the self-care matrix: a unifying framework for self-care · and domains of self-care which could be...

ABSTRACT

BACKGROUND: There is resurgent interest in the concept and practice of self-care as a means to

improve the health, wellness and wellbeing of individuals, and as an avenue to mitigate financial

pressures and growing demands on health and social care systems worldwide. An ongoing challenge

has been the lack of clarity on the specific nature and entire scope of self-care, coupled to a lack of a

universal or widely accepted framework that could support the conceptualisation and study of self-

care in its totality, in all settings and from different perspectives.

OBJECTIVES: To advance a comprehensive yet pragmatic and widely accessible framework to support

the conceptualisation of self-care in its totality, in order to facilitate the development, commissioning,

evaluation and study of self-care initiatives across a variety of settings.

METHOD AND FRAMEWORK DEVELOPMENT: A pragmatic review of the academic and lay literature

was undertaken to identify extant theories and conceptual models of self-care. Following a content

analysis, the models were characterised, and a configuration matrix was constructed to illustrate the

key components and main themes of each model. These themes were organised into a number of

domains which were grouped together into cardinal dimensions of self-care. The dimensions of self-

care were consolidated in an inclusive framework and visually depicted on a schema to illustrate their

inter-relationship.

RESULTS: We identified a total of 32 candidate models, theories and frameworks of self-care.

Characterising these models led to the identification of various themes and domains. These were

found to naturally group into four cardinal dimensions of self-care: (1) Activities, (2) Behaviours, (3)

Context, and (4) Environment. A new model was synthesised to illustrate the relationship between

each dimension on a configuration matrix resulting in the creation of the Self-Care Matrix (SCM).

CONCLUSION: The Self-Care Matrix (SCM) is a useful framework that can be used to conceptualise

and frame the totality of self-care and its various interlinked elements. SCM is intended for use by all

stakeholders who are interested in the study, development, commissioning and evaluation of self-care

initiatives.

©SELFCARE 201938www.selfcarejournal.com

SelfCare 2019;10(3):38-56

A RT I C L E

Advancing the study&understanding of self-care

THE SELF-CARE MATRIX: A UNIFYING FRAMEWORK FOR SELF-CARE

AUSTEN EL-OSTA1*, DAVID WEBBER2, SHAMINI GNANI1, RICKY BANARSEE1, DAVID MUMMERY1,

AZEEM MAJEED1, PETER SMITH3**

1The Self-Care Academic Research Unit (SCARU), Department of Primary Care & Public Health, Imperial College London, UK 2International Self-Care Foundation (ISF), London UK

3The Self-Care Forum UK, London UK

*Corresponding author, **Supervisory author.

Key words: Self-care, Theory, Framework, Conceptual model, The Self-Care Matrix, SCM

INTRODUCTION

The global epidemic of long-term noncommunicable diseases (NCDs) and so called ‘lifestyle

diseases’ observed today is a direct result of our inability to self-care1,2. Consequently, policymakers

and commissioners of health services in England and elsewhere are increasingly looking at self-care

initiatives as a potential means of promoting health and wellbeing in individuals and communities,

whilst reducing costs and demand on scarce national healthcare resources.

There are many potential policies which support self-care activities and the sustained adoption

of positive lifestyle behaviours in everyday life. However, because existing self-care interventions

are usually linked to a general disease area or the management of a specific condition3, there is

scant evidence on the cost-effectiveness of self-care interventions across different settings4-6. An

additional barrier to the widespread adoption of self-care initiatives is the lack of a suitable model

to support the conceptualisation of self-care in its totality, explaining the relationship between self-

care activities and behaviour change in the context of resource utilisation, and how self-care praxis

can be modulated by external forces and the wider environment.

A recent study identified over 136 definitions of self-care7, with various terms including ‘self-

management’, ‘self-efficacy’, ‘self-treatment’ and ‘collaborative care’ often used interchangeably8-10

depending on the correlating theories and the academic field of interest7,11-16. Consequently, various

definitions of self-care have emerged as a result of differing perspectives between healthcare

professionals and the general public, and between health professionals in different disciplines7.

Various instruments have been used to assess proxy measures of self-care capacity and capability17-19,

including the Patient Activation Measure (PAM)20-22. However, health and social support concepts

such as self-care are generally less amenable to direct measurement and evaluation due to a lack of

efficient indicators23-26 and the wide potential range of measurables. Because self-care is intimately

linked to behaviour change theory which merges the fields of sociology and psychology and refers to

a mutation in human health behaviour29,30, any measurement related to self-care, either as a concept

or a set of actions or behaviours, is also dependent on the specific impairment perspective27,28. Thus,

whereas several existing frameworks and models can be used to explore the relationship between self-

care and behaviour change31-48, there is currently no univocal definition of self-care, no instrument

that can measure the totality of self-care indicators directly, and no candidate model or unifying

framework that can be used to explicate self-care in its totality.

Conceptualising self-care

Godfrey identified various models of self-care from the academic literature13, but her seminal

analysis excluded the study of other widely accepted but non-academic conceptual models of self-

care. For example, there exist in the lay literature a number of alternative yet non-mutually exclusive

mid-level descriptions and conceptual models to support the study and application of self-care in

various settings. These include: (1) the widely used Seven Pillars of Self-Care Framework49 which

describes the main activities and elements of self-care relevant to the individual self-carer, and

©SELFCARE 201939


(2) the Self-Care Continuum50 which describes the placement of an individual along a continuum

of care in the context of resource utilisation. However, neither model from academic or lay

literature was developed specifically for the purpose of conceptualising self-care in its totality, or

could explain the link between self-care activities, behaviour change and resource utilisation in

the context of the prevailing culture and the external environment. The lack of a conceptual and

unifying framework that attempts to capture the totality of self-care may impede the development

and deployment of self-care initiatives in the contemporary setting.

Aim

To characterise and consolidate existing models of self-care theory and practice gleaned from both

academic and lay literature to advance a comprehensive yet pragmatic framework that facilitates

the conceptualisation of self-care in its totality and its study across all settings.

METHODS

Pragmatic review of the literature

A pragmatic review of the literature was conducted to identify published theories linked to self-care

and relevant models and frameworks used to conceptualise self-care across various settings. We

conducted searches based on titles on all relevant databases including MEDLINE; Embase; HIMIC;

Global Health; and PsychINFO through Ovid. The initial search identified 752 publications for the

period 1983-2018. Additionally, we searched on CINAHL, Scopus and Cochrane databases which

revealed 436, 563 and 68 publications respectively. The search in all databases used the terms: self

care, self monitoring and self management to identify the relevant articles. The results of each

category were combined using Boolean terms ‘AND’ and ‘OR’ to narrow down the search findings

after linking with keywords like “model*”, “framework*” and “scheme*”. We also included relevant

models and frameworks gleaned from non-academic literature including websites of various non-

governmental organisations, charities and other entities engaged in the self-care discourse such

as the World Health Organisation (WHO), Kaiser Permanente, the Self-Care Forum UK and the

International Self-Care Foundation.

