitney test showed a p-value
= 0.001 where the value is smaller than 0.05 so there is a significant different of
(significant) self management in patients with chronic disease were given telehealth by
phone and SMS and chronic disease patients who were not given telehealth. Telehealth
method by using phone and SMS is a method that can be used to enhance the ability of
self-management in patients with chronic disease. This method can be applied as part of
the patient discharge planning as a method of continuous treatment to control the disease.
Further research on self-management methods need to be performed with the telehealth
control some of the factors that affect the self-management strictly. Further research can
be done by adding variables such as the number of hours phoning penialian effective,
recurrence or complications that could be prevented as well as costs incurred
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MANUSCRIPT
AINEC RESEARCH AWARD
TELEHEALTH FOR SELF MANAGEMENT IN CHRONIC DISEASES
Researchers:
Ns. Putu Oka Yuli Nurhesti, S.Kep., MM., M.Kep
NIDN.0530078001
Ns. Made Oka Ari Kamayani, S.Kep., M.Kep
NIDN. 001888018306
SCHOOL OF NURSING, FACULTY OF MEDICINE
UDAYANA UNIVERSITY
2015
ABSTRACT
TELEHEALTH FOR SELF MANAGEMENT IN CHRONIC DISEASES
Putu Oka Yuli Nurhesti, Made Oka Ari Kmayani
The development of information technology is getting better. It can help to improve the quality
of nursing care in patients with chronic disease. Innovation and social engineering in the field of
health care with the empowerment of patients and their families is one of information technology
products in the field of health to help patients perform the management of the chronic diseases.
Telehealth is a method to provide information related to self management in patients with
chronic disease with the help of communication tools and social media. Telehealth method goal
is to help patients with chronic diseases controlling the disease through self-management. The
models used in this study is the Chronic Care Model (CCM). The tool for measuring patient’s
self management is Patient Activation Measure (PAM).
This research is quasy experiment conducted in patients with chronic disease in Sanglah Hospital
Denpasar. The sampling technique used is purposive sampling with randomization to divided
respondents into control and treatment groups. Telehealth method was applied to perform
discharge planning for patients with chronic diseases who were treated at Sanglah Hospital. The
discharge follow-up conducted by telephone and short message twice a week for theree weeks.
Patient self-management assessed either in the control group or treatment with a questionnaire
translated instrument of PAM. The process of validity and reliability test performed by the test
content and back translation method.
The results show a significant difference between the self-management of patients with chronic
diseases who gets telehealth follow-up and with chronic disease patients who do not get
telehealth follow-up with an average PAM score of 75.6 ± 10.4 in the treatment group and 62.5
± 10.0 in the control group. The value of independent t-test with a 95% confidence level is
0.001. This value is smaller than 0.05
Telehealth can help patients with chronic diseases to improve self-management and active
involvement in the control of their chronic condition
Key words: chronic diseases, self management, telehealth
INTRODUCTION
Technological and social innovation in health care is one way to make the self
management of various chronic diseases. Adult nursing technology is growing rapidly in
many parts of the world, as part of the development of science and technology in general.
Countries in the world have started to do research on nursing technology use in the
prevention and management of disease. Indonesia as one of the developing countries
have not optimally developed technology of nursing in the prevention and management
of diseases, especially chronic diseases. Chronic disease is a condition in which an
individual suffering from a disease that is not curable but can be controlled. According to
WHO (2010), which includes chronic diseases are heart disease, stroke, Chronic
Obstructive Pulmonary Disease (COPD), cancer, hypertension, diabetes and kidney
disease. Chronic diseases have various influences on physical function, psychological,
economic, social and spiritual. The disease is generally followed by a variety of chronic
conditions such as pain, disability, and limitations of function as well as psychosocial
issues that influence the quality of life of patients (CDC, 2006). Chronic diseases require
the active participation of the patient and family for controlling and managing the disease
throughout the life.
