Introduction: Self-management is considered a potential answer to the increasing demand for family medicine by people suffering from a chronic condition or multi-morbidity. A key element of self-management is goal setting. Goal setting is often defined as a moment of agreement between a professional and a patient. In the self-management literature, however, goal setting is regarded as a circular process. Still, it is unclear how professionals working in family medicine can put it into practice. This background paper aims to contribute to the understanding of goal setting within self-management and to identify elements that need further development for practical use. Debate: Four questions for debate emerge in this article: (1) What are self-management goals? (2) What is necessary to accomplish the process of goal setting within self-management? (3) How can professionals decide on the degree of support needed for goal setting within self-management? (4) How can patients set their goals and how can they be supported? Implications: Self-management goals can be set for different (life) domains. Using a holistic framework will help in creating an overview of patients’ goals that do not merely focus on medical issues. It is a challenge for professionals to coach their patients to think about and set their goals themselves. More insight in patients’ willingness and ability to set self-management goals is desirable. Moreover, as goal setting is a circular process, professionals need to be supported to go through this process with their patients.
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In this study we examine if and how self-evaluated financial knowledge and competences, financial behaviour, financial self-efficacy, and motivation are associated with the severity of financial problems of clients in ‘financial self-management projects’ (Dutch: Thuisadministratie). These projects involve support provided by volunteers. Our data included 249 respondents who filled out a questionnaire at the start of the support. The results indicate that particularly unhealthy financial behaviour and lower levels of financial self-efficacy relate to more serious financial problems. Volunteers support people with serious financial problems in getting access to formal debt counselling. Besides this, volunteers should not only focus on improving financial knowledge and competences, but also on contributing to higher levels of financial self-efficacy and healthier financial behaviour of their clients.
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The theoretical framework of this dissertation is based on Amartya Sen’s capability approach (Chapter 2). In the early 1980s, development economist Amartya Sen developed the capability framework as a broad normative framework for the evaluation and assessment of individual well-being and social arrangements mainly in countries in the Global South (Sen, 1999, 2009). I chose the capability approach was chosen because of its strong focus on the notion of freedom as the capability to live the life each individual is aiming for. The freedom to choose a particular lifestyle is an intrinsic part of Sen’s notions of agency and well-being (Sen, 1999). After elaborating on notions of agency and well-being in detail, I turn to the role of financial self-help groups and how their members are influenced by social structures. This chapter concludes by operationalizing the theoretical framework into three capabilities (C1–C3) that serve as sensitizing concepts throughout the dissertation. These capabilities focus on the potential impact CAF groups have on members’ abilities to develop social networks (C1), to control their financial household management (C2), and to adopt an enterprising attitude (C3). Chapter 3 discusses my research methodology. I describe how the three capabilities (C1–C3) were applied as sensitizing concepts in the set-up of this particular action research (Blumer, 1954). I also explain in more detail how, by using sensitizing concepts, I combined an inductive research approach with a deductive angle. Then, I elaborate on the fundamental elements of this action research project: the implementation of the CAF groups as well as the collection and analysis of the empirical data. Finally, I reflect on how I designed and carried out this action research, with a special focus on the interaction between researcher and CAF members as research participants. A more detailed background description of the Dutch financial landscape is provided in Chapter 4. The chapter focuses on two particular financial self-help groups: ROSCAs among Ethiopians and Ghanaians living in the Netherlands. Compared to the formal banking system dominating the current financial landscape, these financial self-help groups claim effectivity instead of efficiency in the operation and management of their respective groups. By exploring developments in the current financial landscape, this chapter argues that distinguishing different kinds of resilience creates possibilities for analysing the different roles of financial arrangements and institutions for the financial landscape. Thus, this explorative study on ROSCAs questions the dominance of the financial side of the coin that has resulted from the efficiency-driven institutions of the financial sector. Chapter 5 presents each CAF