Characterising self-care models and theories

An initial review of single-disease specific models and frameworks aimed at explaining self-care

theory and praxis was undertaken, which resulted in a list of 631 manuscripts. After scanning

this list, a total of 44 papers were found to pertain to self-care models, frameworks, concepts or

theories. This initial list included various examples of how self-care links with behaviour change

theory (n=12). The latter were excluded, and the final list (n=32) was used to characterise various

aspects of each self-care model.

Framework synthesis

A qualitative content analysis approach was used to identify the key assumptions, characteristics,

themes and domains of self-care pertaining to each model. Further to characterising each model,

©SELFCARE 201940


we identified a number of themes and perspectives which could be conveniently grouped into

various domains. These domains were found to naturally group together under four cardinal

‘dimensions’ of self-care.

The inter-relationship between each self-care dimension was considered. A visual depiction

of each dimension was juxtaposed on a matrix resulting in a schema of the newly synthesised

framework that could be used to conceptualise self-care theory and practice in its totality. The

resulting unifying framework (the Self-Care Matrix) was assessed for congruence by determining

the extent to which it supported the formal study of self-care as an applied field of research, whilst

providing a logical connection between each dimension.

RESULTS

Characterising existing models and concepts of self-care

Our pragmatic review of lay and academic literature identified a range of perspectives on self-care

in various contexts. We identified and characterised 32 different theories, models and frameworks

that attempted to describe self-care from different perspectives. Table 1 summarises the key points

of the most relevant theories and models of self-care, grouped as either prevention-focused

(n=9), rehabilitation-focused (n=16) or concerned with both prevention and rehabilitation (n=7).

Theories ranged from academic theories illustrating the antecedents (i.e. aspects necessary for the

performance) and the consequences (i.e. results of the performance) of self-care, to more applied

concepts that supported the understanding of self-care in the context of resource utilisation, or

applied interventions for behaviour change in autonomous or assisted care settings.

The four cardinal dimensions of self-care

Content analysis and characterisation of each model resulted in the identification of various themes

and domains of self-care which could be naturally grouped under four dimensions of self-care

(table 2). The four cardinal dimensions of self-care identified were: (1) Self-Care Activities, (2) Self-

Care Behaviours, (3) Self-Care Context, and (4) Self-Care Environment (table 2). Each dimension

pertains to a different aspect of self-care as follows:

1st Dimension: Self-care activities (micro-level: person-centred)

The first dimension is concerned primarily with individual activities, capacities and capabilities,

and what people know and do to self-care. At this micro-level, self-care is considered from a

person-centred perspective. Suitable interventions may be developed to improve and promote

health maintenance, monitoring and self-management of common, every-day or long-term

conditions. The Health Belief Model, Orem’s Self-Care Deficit Nursing Theory51-53, and the

widely used Seven Pillars of Self-Care model54 are suitable candidate models that can be used

to explore this cardinal dimension. The first dimension of self-care is necessarily concerned

with the ‘self ’, is person-centric and activities therein relate directly to what individuals can do

for themselves, as well as the knowledge required to inform suitable self-care choices, such as

health literacy and self-awareness.

©SELFCARE 201941


2nd Dimension: Self-care behaviours (meso-level: Individual and group focused)

The second dimension is concerned with the principles and actions that support and motivate

individuals to engage in positive self-care behaviours and achieve the sustained adoption of

health-seeking behaviours and lifestyles choices. Interventions operating at this meso-level include

efforts to improve PAM scores, the use of digital health technology including nudges, gamification

an incentivisation strategies to promote the sustained adoption and maintenance of desirable

lifestyle choices and habits. Associated theories include the Middle Range Theory of Self-Care55

which addresses health promoting practices within the context of the management of a chronic

illness. The widely used trans-theoretical model of behaviour change and the Behaviour Change

Wheel48 are suitable candidate models that adequately describe activation and behaviour change

elements relevant to self-care. The second dimension is focused on the individual, but may also

extend to the social network as it describes the prevailing ‘lifestyle’ habits, normative attitudes

and routine interactions with the immediate environment, including interface with technology and

decision support tools.

3rd Dimension: Self-care context and reliance on resources (meso-level: patient-

centred, health system focused)

The third dimension considers the extent to which an individual is reliant on external resources

in the home, community, assisted care or professional healthcare settings. Interventions at this

meso-level are often health system-focused, whereby an individual, a demography or a segment

of society is routinely considered from a ‘statist’ or medicalised patient-perspective as opposed

to a person-centred perspective. Interventions at this level are often concerned with modulating

resource utilisation, including access to services, clinical pathways and/or the extent of

integration of care. The widely used Self-Care Continuum54 and the Kaiser Permanente Pyramid

of Self-Care model56 are suitable candidates for this dimension as they dynamically illustrate the

inverse relationship between individual autonomy and reliance on external resources or need for

increasing support.

4th Dimension: Self-care environment, barriers and drivers to self-care (macro-level:

policy-driven, health system focused)

The fourth dimension is concerned with existing drivers and barriers to self-care in relationship

to the operating fiscal and policy environment, and in the context of the prevailing culture and

normative attitudes that inform self-care praxis in the wider community. This dimension takes into

account the built and natural environment and other mediating factors. At this macro-level, drivers

and barriers to self-care operate at scale or at population level. The fourth dimension is thus related

to the public health landscape and informs the ‘country narrative for self-care’, which is largely

influenced by the prevailing cultural and societal attitudes and perceptions concerned with health

and wellbeing. Suitable candidate models that could be used to study this self-care dimension

include Public Health Theory, Public Management Theory, Public Policy Theory and any existing

Health in All Policy (HiAP) prescriptions, including directives for the built environment.

©SELFCARE 201942


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1989

1990

1990

1998

2002

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1 2 3 4 5 6 7 8 9

Prim

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erns

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th.

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ory.

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func

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, dra

win

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om

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enst

ock’

s H

ealth

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ief

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el a

nd P

ende

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ealth

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mot

ion

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el. E

mph

asis

es t

he im

port

ance

of

self-

care

pra

ctic

es r

elat

ed

to n

utrit

ion,

per

sona

l hyg

iene

, env

ironm

enta

l san

itatio

n,

inte

rper

sona

l com

mun

icat

ions

, spi

ritua

lity,

sex

ualit

y, e

duca

tion,

re

st a

nd r

ecre

atio

n an

d pr

otec

tion

of f

amily

mem

bers

.

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mod

el is

bas

ed o

n a

thor

ough

lite

ratu

re r

evie

w o

n he

alth

pr

omot

ion

and

wel

l-be

ing

in t

he c

onte

xt o

f ag

eing

.

Ass

umes

tha

t th

e fo

unda

tiona

l asp

ects

of

self-

care

are

the

bu

ildin

g bl

ocks

of

our

conc

eptu

aliz

atio

n of

sel

f-ca

re.

Self-

care

can

be

lear

ned

and

appl

ied

to im

prov

e ov

eral

l hea

lth

and

wel

lbei

ng. I

t co

nsid

ers

how

sel

f-ca

re m

ay b

e ap

plie

d fr

om

diff

eren

t pe

rspe

ctiv

es t

o sa

tisfy

phy

sica

l, ps

ycho

logi

cal,

emot

iona

l, sp

iritu

al, p

erso

nal,

prof

essi

onal

nee

ds.