Self-management is the dynamic, interactive, process where the patient is actively
involved in the control and management of the disease. Self-management refers to the
ability of individuals (patients) to work with families, communities, and health care
providers to manage the symptoms of the disease, therapy, lifestyle changes, and the
consequences of psychosocial, cultural and spiritual related disease conditions (Richard
& Shea, 2011), The use of medical technology and nursing in the treatment of patients
with chronic diseases is essential to help patients controlling the disease through selfmanagement. Telehealth is one way to facilitate patient self-management using the
nursing and medical information technology in the form of telephone, SMS and social
media use. According to Locsin, 2005, an important nursing technology was developed to
support the delivery of nursing care.
According to WHO (2010) Chronic diseases cause 36 million (63%) deaths of 57
million deaths worldwide in 2008. Based on data from the Ministry of Health (2008), in
Indonesia the proportion of the numbers of deaths from chronic diseases increased from
41.7% in 1995 to 49.9% in 2001 and 59.5% in 2007. The problems in chronic diseases
affect individuals throughout their lives. This disease occurs in individuals early
adulthood, middle, and end with age and many individuals who suffer from more than
one chronic disease. Most chronic diseases have the same characteristics associated with
symptoms such as fatigue and pain that interferes with the activity of individuals in our
daily lives and demanding change individual lifestyles. Psychological and emotional
reaction to the disease can be depression, anger, anxiety and stress (Mart & Livneh, 2007;
Smeltzer, Bare, Hinkle, Cheever, 2010). Research Clarke & Currie, 2009 showed that
69% of patients with chronic diseases experience anxiety and depression.
Telehealth is a service using electronic technology to patients in the distance limitations.
Telehealth is a new method in nursing care. Telehealth include the use of websites, social
media, telephone, mobile phone and interactive video in providing care to patients (Lee,
Chen, Haiso 2007; Locsin, 2005).
LITERATURE REVIEW
Chronic disease is defined as a medical condition or health problems associated
with the symptoms or disability requiring long-term management. Part of this
management involves learning to live with this disease and disability that might occur,
and modify lifestyle to control the signs and symptoms. This disease can be suffered by
all age groups, socio-economic and cultural level. Examples of common chronic diseases:
chronic sinusitis, arthritis, hypertension, heart disease, chronic bronchitis, asthma,
diabetes, chronic kidney disease (Falvo, 2005; Smelthzer Bare, Hinkle, Cheever, 2010).
According to WHO (2005), which includes chronic diseases are heart disease, stroke,
respiratory disease, cancer and diabetes mellitus.
According Oeffinger, Mertens & Sklar, (2006), the cause of the growing number
of people with chronic diseases are: 1) The decline in the death rate from infectious
diseases for example measles, diphtheria, infections associated with HIV / AIDS, and
good management of various acute conditions such as trauma; 2) Lifestyle factors such as
smoking, chronic stress, and monotonous lifestyle that enhances the risk of chronic health
problems such as respiratory disease, hypertension, cardiovascular disease and obesity.
Although the signs and symptoms of chronic disease often appears first in adulthood but
the progression of the disease may have been started since the age of the children; 3)
Increased life expectancy as a result of advances in science and medical technology,
improved nutritional status, working conditions safer, and easier access to health
services; 4) Increased screening and diagnostic procedures so that early detection and
disease management can be done and improve yield management and treatment of
various chronic diseases
Barlow, Wright, Sheasby, Turner, & Hainsworth, (2002) based on the results of
review (in 28 diseases) find the components of self management in chronic disease
consists of information needs, medication management, symptom management,
management of psychosocial, lifestyle, social support, communication and others. The
increased understanding by clients, lowering disease recurrence and acute conditions
between the period of chronic illness. Lorig and Holman (2003) identified five basic
skills in self-management; 1) solve the problem: the ability to find solutions to maintain
the health of patients with chronic diseases; 2) make decisions: a part of problem-solving
skills, including knowledge for the management of symptoms and choose appropriate
treatments; 3) the use of resources: the ability of individuals with chronic illnesses
searching services and information while on the community to assist in the management
of the disease; 4) build partnerships with health personnel is very important to have this
ability to obtain more information on self-management; 5) the ability to take action:
individuals with chronic diseases are expected to have the ability to take action and
participate in self-management. This capability is based on self-efficacy theory of
Bandura, where every patient with chronic disease should have confidence in doing selfmanagement.