group in more detail. The reader gets to know the different members of each CAF group and their motivations to join. Financial performance is assessed according to members’ savings and loan behaviour during the period of their participation. The quantitative data is analysed on how much the members of a respective CAF group saved and how much they borrowed from the group’s fund during the entire period of the research. These insights help the reader to better understand the differences and similarities between the five CAF groups. Chapter 6 discusses the empirical findings from the first three CAF groups. This chapter explores whether and how participation in a CAF group improves individuals’ well-being with regard to expanding their social networks, improving their financial household management, and strengthening their entrepreneurial positions. It also shows how participating in CAF groups at the grassroots level contributes to the well- Balancing the social and financial sides of the coin26being of vulnerable people in the Netherlands. Finally, the chapter reconsiders Sen’s notion of freedom for the particular context of overconsumption, inequality, and overindebtedness. In applying Sen’s capability approach, I realized that the approach has a “blind spot” regarding individuals’ possible impacts on the structures within and around them. By adding notions of Giddens’s structuration theory to the core concepts of the capability approach, I rendered the capability approach more sensitive to how CAF-group members may interact with their surrounding structures (Chapter 7). The relation between individuals and surrounding societal structures is extensively discussed in what is often referred to as the agency-structure debate (Ritzer, 2003). This debate is based on differing views about whether and to what extent individuals have a free will and can act according to their preferences, values, and personal feelings, or to what extent they are the “product” of their surrounding social structures. By expanding the capability approach with the notions of internal structures, on the one hand, and more proximate and more distant societal structures, on the other (Stones, 2008), I detail not only how individual agents are influenced by their surrounding structures, but how they might also have – however small and modest – an impact on those structures themselves. As a result, this chapter not only provides answers to how CAF-group participation affects individual members’ access to social networks, their financial household management, and their entrepreneurial positioning, but it also enabled me to investigate how and why individuals join a CAF group to take part in a so-called countermovement. Thus, I also consider how CAF members could possibly play a role in their surrounding social structures, like the existing financial landscape and the emerging participation society in the Netherlands.One way in which a CAF group can play a role in the surrounding structures is to become a community of practice. Wenger (1998) describes a community of practice as a group of people who share a certain domain of interest that distinguishes them from others. In a community of practice, it is crucial to learn from each other by engaging in joint activities and discussions. To discuss whether and how some of the CAF groups studied here turned into a community of practice, I apply the criteria of a common goal, trust, democratic leadership, and accumulation of knowledge in Chapter 8. The application of these criteria to the functioning of the CAF groups also provides more insight into how members interacted which each other in the different CAF groups. I will show how two of the five CAF groups indeed turned into communities of practice. Chapter 9 concludes this dissertation by linking the empirical findings on the individual level (Chapters 6 and 7) with those on the group level (Chapter 8). I follow this with a general discussion of the main contribution to theory development made by the Balancing the social and financial sides of the coin27expansion of Sen’s capability approach with Giddens’s structuration theory. Then, I discuss the role of CAF groups in enabling individual participants to balance the social and financial sides of the coin. Finally, I conclude this dissertation by showing how CAF groups have the potential to empower their members to meet the expectations of the participation society and the challenges of the contemporary financial landscape. I also provide recommendations for how engaged scholars doing action research can be reflective about the way they interact with their research participants and for how practitioners can set up CAF groups in the field. In the Epilogue, I tell the story of Cash2Grow. Based on the experiences and findings of my research, I co-founded the Cash2Grow foundation to promote savings groups in the Netherlands as a tool for financial and social empowerment. By developing improved savings-group methodologies and financial education tools, the foundation aims to train staff and volunteers from different types of (welfare) organizations to establish savings groups among their target populations. At the moment, we are also collaborating with similar organizations in Spain, Italy, Germany, and Poland to learn more from each other in a project subsidized by the EU.