Tabl

e 1:

Cha

ract

eris

tics

of

32 g

ener

ic t

heor

ies,

mod

els

and

fram

ewor

ks a

ssoc

iate

d w

ith

self

-car

e

Prev

enti

on-f

ocus

ed

43


Tabl

e 1:

con

tinu

ed

‡‡ye

arM

odel

/ T

heor

y /

Fram

ewor

kD

escr

ipti

onU

ses

Theo

reti

cal b

ackg

roun

d /

Rat

iona

le

Reh

abili

tati

on-f

ocus

ed

The

mod

el is

a r

epre

sent

atio

n of

a p

erso

n’s

grow

th

thro

ugh

life

with

a s

peci

fic f

ocus

on

the

indi

vidu

al’s

ques

t fo

r au

tono

my,

thr

ough

phy

sica

l and

psy

chol

ogic

al

inte

grity

.

The

theo

ry e

xpla

ins

that

an

indi

vidu

al r

equi

res

nurs

ing

– in

ot

her

wor

ds ‘h

elp’

– w

hen

a se

lf-ca

re d

efici

t ex

ists

as

a re

sult

of s

elf-

care

dem

and

exce

edin

g se

lf-ca

re a

genc

y.

The

mod

el is

a m

odifi

catio

n an

d ex

tens

ion

of t

he H

ealth

Be

lief

Mod

el. I

t fo

cuse

s m

ore

on h

ow t

o pr

omot

e se

lf-ca

re

as o

ppos

ed t

o un

ders

tand

ing

heal

th b

ehav

iour

cha

nge.

A c

once

ptua

l mod

el b

ased

on

the

dyna

mic

s of

car

e w

hich

st

em f

rom

the

per

sona

l exp

erie

nce

of d

evel

opm

enta

l di

sabi

lity.

Info

rms

educ

atio

nal p

rogr

am t

hat

aim

s to

incr

ease

the

pr

actic

e of

sel

f-m

anag

emen

t ac

tiviti

es a

mon

g pa

tient

s w

ith o

ne o

r m

ore

chro

nic

dise

ases

and

/or

com

orbi

ditie

s.

Con

side

rs f

our

mod

es o

f se

lf-ca

re d

epen

ding

on

diff

eren

t co

nditi

ons

that

ent

ail d

iffer

ent

actio

ns a

nd m

eani

ngs.

The

m

odes

incl

ude

resp

onsi

ble

self-

care

, for

mal

ly g

uide

d se

lf-ca

re, i

ndep

ende

nt s

elf-

care

and

aba

ndon

ed s

elf-

care

.

Prov

ides

an

appr

oach

to

unde

rsta

ndin

g an

d pr

ovid

ing

self-

care

sup

port

for

peo

ple

with

long

-ter

m c

ondi

tions

.

Illus

trat

es t

he li

nks

betw

een

peop

le s

uffe

ring

from

long

-te

rm c

ondi

tions

to

thei

r su

ppor

t ne

twor

k in

clud

ing

heal

th

prof

essi

onal

s, c

omm

unity

and

vol

unta

ry g

roup

s, n

on-

heal

th p

rofe

ssio

nals

and

per

sona

l com

mun

ities

.

A c

ompr

ehen

sive

con

cept

ual m

odel

tha

t ar

ticul

ates

the

in

divi

dual

, fam

ily, c

omm

unity

, and

hea

lth c

are

syst

em le

vel

influ

ence

s th

at im

pact

sel

f-m

anag

emen

t be

havi

ours

.

Gro

wth

Mod

el o

f Se

lf-C

are66

Self-

Car

e D

efici

t N

ursi

ng

Theo

ry51

-53

Mod

el o

f Se

lf-ca

re in

Chr

onic

Ill

ness

es67

Con

cept

ual M

odel

for

Car

e in

Dev

elop

men

tal D

isab

ility

Se

rvic

es68

Chr

onic

Dis

ease

Sel

f-M

anag

emen

t69

Mod

el f

or s

elf-

care

(of

hom

e-dw

ellin

g el

derly

)70

Who

le S

yste

m In

form

ing

Self-

Man

agem

ent

Enga

gem

ent

(WIS

E)71

Soci

al N

etw

orks

, Wor

k an

d ne

twor

k-ba

sed

Res

ourc

es f

or

the

Man

agem

ent

of L

ong-

term

Con

ditio

ns72

Paed

iatr

ic S

elf-

Man

agem

ent73

10 11 12 13 14 15 16 17 18

It is

em

ploy

ed a

s a

met

hod

to e

nabl

e nu

rses

to

deve

lop

nurs

ing

care

pla

ns b

ased

on

the

pat

ient

’s ab

ility

to

mee

t sp

ecifi

c se

lf-ca

re n

eeds

.

Can

be

used

as

a ba

sis

to c

oord

inat

e nu

rsin

g ca

re b

y m

aint

aini

ng n

urse

-pat

ient

re

latio

nshi

ps, d

esig

ning

and

man

agin

g nu

rsin

g ca

re a

nd r

espo

ndin

g to

pat

ient

s’

need

s an

d de

sire

s fo

r nu

rsin

g as

sist

ance

.

The

prom

otio

n of

sel

f-ca

re a

nd s

elf-

man

agem

ent

beha

viou

rs a

mon

g ch

roni

cally

ill p

atie

nts.

The

mod

el is

em

ploy

ed in

nur

sing

car

e fo

r th

e tr

aini

ng o

f pe

ople

with

dev

elop

men

tal

disa

bilit

ies.

Can

be

used

to

assi

sts

patie

nts

in g

aini

ng

skill

s an

d co

nfide

nce

for

appl

icat

ion

on

a da

ily b

asis

for

the

pur

pose

of

chro

nic

dise

ase

self-

man

agem

ent.

The

mod

el w

as e

nvis

ione

d as

a w

ay f

or

heal

th p

rofe

ssio

nal a

nd n

ursi

ng r

esea

rch

to u

nder

stan

d ho

w a

pat

ient

’s hi

stor

y an

d vi

ews

of t

he f

utur

e in

fluen

ce h

is/h

er s

elf-

care

beh

avio

ur.

Can

be

used

to

deve

lop

self-

care

and

se

lf-m

anag

emen

t in

terv

entio

ns a

t th

ree

diff

eren

t le

vels

: the

pat

ient

-lev

el, t

he

prov

ider

-lev

el a

nd t

he w

ider

sys

tem

-lev

el.

Info

rms

the

deve

lopm

ent

& d

eliv

ery

if se

lf-ca

re s

uppo

rt s

yste

ms

by v

iew

ing

com

mun

ities

and

net

wor

ks a

nd ‘e

xper

t pa

tient

s’ a

s a

key

mea

ns o

f su

ppor

t fo

r m

anag

ing

long

-ter

m c

ondi

tions

.

Can

be

used

to

guid

e de

velo

pmen

t of

ev

iden

ce-b

ased

inte

rven

tions

to

impr

ove

self-

man

agem

ent,

and

in t

he d

esig

n of

pro

gram

s ai

med

at

prev

entin

g th

e de

velo

pmen

t of

poo

r se

lf-m

anag

emen

t be

havi

ours

.