Self-management model has been developed to provide a frame of reference in
providing self-management techniques in patients with chronic disease. Chronic Care
Model (CCM) is a model that is evidence based integrated of health knowledge by
prevention, treatments, diagnosis, monitoring and controlling chronic diseases in order to
achieve outcomes related to optimal quality of life for patients with chronic diseases
(Epping-Jordan et al 2004). This model considers that self-management can improve
clinical and functional outcomes of patients, disease management through productive
interaction between information providers, liveliness and readiness of patients, health
professionals proactive team with the support of a good information system.
According to Harvey, (2006); Popoola, (2005) some of the factors that influence
self-management in individuals with chronic diseases have been identified: 1)
Demographic factors: These factors include socioeconomic and cultural status; 2) clinical
factors: morbidity, mortality and the degree of complexity of the clinical condition of the
patient; 3) system: these factors include the quality of the relationship and
communication with health care providers. Measurement of the ability of selfmanagement of patients with chronic disease can be done with a variety of measuring
instruments, including the Patient Activation Measure (PAM), which is a measurement
tool to assess the knowledge, confidence levels and the ability of the patient in selfmanagement. This instrument consists of 22 questions grouped into three components,
namely: believe in the importance of active involvement, confidence and knowledge of
actions related to self-management, the act of self-management, the ability to maintain
self-management in conditions of stress (Hibbard & Tusler, 2007; Lieberman, 2003). ,
According to The Picker Institute Europe, 2005, interpretation PAM score is as
follows: Stage 1: the trust of patients to the importance of the roles, PAM score of 47.0 or
less; Stage 2: the confidence and knowledge to take action PAM score of 47.1 - 55.1;
Stage 3: take action PAM score of 55.2 - 67.0; Stage 4: keep doing self management even
under stress or pressure PAM score of 67.1 or more.
Telehealth is the use of information technology in providing health care to
patients. Telehealth may include the use of information technology by various health
professionals including doctors and nurses. Information technology in the field of nursing
is an information technology that integrates nursing science, computer science, and
information science to manage and communicate data, information, and knowledge in
nursing practice. Nursing informatics facilitates the integration of data, information, and
knowledge to support clients, nurses, and other health care providers (Moscato et al.
2007; Fitzner & Moss, 2013).
According to Hughes (2001), Dumitriu (2014) there are some skills that need to
be mastered by nurses when performing the method: 1) Skill interpersonal
communication: effective communication of nurses and patients affected by various
factors. Nurse client relationship must be developed well in order to be able to
communicate care-related diseases. Negative attitudes that emerged from the nurse and
the patient can be a barrier to effective communication between nurses and patients; 2)
Skill of collaboration: the ability to collaborate in a team of nurses to patients, families
and other health professionals will support the implementation of telenursing and ensure
adequate flow of information to the patient; 3) Clinical skill assessment: a nurse who do
clinical telenursing are required to have the ability to recognize various emotional
changes, physical changes that occurs in patients to provide effective treatment for acute
conditions; 4) Skill related to information technology: the nurse who did telenursing must
have a mind and an open attitude towards the development of information technology.
Self-management with telenursing method is a method that integrates the concept
of self-management with the help of technology onformasi and carried out by nurses.
This method is widely used in helping patients with chronic diseases to the management
of the disease through lifestyle changes. Chronic disease with a variety of characteristics
such not curable condition, require control throughout a patient's life, there is a period
between the acute and chronic conditions that need the stress management and social
support .
Research conducted by Nilsson (2009) on the use of SMS to medication
adherence in chronic disease patients in the district perawa in Sweden, shows there is
increased confidence in nurses and patient adherence to therapy protocols. Research
conducted by Solomon (2008), Knight & Shea (2014) showed that there was significant
relationship between self-management, patient characteristics and the use of technology.
Telenursing increasing the capability of nurses to provide a variety of information related
to self management in patients with chronic diseases such as; nutrient management,
protocol therapy, social support and stress management.
RESEARCH METHODS
This research is quasy experimental to analyze differences in the ability of selfmanagement in the group of patients with chronic disease given telehealth method
(treatment group) and the group of patients with chronic diseases are not given telehealth
method (the control group). Telehealth method does is combined telephone and SMS.