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Background Literature on self-management innovations has studied their characteristics and position in healthcare systems. However, less attention has been paid to factors that contribute to successful implementation. This paper aims to answer the question: which factors play a role in a successful implementation of self-management health innovations? Methods We conducted a narrative review of academic literature to explore factors related to successful implementation of self-management health innovations. We further investigated the factors in a qualitative multiple case study to analyse their role in implementation success. Data were collected from nine self-management health projects in the Netherlands. Results Nine factors were found in the literature that foster the implementation of self-management health innovations: 1) involvement of end-users, 2) involvement of local and business partners, 3) involvement of stakeholders within the larger system, 4) tailoring of the innovation, 5) utilisation of multiple disciplines, 6) feedback on effectiveness, 7) availability of a feasible business model, 8) adaption to organisational changes, and 9) anticipation of changes required in the healthcare system. In the case studies, on average six of these factors could be identified. Three projects achieved a successful implementation of a self-management health innovation, but only in one case were all factors present. Conclusions For successful implementation of self-management health innovation projects, the factors identified in the literature are neither necessary nor sufficient. Therefore, it might be insightful to study how successful implementation works instead of solely focusing on the factors that could be helpful in this process.
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Europe’s aging population is leading to a growing number of people affected by chronic disease, which will continue over the coming decades. Healthcare systems are under pressure to deliver appropriate care, partly due to the burden imposed on their limited financial and human resources by the growing number of people with (multiple) chronic diseases. Therefore, there is a strong call for patient self-management to meet these patients’ healthcare needs. While many patients experience medication self-management as difficult, it poses additional challenges for people with limited health literacy. This thesis aims to explore the needs of patients with a chronic disease and limited health literacy regarding medication self-management and how support for medication self-management can be tailored to those needs.
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Financially vulnerable consumers are often associated with suboptimal financial behaviors. Evaluated financial education programs so far show difficulties to effectively reach this target population. In our attempt to solve this problem, we built a behaviorally informed financial education program incorporating insights from both motivational and behavioral change theories. In a quasi-experimental field study among Dutch financially vulnerable people, we compared this program with both a control group and a traditional program group. In comparison with the control group, we found robust positive effects of the behaviorally informed program on financial skills and knowledge and self-reported financial behavior, but not on other outcomes. Additionally, we did not find evidence that the behaviorally informed program performed better than the traditional program. Finally, we discuss the findings and limitations of this study in light of the financial education literature and provide implications for policymaking and directions for future research.
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Objective: Self-management is a core theme within chronic care and several evidence-based interventions (EBIs) exist to promote self-management ability. However, these interventions cannot be adapted in a mere copy-paste manner. The current study describes and demonstrates a planned approach in adapting EBI’s in order to promote self-management in community-dwelling people with chronic conditions. Methods: We used Intervention Mapping (IM) to increase the intervention’s fit with a new context. IM helps researchers to take decisions about whether and what to adapt, while maintaining the working ingredients of existing EBI’s. Results: We present a case study in which we used IM to adapt EBI’s to the Flemish primary care context to promote self-management in people with one or more chronic disease. We present the reader with a contextual analysis, intervention aims, and content, sequence and scope of the resulting intervention. Conclusion: IM provides an excellent framework in providing detailed guidance on intervention adaption to a new context, while preserving the essential working ingredients of EBI’s. Practice Implications: The case study is exemplary for public health researchers and practitioners as a planned approach to seek and find EBI’s, and to make adaptations.
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To make effective financial decisions, individuals need both financial and numerical competence. The latter includes having numerical knowledge and skills, and the ability to apply them in a financial context. A positive attitude towards numbers, combined with the absence of math anxiety, proves beneficial. Additionally, higher-order numerical skills enhance the quality of financial decision-making. Challenges in any of these numeracy aspects may contribute to financial difficulties. However, the specific aspects of numeracy that are of crucial importance remain unclear. Therefore, our research addresses the question: Which aspects of numeracy are related to having financial problems? In this article, we explore this question through a literature review.