1983

1985

1987

1989

1996

1999

2007

2011

2012

The

mod

el e

volv

ed f

rom

ana

lyse

s of

kno

wle

dge

and

prac

tice

that

de

scrib

e nu

rsin

g ac

tion.

Base

d on

inte

rrel

ated

con

stru

cts

of s

elf-

care

and

the

fou

ndat

ion

of n

ursi

ng p

ract

ice.

It a

lso

focu

ses

on a

sys

tem

s ap

proa

ch t

o he

alth

care

.

Sugg

ests

tha

t se

lf-ca

re b

ehav

iour

s ar

e in

fluen

ced

by p

redi

spos

ing

varia

bles

(se

lf-co

ncep

t, h

ealth

mot

ivat

ions

, pat

ient

per

cept

ion

of

serio

usne

ss, v

ulne

rabi

lity,

effi

cacy

), a

nd e

nabl

ing

varia

bles

(pa

tient

ch

arac

teris

tic, p

sych

olog

ical

sta

tus,

reg

imen

sta

tus,

cue

s to

act

ion,

so

cial

sup

port

, sys

tem

cha

ract

eris

tic).

Stem

s fr

om n

ursi

ng p

ract

ice

and

the

eval

uatio

n of

hea

lth s

ervi

ces

prov

ided

to

indi

vidu

als

with

dev

elop

men

tal d

isab

ilitie

s. A

ssum

es

that

the

nat

ure

of c

are

has

a co

rolla

ry t

hat

is s

elf-

care

, tha

t is

ap

plic

able

in b

oth

gene

ral t

erm

s as

wel

l as

thos

e te

rms

spec

ific

to

the

field

of

deve

lopm

enta

l dis

abili

ty.

The

prog

ram

gre

w o

ut o

f th

e A

rthr

itis

Self-

Man

agem

ent

The

prog

ram

is g

eare

d to

inco

rpor

ate

educ

atio

n on

all

chro

nic

dise

ases

as

opp

osed

to

educ

atio

nal p

rogr

ams

focu

sed

on o

ne d

isea

se o

nly.

Base

d on

prim

ary

rese

arch

am

ong

elde

rly p

opul

atio

ns, l

itera

ture

re

view

s an

d qu

alita

tive

rese

arch

usi

ng a

gro

unde

d-th

eory

ap

proa

ch.

Base

d on

a w

hole

sys

tem

s ap

proa

ch t

o se

lf-ca

re.

This

app

roac

h ta

kes

into

con

side

ratio

n th

e fo

rm a

nd c

onte

nt o

f so

cial

net

wor

ks, n

otio

ns o

f ch

roni

c ill

ness

wor

k, n

orm

alis

atio

n pr

oces

s th

eory

and

the

who

le s

yste

ms

info

rmin

g se

lf-m

anag

emen

t en

gage

men

t ap

proa

ch t

o se

lf-ca

re s

uppo

rt.

It d

escr

ibes

the

rel

atio

nshi

p am

ong

self-

man

agem

ent,

adh

eren

ce,

and

outc

omes

at

both

the

pat

ient

and

sys

tem

-lev

el t

hrou

gh

cogn

itive

, em

otio

nal a

nd s

ocia

l pro

cess

es.

44


Tabl

e 1:

con

tinu

ed

‡‡ye

arM

odel

/ T

heor

y /

Fram

ewor

kD

escr

ipti

onU

ses

Theo

reti

cal b

ackg

roun

d /

Rat

iona

le

Reh

abili

tati

on-f

ocus

ed (

cont

inue

d)

A c

once

ptua

l fra

mew

ork

deve

lope

d to

und

erpi

n th

e tr

aini

ng o

f ce

rtifi

ed c

omm

unity

hea

lth w

orke

rs t

o de

liver

hea

lth c

are,

pre

vent

ive

serv

ices

, and

hea

lth

educ

atio

n fo

r un

ders

erve

d po

pula

tions

to

prom

ote

chro

nic

dise

ase

self-

man

agem

ent.

Add

ress

es t

he p

roce

ss o

f m

aint

aini

ng h

ealth

with

he

alth

pro

mot

ing

prac

tices

with

in t

he c

onte

xt o

f th

e m

anag

emen

t re

quire

d of

a c

hron

ic il

lnes

s.

The

mod

el d

econ

stru

cts

the

task

s as

soci

ated

with

ta

king

pre

scrip

tion

drug

s; in

clud

ing

the

know

ledg

e,

skill

s an

d be

havi

ours

nec

essa

ry f

or p

atie

nts

to

corr

ectly

tak

e m

edic

atio

ns a

nd s

usta

in u

se o

ver

time

in

ambu

lato

ry c

are.

This

fra

mew

ork

iden

tifies

key

rel

atio

nshi

ps a

mon

g se

lf-m

anag

emen

t (p

atie

nt b

ehav

iour

s), h

ealth

for

ce

(pat

ient

cha

ract

eris

tics)

, and

pat

ient

-defi

ned

goal

s in

th

e co

ntex

t of

nur

sing

info

rmat

ics.

A f

ram

ewor

k th

at c

larifi

es f

acili

tato

rs a

nd b

arrie

rs,

proc

esse

s, p

roxi

mal

out

com

es, a

nd d

ista

l out

com

es o

f se

lf- a

nd f

amily

man

agem

ent

and

thei

r re

latio

nshi

ps.

It id

entifi

es k

ey r

elat

ions

hips

am

ong

self-

man

agem

ent

(pat

ient

beh

avio

urs)

, hea

lth f

orce

(pa

tient

ch

arac

teris

tics)

, and

pat

ient

-defi

ned

goal

s.

This

mod

el u

pdat

es a

nd in

tegr

ates

tha

t pr

opos

ed b

y R

icha

rd a

nd S

heaf

. It

expl

ains

the

rel

atio

ns a

mon

g va

rious

inte

r-re

late

d co

ncep

ts s

uch

as s

elf-

care

, sel

f-ca

re a

genc

y, s

elf-

mon

itorin

g, s

elf-

man

agem

ent,

sel

f-m

anag

emen

t su

ppor

t, s

ympt

om m

anag

emen

t, a

nd

self-

effic

acy

from

the

nur

sing

per

spec

tive.

Prov

ides

an

inte

grat

ed f

ram

ewor

k fo

r un

ders

tand

ing

how

pat

ient

s se

lf-m

anag

e al

l asp

ects

of

ever

yday

life

. Su

ppor

ts u

nder

stan

ding

of

self-

man

agem

ent

by u

sing

or

igin

al d

ata

and

a re

cent

con

cept

ana

lysi

s to

pro

pose

a

unify

ing

fram

ewor

k fo

r se

lf-m

anag

emen

t st

rate

gies

.