The study population was patients with chronic diseases who were treated at Sanglah
Hospital in Denpasar. The sampling technique used was purposive sampling. The
inclusion criteria for patients suffering from chronic diseases are diagnosed and treated
for at least 3 days in Sanglah Hospital in Denpasar. Documentation of data specified
sample size of 60 respondents, which was divided into the 30 respondents to the control
group and 30 responders to the treatment group. Processing of the data in the study
include the steps of: editing, coding, and cleaning. Data analysis is done by Man Whitney
test because of the results of the Shapiro Wilk normality test showed the data were not
normally distributed. The confidence level used is 95% and the value of significance =
0.05.
RESEARCH PROCESS
This study began with the preparation, implementation and final. Preparation is
done by applying the test of ethics and conduct trials, asking application letter and permit
research to the research and development Sanglah Hospital, Faculty of Medicine,
University of Udayana. Randomization was performed to include respondents who met
the inclusion criteria into control and treatment groups according to the return from the
hospital. Patients given inform concern then performed 3 times a week telephone and
SMS for 3 weeks. Phones given to the treatment by the investigator (nurse) and in
cooperation with the treating physician resident. After 3 weeks of either the control or the
treatment group was given questionnaires to assess PAM Score. There were 3 patients in
the treatment group dropped out due to a decrease in health conditions and 5 respondents
in the control group whose address is hard to find and a decrease in health conditions.
Researchers have considered the ethical principles in performing any action or
intervention in this study and all activities performed on a patient using the clear
informed consent. Before the study began made ethical ethics clearance through a test
conducted by the research ethics committee FK unud / Sanglah Hospital in Denpasar, so
this study considering the ethical principles like beneficence, Respect for human dignity,
Justice.
RESULT
The age of patients suffering from chronic diseases are above 30 years and in both
groups of patients with highest number of patients is in the age range 31- 40 years,
although in the treatment group as well as large number of respondents in the age range
71-80 years. Falvo, (2005); Smelthzer Bare, Hinkle, Cheever, (2010), state that chronic
diseases can be suffered by all age groups socioeconomic and cultural level. According
Oeffinger, Mertens & Sklar, (2006), the epidemiological transition has changed the
course of various chronic diseases, where chronic diseases appear at an increasingly
young age due to various causes including lifestyle factors. In the control group of
chronic disease affects more men than women are respectively 16 cases (53.3%) and 14
cases (46.7%). The results of this research together with research conducted by Ndraha,
Rinaldi, Hernando and Santosa (2010 ) conducted in Koja Hospital Jakarta, where the
number of patients with chronic diseases more men than women are 30 (54.5%) men and
25 (45.5%) women. The number of patients in the treatment group more women than
men, respectively 13 men (43.3%) and 17 women (56.7%). According to Smeltzer, Bare,
Hinkle, Cheever (2010), a chronic disease can occur at any age and gender.
Most types of chronic disease suffered by patients in the case group were not done
telehealth is CKD with the number 4 (13.3%), while in patients who do not do telehealth
approach most types of chronic disease is cancer the number and frequency of 4 (13.3%),
According to WHO (2010), ten most common chronic disease in 2009 based on data
from inpatient hospitals in Indonesia are cancer, stroke, chronic kidney disease, heart
disease, and the rest is a combination of various diseases. According to Clarke & Currie,
(2009), the emergence of chronic disease will be followed by the emergence of other
chronic diseases in the same individual, so many individuals are not only suffered with
one type of chronic disease. In this research can be seen there are patients who suffer
from more than one chronic disease, it is likely due to a chronic disease is a
predisposition of the other chronic diseases, for example diabetes mellitus predisposes to
the appearance of hypertension, CKD and stroke due to increased blood viscosity due to
high levels of glucose blood.
Self-management level with a score of PAM, most respondents in the group that
did not do telehalth are at stage 3 is taking action with PAM score of 55.2 - 67.0. At this
stage the patient is able to take action if there are conditions that occur related acute
illness, for example subtracts the current salt intake is known to increase blood pressure
in patients with hypertension. In patients with chronic disease self-management level
given telehealth with PAM scores, the majority of respondents were in stage 4 is still
perform self management even under stress or pressure PAM score of 67.1 or more. At
this stage the patient remains capable of controlling the disease is continuously
consistently in various situations. Hypertensive patients remains a diet low in salt even
though her blood pressure was stable or under pressure from a variety of social situations.