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Abstract: Background: Chronic obstructive pulmonary disease (COPD) and asthma have a high prevalence and disease burden. Blended self-management interventions, which combine eHealth with face-to-face interventions, can help reduce the disease burden. Objective: This systematic review and meta-analysis aims to examine the effectiveness of blended self-management interventions on health-related effectiveness and process outcomes for people with COPD or asthma. Methods: PubMed, Web of Science, COCHRANE Library, Emcare, and Embase were searched in December 2018 and updated in November 2020. Study quality was assessed using the Cochrane risk of bias (ROB) 2 tool and the Grading of Recommendations, Assessment, Development, and Evaluation. Results: A total of 15 COPD and 7 asthma randomized controlled trials were included in this study. The meta-analysis of COPD studies found that the blended intervention showed a small improvement in exercise capacity (standardized mean difference [SMD] 0.48; 95% CI 0.10-0.85) and a significant improvement in the quality of life (QoL; SMD 0.81; 95% CI 0.11-1.51). Blended intervention also reduced the admission rate (relative ratio [RR] 0.61; 95% CI 0.38-0.97). In the COPD systematic review, regarding the exacerbation frequency, both studies found that the intervention reduced exacerbation frequency (RR 0.38; 95% CI 0.26-0.56). A large effect was found on BMI (d=0.81; 95% CI 0.25-1.34); however, the effect was inconclusive because only 1 study was included. Regarding medication adherence, 2 of 3 studies found a moderate effect (d=0.73; 95% CI 0.50-0.96), and 1 study reported a mixed effect. Regarding self-management ability, 1 study reported a large effect (d=1.15; 95% CI 0.66-1.62), and no effect was reported in that study. No effect was found on other process outcomes. The meta-analysis of asthma studies found that blended intervention had a small improvement in lung function (SMD 0.40; 95% CI 0.18-0.62) and QoL (SMD 0.36; 95% CI 0.21-0.50) and a moderate improvement in asthma control (SMD 0.67; 95% CI 0.40-0.93). A large effect was found on BMI (d=1.42; 95% CI 0.28-2.42) and exercise capacity (d=1.50; 95% CI 0.35-2.50); however, 1 study was included per outcome. There was no effect on other outcomes. Furthermore, the majority of the 22 studies showed some concerns about the ROB, and the quality of evidence varied. Conclusions: In patients with COPD, the blended self-management interventions had mixed effects on health-related outcomes, with the strongest evidence found for exercise capacity, QoL, and admission rate. Furthermore, the review suggested that the interventions resulted in small effects on lung function and QoL and a moderate effect on asthma control in patients with asthma. There is some evidence for the effectiveness of blended self-management interventions for patients with COPD and asthma; however, more research is needed. Trial Registration: PROSPERO International Prospective Register of Systematic Reviews CRD42019119894; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=119894
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Objective: To examine the underlying factor structure and psychometric properties of the Assessment of Self-management in Anxiety and Depression (ASAD) questionnaire, which was specifically designed for patients with (chronic) anxiety and depressive disorders. Moreover, this study assesses whether the number of items in the ASAD can be reduced without significantly reducing its precision. Methods: The ASAD questionnaire was completed by 171 participants across two samples: one sample comprised patients with residual anxiety or depressive symptoms, while the other consisted of patients who have been formally diagnosed with a chronic anxiety or depressive disorder. All participants had previously undergone treatment. Both exploratory (EFA) and confirmatory factor analyses (CFA) were conducted. Internal consistency and test–retest reliability were also assessed. Results: Both EFA and CFA indicated three solid factors: Seeking support, Daily life strategies and Taking ownership [Comparative Fit Index = 0.80, Tucker Lewis Index = 0.78, Root Mean Square Error of Approximation = 0.09 (CI 0.08–1.00), Standardized Root Mean Square Residual = 0.09 ($2 = 439.35, df = 168)]. The ASAD was thus reduced from 45 items to 21 items, which resulted in the ASAD-Short Form (SF). All sub-scales had a high level of internal consistency (> a = 0.75) and test–retest reliability (ICC > 0.75). Discussion: The first statistical evaluation of the ASAD indicated a high level of internal consistency and test–retest reliability, and identified three distinctive factors. This could aid patients and professionals’ assessment of types of self-management used by the patient. Given that this study indicated that the 21-item ASAD-SF is appropriate, this version should be further explored and validated among a sample of patients with (chronic or partially remitted) anxiety and depressive disorders. Alongside this, to increase generalizability, more studies are required to examine the English version of the ASAD within other settings and countries.
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