A P

atie

nt N

avig

atio

n M

odel

fo

r C

hron

ic D

isea

se S

elf-

Man

agem

ent

(Tra

nsfo

rmat

ion

for

Hea

lth)74

A M

iddl

e R

ange

The

ory

of

Self-

care

of

Chr

onic

Illn

ess

55

Hea

lth L

itera

cy-i

nfor

med

M

odel

of

Med

icat

ion

Self-

man

agem

ent75

A P

atie

nt-f

ocus

ed F

ram

ewor

k In

tegr

atin

g Se

lf-M

anag

emen

t an

d In

form

atic

s76

A r

evis

ed S

elf-

and

Fam

ily

Man

agem

ent

Fram

ewor

k77

Mod

el o

f Se

lf-ca

re a

nd

Rel

ated

Con

cept

s14

The

Taxo

nom

y of

Eve

ryda

y Se

lf-M

anag

emen

t St

rate

gies

(T

EDSS

)78

19 20 21 22 23 24 25

Can

be

used

to

illus

trat

e ho

w in

divi

dual

s co

uld

over

com

e op

pres

sive

con

ditio

ns

– w

heth

er t

hese

con

ditio

ns a

re c

reat

ed

thro

ugh

hum

an d

esig

n or

fro

m s

ituat

iona

l ci

rcum

stan

ces

– th

at le

ad in

diff

eren

t w

ays

to t

he s

ubju

gatio

n of

the

hum

an s

pirit

.

For

use

acro

ss a

var

iety

of

chro

nic

cond

ition

s du

ring

the

proc

ess

of m

aint

aini

ng

heal

th.

The

mod

el c

an b

e us

ed to

revi

ew a

nd c

ritic

ize

curr

ent a

dher

ence

mea

sure

s as

wel

l as

to o

ffer

gu

idan

ce t

o fu

ture

inte

rven

tions

pro

mot

ing

med

icat

ion

self-

man

agem

ent,

esp

ecia

lly

amon

g pa

tient

s w

ith lo

w li

tera

cy s

kills

and

to

dem

onst

rate

how

cur

rent

ly a

vaila

ble

mea

sure

s of

adh

eren

ce a

re in

adeq

uate

.

It is

use

d to

gui

de c

hron

ic il

lnes

s se

lf-m

anag

emen

t in

terv

entio

ns t

hrou

gh t

he

inte

grat

ion

of s

elf-

man

agem

ent

and

nurs

ing

info

rmat

ics,

to

focu

s se

lf-m

anag

emen

t re

sear

ch a

nd p

rom

ote

ethi

cal,

patie

nt-

empo

wer

ing

tech

nolo

gy u

se b

y pr

actic

ing

nurs

es.

It c

an b

e us

ed in

stu

dies

aim

ed a

t ad

vanc

ing

self-

and

fam

ily m

anag

emen

t sc

ienc

e an

d al

low

for

the

des

ign

of s

tudi

es t

hat

can

addr

ess

mor

e cl

early

how

sel

f-m

anag

emen

t in

terv

entio

ns w

ork

and

unde

r w

hat

cond

ition

s.

It c

an h

elp

nurs

es, h

ealth

care

pro

fess

iona

ls

and

com

mis

sion

ers

of h

ealth

to

sele

ct,

appl

y, a

nd a

sses

s se

lf-ca

re c

apab

ilitie

s an

d ca

paci

ties

in a

var

iety

of

popu

latio

ns a

nd

cond

ition

s.

Prov

ides

a u

nify

ing

taxo

nom

y th

at m

ight

re

solv

e co

ncep

tual

con

fusi

on w

ithin

the

fie

ld o

f se

lf-m

anag

emen

t sc

ienc

e. It

has

po

tent

ial t

o gu

ide

heal

th s

ervi

ce d

eliv

ery

and

rese

arch

and

may

hel

p gu

ide

and

tailo

r ca

re if

use

d as

a m

easu

rem

ent

fram

ewor

k.

Ass

umes

dev

elop

men

t in

4 p

hase

s: (

1) c

ogni

tive

phas

e de

velo

ps

criti

cal c

onsc

ious

ness

, (2)

Inte

ntio

n ph

ase:

mot

ivat

iona

l sys

tem

is

activ

ated

to

asse

ss c

apac

ities

for

tra

nsfo

rmat

ive

proc

ess,

(3)

Dec

isio

n ph

ase:

indi

vidu

al a

ctua

lises

dec

isio

ns t

hat

wer

e m

ade

to c

hang

e an

d m

aint

ain

beha

viou

rs t

hat

prom

ote

effe

ctiv

e se

lf-m

anag

emen

t, a

nd

(4)

Tran

sfor

mat

ion

phas

e: s

elf/

guid

ed e

valu

atio

ns y

ield

evi

denc

e of

ac

tions

tak

en in

divi

dual

s to

impr

ove

proc

ess

man

agem

ent.

Base

d on

thr

ee a

ssum

ptio

ns: (

1) g

ener

al s

elf-

care

and

illn

ess-

spec

ific

self-

care

are

diff

eren

t, (

2) d

ecis

ion

mak

ing

requ

ires

the

abili

ty t

o th

ink

and

unde

rsta

nd in

form

atio

n; a

nd (

3) s

elf-

care

act

iviti

es f

or

mul

tiple

com

orbi

d co

nditi

ons

may

con

flict

sel

f-ca

re c

onsi

dere

d fo

r ea

ch il

lnes

s se

para

tely

.

The

mod

el p

rovi

des

a co

mpr

ehen

sive

exa

min

atio

n of

the

ran

ge o

f ta

sks

that

indi

vidu

als

mus

t su

cces

sful

ly p

erfo

rm t

o m

anag

e th

eir

med

icat

ion

regi

men

.

The

Empo

wer

men

t In

form

atic

s fr

amew

ork

can

guid

e in

terv

entio

n de

sign

and

eva

luat

ion

and

supp

ort

prac

ticin

g nu

rses

’ eth

ical

use

of

tech

nolo

gy a

s pa

rt o

f se

lf-m

anag

emen

t su

ppor

t. It

use

s te

chno

-en

able

d se

lf-m

anag

emen

t in

terv

entio

ns t

o pr

iorit

ise

patie

nt n

eeds

.

As

with

the

orig

inal

fra

mew

ork,

the

mod

el is

ass

umed

to

be

recu

rsiv

e in

tha

t pr

oces

ses

and

outc

omes

influ

ence

fur

ther

sel

f an

d fa

mily

man

agem

ent.

Two

new

con

cept

s ar

e ad

ded

to t

he p

revi

ous

mod

el, w

hich

are

ex

tern

al t

o in

divi

dual

con

trol

but

impo

rtan

t fo

r th

e ca

re o

f pe

ople

w

ith h

ealth

pro

blem

s: s

elf-

man

agem

ent

supp

ort

and

dise

ase

man

agem

ent.

The

y cl

arify

the

diff

eren

t ro

les

and

resp

onsi

bilit

ies

of

heal

thca

re p

rovi

ders

and

the

sha

red

resp

onsi

bilit

y

Base

d on

the

pre

mis

e th

at s

elf-

care

is a

pro

duct

of

5 G

oal-

orie

nted

D

omai

ns (

Inte

rnal

, Soc

ial I

nter

actio

n, A

ctiv

ities

, Hea

lth B

ehav

iour

an

d D

isea

se C

ontr

ollin

g), a

nd t

wo

addi

tiona

l sup

port

-orie

nted

do

mai

ns (

Proc

ess

and

Res

ourc

e).