This research was supported by the results of research conducted Solomon (2008) where
the use of information technology can improve the ability of self-management in patients
with chronic disease. Results of other studies that support this research which scores
menilaib PAM used for self management in patients with chronic disease carried Greene
and Hibbard (2012); Hibbard et al (2005), by providing information over the telephone
and audiovisual in society who are at risk of chronic disease suggests there is an increase
PAM scores for screening the disease in an individual.
According to Harvey, (2006); Popoola, (2005) some of the factors that influence
self-management in individuals with chronic diseases have been identified, namely:
Demographic factors: These factors include socioeconomic status and cultural, Clinical
factors: morbidity, mortality and the degree of complexity of the clinical conditions of
patients, Factor system: factor This includes the quality of the relationship and
communication with health care providers. This study uses a system factor of effective
communication between patients and health provider to provide information on patients
with chronic diseases of various patients with the necessary control and social support
expected.
Patients with chronic disease in the majority Sanglah Hospital has been able to
obtain sufficient information on how to control the chronic diseases suffered. Current
technological developments help patients to learn about the activities that can be done
related chronic diseases suffered. Provision of information carried on pasein helping
patients to remain continous controlling the chronic diseases.
Mann Whitney test results demonstrate the value of p = 0.001 where the value is
smaller than 0.05 so there is a significant different of (significant) self management in
patients with chronic disease were given telehalth by phone and SMS and chronic disease
patients who were not given telehealth. Results of this research together with research
conducted by McCabe et al (2014), in which there is an increase in self-management
knowledge, and ability to support rehabilitation in patients with chronic lung disease after
being given information about the management of the disease. Research of Chiang et al
(2012) showed that there is an increased ability of stress management, family
involvement and confidence in patients with chronic disease given telehealth method that
given as a follow-up after discharge of patients from hospital. Research Sharma and
Clark (2014) suggests that telehealth service delivery with support of nurses who provide
care to patients with chronic diseases as a new method in the delivery of nursing care.
According Dabb et al (2013) of the patients and families are the main systems that
help individuals with chronic disease to manage themselves to controlling the disease.
Effective self-management requires the active involvement of patients to make lifestyle
changes and remain consistent to do so even in a stable condition or under a certain
pressure. Acording to Russel (2012) nursing technology capable of supporting the
provision of nursing care to be effective and efficient as well as making an important
decision in nursing to improve the various outcomes in the treatment of patients with
chronic diseases.
Patients with chronic diseases were treated at Sanglah Hospital in Denpasar, most
have suffered from chronic diseases over 2 years. Knowledge about the illness is quite
good. The desire to control the disease have consistently not been so good in patients
with chronic disease were not given telehealth, where the average value of PAM is 62.6.
Patients with chronic diseases are given methods of telehealth has knowledge as well as
the desire to consistently control the chronic disease experienced by the average value of
PAM 75.5. Almost all patients with chronic diseases very cooperative receive calls and
SMS answer from researchers. Many questions they asked and they want to get
information about the illness. This is probably because the patients who went to Sanglah
Hospital is the referral of patients who have long exposed about the disease. Besides,
discharge planning have been started by the nurses and doctors who deal even though the
information provided there is not yet optimal according to the needs of the patient.
CONCLUSIONS AND SUGGESTIONS
Based on the results of research and discussion of the influence of telehealth on
self-management methods in patients with chronic disease can be concluded that PAM
scores of patients with chronic diseases are given telehelath higher compared to patients
who were not given telehealth kronim. Analysis by Mann Whitney test showed a p-value
= 0.001 where the value is smaller than 0.05 so there is a significant different of
(significant) self management in patients with chronic disease were given telehealth by
phone and SMS and chronic disease patients who were not given telehealth. Telehealth
method by using phone and SMS is a method that can be used to enhance the ability of
self-management in patients with chronic disease. This method can be applied as part of
the patient discharge planning as a method of continuous treatment to control the disease.
Further research on self-management methods need to be performed with the telehealth
control some of the factors that affect the self-management strictly. Further research can
be done by adding variables such as the number of hours phoning penialian effective,
recurrence or complications that could be prevented as well as costs incurred
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