2012

2012

2013

2014

2015

2018

2018

45


‡‡ye

arM

odel

/ T

heor

y /

Fram

ewor

kD

escr

ipti

onU

ses

Theo

reti

cal b

ackg

roun

d /

Rat

iona

le

Prev

enti

on a

nd R

ehab

ilita

tion

foc

used

A s

yste

mat

ic m

etho

d to

exp

lain

and

pre

dict

hea

lth-

rela

ted

beha

viou

r ch

ange

. Con

side

red

a he

alth

-sp

ecifi

c so

cial

cog

nitio

n m

odel

tha

t w

as d

evel

oped

to

und

erst

and

the

failu

re o

f tu

berc

ulos

is s

cree

ning

pr

ogra

ms

in t

he U

S.

The

Self-

Car

e C

ontin

uum

des

crib

es t

he p

lace

men

t of

an

indi

vidu

al a

long

a c

ontin

uum

of

care

, ass

umin

g pu

re

self-

care

on

one

end

of t

he s

cale

, to

pure

med

ical

ised

ca

re o

n th

e op

posi

te e

nd.

A p

atie

nt s

egm

enta

tion

and

stra

tifica

tion

tool

illu

stra

ting

the

popu

latio

n su

itabl

e to

rec

eive

hea

lth p

rom

otio

n an

d pr

even

tion

serv

ices

alo

ng w

ith s

uppo

rt f

or s

elf-

man

agem

ent

for

chro

nic

care

pat

ient

s, w

here

as h

igh-

risk

patie

nts

rece

ive

dise

ase

and

case

man

agem

ent.

A c

once

ptua

l mod

el o

f th

e se

lf-ca

re p

roce

ss, d

efine

d as

m

aint

aini

ng h

ealth

thr

ough

tre

atm

ent

adhe

renc

e an

d sy

mpt

om m

onito

ring.

Theo

retic

al c

once

ptua

lizat

ion

of s

elf-

care

and

rel

ated

co

ncep

ts in

clud

ing

self-

man

agem

ent,

sel

f-ef

ficac

y,

sym

ptom

s m

anag

emen

t an

d se

lf-m

onito

ring.

A v

isua

l fra

mew

ork

that

des

crib

es t

he m

ain

elem

ents

of

self-

care

rel

evan

t to

the

indi

vidu

al s

elf-

care

r. It

app

lies

to p

eopl

e of

all

ages

and

all

stat

es o

f he

alth

.

This

mod

el c

onsi

ders

the

nee

ds o

f pe

rson

s/pa

tient

s in

the

con

text

of

soci

o-m

edic

al e

nviro

nmen

t ar

ound

th

e pe

rson

’s ne

eds,

and

wha

t in

term

edia

te a

nd fi

nal

outc

omes

of

an in

itiat

ive

coul

d re

sult

in im

prov

emen

t of

se

lf-ca

re c

apac

ity.

Hea

lth B

elie

f M

odel

(H

BM)37

The

Self-

Car

e C

ontin

uum

49,7

9

Kai

ser-

Perm

anen

te P

yram

id56

,80

Situ

atio

n Sp

ecifi

c Th

eory

of

Self-

Car

e81

Con

cept

ual M

odel

of

Self-

Car

e82

The

Seve

n Pi

llars

of

Self-

Car

e49

The

inpu

t/ou

tput

mod

el f

or

self-

care

83

26 27 28 29 30 31 32

It is

the

mos

t w

idel

y us

ed m

odel

in

the

desi

gn a

nd e

valu

atio

n of

hea

lth

beha

viou

r in

terv

entio

ns.

The

aim

of

the

cont

inuu

m is

to

embe

d se

lf-ca

re in

to e

very

day

life.

Use

d to

pro

vide

a d

etai

led

anal

ysis

of

cas

e fin

ding

, ris

k st

ratifi

catio

n an

d po

pula

tion

segm

enta

tion

in r

elat

ion

to

redu

cing

em

erge

ncy

adm

issi

ons.

Use

d to

mai

ntai

n ph

ysio

logi

c st

abili

ty,

sym

ptom

mon

itorin

g an

d tr

eatm

ent

adhe

renc

e th

roug

h se

lf-m

anag

emen

t.

Enab

les

nurs

es t

o us

e ev

iden

ce t

hat

targ

ets

spec

ific

inte

rven

tions

to

indi

vidu

aliz

e ca

re t

owar

d ac

hiev

ing

the

mos

t re

leva

nt g

oals

.

Use

d as

a p

ract

ical

too

l to

help

co

mm

unic

ate

and

stud

y se

lf-ca

re a

s a

mul

ticom

pone

nt a

nd in

ter-

rela

ted

set

of

activ

ities

whi

ch c

ould

be

grou

ped

into

7

pilla

rs, b

ut a

lso

view

ed h

olis

tical

ly.

Whe

n co

uple

d to

a m

anag

emen

t m

odel

/cyc

le li

nkin

g th

e m

ain

obje

ctiv

e,

the

inpu

t/ou

tput

mod

el f

or s

elf-

care

can

be

used

to

form

ulat

e po

licy

reco

mm

enda

tions

on

self-

care

.

Tabl

e 1:

con

tinu

ed

Ass

umes

tha

t su

stai

ned

beha

viou

r ch

ange

is d

eter

min

ed b

y si

x va

riabl

es, w

hich

are

per

ceiv

ed b

arrie

rs, p

erce

ived

ben

efits

, per

ceiv

ed

seve

rity,

per

ceiv

ed s

usce

ptib

ility

, sel

f-ef

ficac

y an

d cu

e to

act

ion.

The

cont

inuu

m f

ollo

ws

a ‘li

fe-c

ycle

’ app

roac

h to

dis

ease

pro

gres

sion

. It

was

dev

elop

ed b

y th

e Se

lf-C

are

Foru

m in

the

UK

.

This

sta

tist

tool

is b

ased

on

the

conc

ept

of c

linic

al in

tegr

atio

n of

he

alth

pla

n, h

ospi

tal,

phys

icia

ns a

nd m

edic

al g

roup

.

In t

his

mod

el, s

elf-

care

mai

nten

ance

is t

he f

ound

atio

n of

eff

ectiv

e se

lf-ca

re in

volv

ing

sym

ptom

mon

itorin

g as

a p

rere

quis

ite f

or

sym

ptom

rec

ogni

tion,

eva

luat

ion,

tre

atm

ent

impl

emen

tatio

n an

d tr

eatm

ent

eval

uatio

n in

the

sco

pe o

f se

lf-ca

re f

or lo

ng-t

erm

co

nditi

ons.

Ass

umes

tha

t se

lf-ca

re is

the

mos

t en

com

pass

ing

conc

ept,

and

tha

t sy

mpt

om r

ecog

nitio

n an

d se

lf- m

anag

emen

t fa

ll un

der

the

umbr

ella

of

sel

f-ca

re, b

ut t

hat

whe

n pe

rfor

med

by

heal

thca

re p

rofe

ssio

nals

it

is n

o lo

nger

exc

lusi

vely

with

in t

he d

imen

sion

of

self-

care

.

Each

of

the

seve

n pi

llars

pro

vide

s a

sum

mar

y de

scrip

tion

of lo

gica

l se

ts o

f se

lf-ca

re a

ctiv

ities

and

ele

men

ts, w

hich

pro

vide

a p

ragm

atic

, ho

listic

fra

mew

ork;

(1)

Kno

wle

dge

& H

ealth

Lite

racy

, (2)

Men

tal

wel

lbei

ng, S

elf-

awar

enes

s &

Age

ncy,

(3)

Phy

sica

l act

ivity

, (4)

H

ealth

y ea

ting,

(5)

Ris

k av

oida

nce,

(6)

Goo

d hy

gien

e, a

nd (

7)

Rat

iona

l and

res

pons

ible

use

of

prod

ucts

& s

ervi

ces.

The

mod

el r

elie

s on

soc

io-m

edic

al e

nviro

nmen

t an

d se

lf-ca

re

capa

city

.

1956

-19

74/

1979

2004

2007

2008

2011

2011

2014

46


Tabl

e 2:

Cha

ract

eris

tics

of

the

four

car

dina

l dim

ensi

ons

of s

elf-

care

Self

-Car

e di

men

sion

Pers

pect

ive

(Foc

us)

Suit

able

Can

dida

te

theo

ry/m

odel

Des

crip

tion

Them

es /

Dom

ains

Exam

ple

Inte

rven

tion

are

as

Wha

t pe

ople

kno

w a

nd d

o to

se

lf-ca

re (

daily

life

styl

e ha

bits

&

choi

ces)

The

prin

cipl

es a

nd a

ctio

ns u

sed

to

sust

ain

an o

utco

me

or b

ehav

iour

The

exte

nt t

o w

hich

an

indi

vidu

al

is r

elia

nt o

n ex

tern

al r

esou

rces

Exta

nt d

river

s an

d ba

rrie

rs t

o se

lf-ca

re (

soci

al, p

oliti

cal,

fisca

l, cu

ltura

l)

Pers

on-c

entr

ed

(mic

ro-l

evel

)

Indi

vidu

al /

soci

al

netw

ork

focu

sed

(mes

o-le

vel)

Med

ical

ised

-pat

ient

(mes

o-le

vel)

Syst

em f

ocus

ed

(mac

ro-l

evel

)

1- S

elf-

Car

e A

ctiv

itie

s

2- S

elf-

Car

eB

ehav

iour

s

3- S

elf-

Car

e C

onte

xt

4- S

elf-

Car

e En

viro

nmen

t

The

Seve

n Pi

llars

of

Self-

Car

e

Hea

lth B

elie

f M

odel

Tran

s-th

eore

tical

Mod

el o

f Be

havi

our

Cha

nge

The

Beha

viou

r C

hang

e W

heel

The

Self-

Car

e C

ontin

uum

Res

ourc

e M

anag

emen

t Th

eory

Org

anis

atio

nal T

heor

y

Publ

ic M

anag

emen

t Th

eory

1. K

now

ledg

e &

Hea

lth li

tera

cy

2. M

enta

l wel

lbei

ng, s

elf-

awar

enes

s &

Age

ncy

3. P

hysi

cal a

ctiv

ity4.

Hea

lthy

eatin

g5.

Ris

k av

oida

nce

or m

itiga

tion

6. G

ood

hygi

ene

7. R

atio

nal u

se o

f pr

oduc

ts a

nd s

ervi

ces

Act

ivat

ion

Mot

ivat

ion

Beha

viou

r ch

ange

Res

ourc

e ut

ilisa

tion

Acc

ess

to s

ervi

ces

Ret

urn

on In

vest

men

t (R

OI)

pot

entia

l

Wid

er d

eter

min

ants

of

heal

th

The

built

env

ironm

ent

Fisc

al r

esou

rces

& p

reva

iling

cul

ture

Hea

lth p

rom

otio

n in

itiat

ives

Hea

lth li

tera

cy in

terv

entio

ns

Educ

atio

n &

coa

chin

g

Life

styl

e in

terv

entio

ns

Wor

kpla

ce H

ealth

Pro

mot

ion

Dig

ital H

ealth

inte

rven

tions

Inte

grat

ion

of c

are

Com

mun

ity p

harm

acy

initi

ativ

e

Soci

al p

resc

ribin

g

Hea

lth s

yste

ms

resi

lienc

e

The

built

env

ironm

ent

Hea

lth in

All

Polic

y (H

iAP)

pre

scrip

tions

47

Model synthesis

Figure 1 shows how the four cardinal dimensions of self-care can be juxtaposed on a matrix to

illustrate the relationship between them. In this new conception, the Self-Care Matrix (SCM) is a

synthesis of 32 existing models and frameworks which makes it possible to consider self-care in

its totality (figure 1). The two left panes of the schema congruently describe the level of focus and

the perspective relevant to each dimension of self-care. The schema also shows diagrammatically

how self-care activities, behaviours and activation, and reliance on resources (i.e. dimensions

1-3) are sequentially connected, whereas the self-care environment (i.e. dimension 4) exerts an

omnidirectional influence on all other three dimensions of self-care.

Figure 1: The Self-Care Matrix (SCM)

©SELFCARE 201948


DISCUSSION

Self-care has been extensively defined and considered by various academic groups and

conceptualised from many different perspectives (table 1). The lack of a unified conceptual

framework that consolidates existing non-disease specific models and theories of self-care has

been a significant barrier to the development of suitable self-care interventions in the contemporary

setting. The strategic global development and adoption of a unified commonly-understood and

widely accepted conceptual model of self-care is desirable and can benefit all stakeholders. It is

also helpful to move towards understanding self-care as an applied field of research as opposed to

framing the concept as a purist academic pursuit.

To this end, we advance a comprehensive yet pragmatic model that supports the conceptualisation

of self-care in its totality, and that can be used by all stakeholders. The proposed Self-Care Matrix

(SCM) signals a new point of departure for self-care thinking that could inform the development,

commissioning and evaluation of self-care interventions.

The proposed Self-Care Matrix (SCM) thus provides a new point of departure for self-care thinking

that could inform the development, commissioning and evaluation of self-care interventions in the

contemporary setting by describing various aspects that could be grouped into four interlinked

dimensions.

Characterising the Self-Care Matrix

Our synthesis consolidated various perspectives gleaned from 32 existing models of self-care and

considered emergent themes and domains which naturally grouped into four cardinal dimensions

(table 2, figure 1). The SCM schema illustrates that each dimension operates at one of three

independent levels (micro, meso and macro-level). Dimensions 1 and 2 of the Self-Care Matrix

consider the individual from a person-centred perspective, while dimensions 3 and 4 frame the

individual or a segment of the population from the medicalised patient perspective or a broader

health system viewpoint.

Self-care involves a wide range of personal activities such as physical activity, healthy eating, good

hygiene and the avoidance of risks such as tobacco and excessive alcohol consumption. Although

it is recognised that these activities are inter-connected, they are often approached ‘vertically’ in

public health programmes and tend to be considered as separate activities. The Self-Care Matrix

thus provides a congruent system which covers all aspects of self-care, offers a logical connection

between them, and creates a framework on which metrics can be based and developed. In this

regard, SCM represents real-world conditions and provides a logical unifying framework for the

individual – and all other stakeholders – to make sense of all the different self-care elements and

their inter-connections.

Strength and limitations

A particular strength of SCM is that it emphasises the inter-relationship between the four dimensions

©SELFCARE 201949


of self-care. This can help stakeholders identify the various discrete elements that could impact

self-care capacities and capabilities across a wide range of settings and scenarios (e.g. during urban

and environmental planning, or the development of public health initiatives or person-centred self-

care interventions). By way of illustration, many urban planners use Barton & Grant’s Settlement

Health Map84 as their conceptual framework. The Health Map has been widely referenced by the

WHO Healthy City programmes across the world, and is inspired by three sources: (1) theories of

the social determinants of health, (2) principles of human ecology, and (3) an understanding of the

disciplines of planning. The Health Map has clear antecedents in Hancock’s (1985) ‘mandala of

health’85, which linked health to human ecosystems and discussions on the social determinants of

health. Although the Settlement Health Map does not focus specifically on self-care, its concentric

circles of ecosystem, environment, community and lifestyle are entirely consistent with the four

dimensions of self-care expressed in the unifying Self-Care Matrix.

The principal limitation of our new conception is that the various models, theories, and frameworks

of self-care used to synthesise the Self-Care Matrix did not result from a systematic review of the

literature. However, our extensive pragmatic review identified the most widely used and accessible

conceptions of self-care gleaned from academic and lay literature and with reference to statutory

and non-governmental stakeholder groups concerned with the study and advocacy of self-care.

Integrating conceptual models with the evidence base

Because the Self-Care Matrix is a synthesis of existing theories and models, it is possible for

stakeholders to use an evidence-based approach to inform the development of suitable self-care

interventions for application across a wide range of settings. For example, SCM illustrates that the

second dimension of behaviour, activation and change is linked to, but ultimately separate from

the first dimension pertaining to self-care capacities, capabilities and activities. This delineation

makes it possible to integrate the evidence base for behaviour change in a way that fosters the

development of suitable self-care interventions through the application of knowledge from a broad

range of behaviour change theories31,32,36,44,48,86. Interventions at this level may be developed that

activate any number of pillars of self-care represented in the first dimension, whilst for example

using incentivisation and gamification techniques to ensure traction and lead to sustained behaviour

change in individuals represented in the second dimension.

Equally, the integration of the evidence base for the Self-Care Continuum54 represented by the third

dimension in SCM can be supported through a detailed analysis of case finding, risk stratification

and population segmentation. This could help make the economic case for the development and

funding of coherent self-care initiatives aimed at reducing reliance on resources56, and the funding

of social prescribing initiatives and workplace health promotion programmes that seek to promote

the routine adoption of healthy lifestyle habits and health seeking behaviours to improve overall

health and wellbeing.

©SELFCARE 201950


©SELFCARE 201951

Elucidating the relationship between the wider or external environment and how this can impact

self-care activities and behaviours in a segment of society can help drive fiscal and public health

policy prescriptions that could refocus health systems towards a Health in All Policy (HiAP)

approach87. For example, the WHO final report of the Commission on Social Determinants of

Health concluded that ‘social injustice is killing people on a grand scale’88, and identified key

commonalities between primary health care and the social determinants of health paradigms. This

places a central focus on health equity, which is relevant in all countries and contexts, regardless of

income level, and considers health as more than the absence of disease89. This evidence base can

be used to develop programmes which promote multi-sectoral action and the step-wise adoption

of progressive HiAP and other self-care ‘best-buys’ and policy prescriptions.

The Self-Care Matrix is therefore a suitable tool that could be used to model the impact that

an intervention could have on the various inter-related dimensions of self-care. To exemplify, the

schema shows that an intervention that causes a change in self-care activities (Dimension 1) would

not necessarily precipitate a change in an individual’s reliance on resources (Dimension 3) without

the mediation of factors concerned with activation and the sustained adoption of a desirable

lifestyle habits (Dimension 2). The schema also suggests that a change in the external environment

(Dimension 4) could exert a powerful and omnidirectional influence on all other three dimensions of

self-care. This analysis highlights the importance of resource mobilisation and policy development

work to promote a progressive commissioning landscape which encourages the piloting of suitable

evidence-based self-care interventions in the educational, applied care or community care settings.

Implications for policy makers and researchers

The emergence of long-term NCDs as a major health issue around the world has put the spotlight on

self-care90. Through self-care, people can delay or prevent many chronic diseases such as coronary

heart disease, strokes, diabetes and cancers, in which an unhealthy lifestyle is well established as a

key causative agent91. Many countries have incorporated aspects of self-care into policies through

innovative and notable practices92. However, all countries are a long way from implementing robust

and meaningful policy prescriptions designed to promote individual and population wide self-care

capabilities, whilst shifting professional practices and reorienting healthcare systems towards a

preventative ethos. The development of self-care as an academic subject and as a practical choice

for policymakers and health professionals presents important opportunities for the development of

sustainable policy prescriptions that support a coherent ‘cradle to grave’ approach to national and

international self-care narratives.

SCM can thus be used as a suitable lens by which to evaluate self-care interventions by considering

different components of self-care across four dimensions, and provides a common framework for

the study and development of policy prescriptions for self-care for application in the real-world

setting. Objective evaluation of self-care initiatives using the SCM approach could help foster a

culture of evidence-based commissioning for self-care interventions in the health and wellbeing

space.


©SELFCARE 201952

Summary & Conclusion

The proposed Self-Care Matrix is a pragmatic and unifying framework that can be used to

conceptualise the totality of self-care and its various interlinked dimensions. SCM can be used as

a lens by which to view, identify, study and evaluate self-care elements in any health and wellbeing

intervention, independent of the disease category or setting. The mid-level descriptions and the

visual schema illustrating the inter-relationship between each of the four cardinal dimensions of

self-care render this model widely applicable and easily accessible to a wide audience, including

policymakers, commissioners of health and all other self-care stakeholders. The Self-Care Matrix

signals a new point of departure for self-care thinking and can be used as a common ground

between all stakeholders interested in advancing the study, practice, development, commissioning

and evaluation of self-care initiatives in the contemporary setting.

Correspondence to: Dr Austen El-Osta, The Self-Care Academic Research Unit (SCARU). Department of Primary Care & Public Health, Imperial College London, 323 Reynolds Building, Charing Cross Hospital, London W6 8RF.

Acknowledgements: Ms Evelina Barbanti (SCARU Research Assistant), Dr Ahmed Alboksmaty (SCARU Research Assistant), Ms Mashael Almadi (SCARU Research Assistant), Ms Farah Masood (SCARU Research Assistant) & Dr Marize Bakhet (SCARU Research Fellow) provided support in data acquisition and analysis.

Contributors: All authors provided substantial contributions to the conception (AEO, DW, SG, RB, DM, AM, PS), design (AEO, PS), acquisition of the data (AEO, EB, AA, MA, FM, MB), and the analysis and interpretation of the pragmatic review (AEO, DW). AEO, DW and PS did the decision making of the framework construction. AEO took the lead in planning the study with support from the co-authors and carried out the data analysis with support from AA, EB, DW and PS. AEO is the guarantor.

Funding: This article presents independent research in part funded by the National Institute for Health Research (NIHR) under the Collaborations for Leadership in Applied Health Research and Care (CLAHRC) programme for North West London. The views expressed in this publication are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care.

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