| BackgroundTuberculosis(TB)represents a significant global public health challenge,ranking among the top ten fatal diseases worldwide.China is recognized as one of the 30 countries with the highest burden of TB,with a particularly high number of incident cases reported in 2021,ranking third globally.The World Health Organization(WHO)recommends Directly Observed Therapy,Short-course(DOTs)as the global strategy for TB control.DOT,which entails healthcare workers directly observing patients during medication intake,forms the cornerstone of this strategy.However,the implementation of DOT in China faces various obstacles,including a shortage of primary healthcare personnel,transportation difficulties,and limited patient autonomy.Consequently,the implementation rate of DOT remains low,failing to adequately address the needs of all TB patients.Therefore,it is crucial to explore alternative patient management models that can effectively complement DOT.Selfmanagement has emerged as a novel healthcare approach,aiming to empower patients to actively participate in their treatment and proactively modify their behaviors.This patientcentered approach is aligned with the patient-focused principles advocated by the WHO.TB self-management(TBSM)serves as a promising complementary strategy to DOT,particularly for TB patients who are either unwilling or face challenges in accessing DOT.By implementing TBSM,these patients can benefit from an alternative form of management that caters to their unique needs and circumstances.ObjectivesThis study aims to construct a theoretical model for TBSM and evaluate its effectiveness.Using Chongqing City in China as a case study,the self-management levels of TB patients will be assessed,and the determinants influencing their self-management behaviors will be identified.The study aims to determine the causal pathways through which these determinants influence TBSM,validate and refine the TBSM theoretical model,and develop evidencebased self-management intervention strategies to enhance the implementation effectiveness of TBSM,improve treatment adherence,and enhance the prevention and treatment outcomes of TB.Methods1.Literature research:A comprehensive literature review was conducted to examine the literature related to TBSM.Suitable scientific theories were preliminarily screened to provide guidance for the construction of the TBSM theoretical model.Systematic searches were performed in databases including Pubmed/Medline,Wanfang,CNKI,and others to gather relevant information.The objective of these searches was to identify potential strategies that address the determinants of TBSM.2.Theoretical researchBased on the findings of literature research,the advantages and disadvantages of different theories are further compared and analyzed,suitable behavioral theories and public health theories are selected according to the research objectives,the perspectives of different theories are integrated,and the theories are developed and innovative,and finally a patientcentered multi-stage multi-factor TBSM model is constructed.Through theoretical research,the evidence of determinants of TBSM was transformed into intervention strategies for TBSM.3.Questionnaire surveyThe Self-Management Scale for SMTP was developed and its reliability and validity were verified through a questionnaire survey.The initial scale was formulated by referencing the Technical Specifications for Tuberculosis Prevention and Control in China(2020 Edition),the Health Education Prescription(2020 Edition),and Behavioral Indicators for Outcome Evaluation of TB Health Promotion,in line with the definition and theoretical model of TBSM.A total of 231 TB patients were recruited from Chongqing Public Health Medical Treatment Center to participate in the initial scale survey.The critical ratio,total item correlation,and exploratory factor analysis were utilized to construct the self-management behavior rating scale for TB patients.An additional 231 TB patients were recruited to fill out the final scale in order to assess its reliability through internal consistency testing and testretest reliability.The content validity of the scale was evaluated using Pearson correlation analysis,while the structural validity was assessed using fit indices,convergent validity,and discriminant validity.To evaluate the level of self-management among TB patients in Chongqing,a questionnaire survey was conducted using stratified random sampling.Chongqing was divided into three layers based on the TB incidence in each district and county,namely high,medium,and low TB epidemic areas.One district and county were randomly selected from each layer as study sites.A network questionnaire was administered to 562 TB patients in the selected study sites,consisting of the self-developed TBSM behavior assessment questionnaire and a questionnaire on influencing factors.Data analysis was performed using SPSS 21.0.Descriptive statistics were used to present the sociodemographic characteristics,tendency factors,contributing factors,reinforcement factors,and distribution of behavioral stages.Independent sample t-tests were employed to compare group differences for dichotomous variables,while ANOVA was used for multiple categorical variables.In multivariate analysis,the dependent variables were considered as outcomes,and significant results from the univariate analysis were used as independent variables.Categorical variables were treated as dummy variables,and continuous variables were directly included in the model for multiple stepwise regression analysis.Statistical significance was set at P < 0.05 for all analyses.4.Pathway analysisPath analysis was used to screen the determinants affecting TBSM.Based on the TBSM theoretical model and the results of the multi-factor analysis of influencing factors,relevant variables were included in the path analysis.The AMOS 21.0 software was used to assess the fit of the patient-centered multi-stage and multi-factor TBSM model,utilizing measures such as the chi-square degree of freedom ratio,goodness of fit index,and adjusted goodness of fit index.The regression coefficients of each path were calculated to determine the impact of each factor on self-management behavior and its respective pathway.5.Delphi methodDeveloped the TBSM intervention strategy expert consultation questionnaire 12 experts in the field of TB prevention and control from eastern,western,northern and southern China were invited to conduct two rounds of Delphi expert consultation on the TBSM intervention strategy,and finally the TBSM intervention strategy was determined.Results1.A patient-centered multi-stage and multi-factor TBSM theoretical modelBased on the "Green Model" and "Health Action Process Approach" behavioral theories,a patient-centered multi-stage and multi-factor TBSM theoretical model was constructed,incorporating the "New Public Service Theory" from the perspective of public management.The model consists of three main modules: the individual behavior module,health service support module,and social environment module.The individual behavior module includes factors related to behavioral stages(self-management cognition and self-management intention),contributing factors such as tendency factors and self-management skills.The health service support module encompasses three types of support: health education as an enabling factor,national policies,information,and emotional support as reinforcing factors.The social environment module comprises socio-environmental factors,including the TB epidemic situation in the patient’s location,family members with TB,and access to health resources as contributing factors.Additionally,support from family members,peers,and community neighborhood committees are considered reinforcing factors.When applying the model to different regions,it is important to consider the population background of each specific region to ensure contextual relevance and effectiveness.2.The SMPTThe SMPT consists of a total of 17 items in three dimensions: "adherence to treatment behavior","prevent transmission behavior" and "supporting treatment behavior",which can explain 76.60% of the difference in the total table.The internal consistency coefficients of the total scales and the three subscales were 0.936,0.933,0.925,and 0.905,and the within-group correlation coefficients of the three subscales were 0.897,0.814,0.834,and 0.885,respectively.Pearson correlation analysis showed each item was strongly correlated with the dimension to which it belonged(r=0.849-0.915,p <0.001),a weak correlation between each dimension(r=0.267-0.344,p <0.001),and the correlation between each item and its dimension was higher than with the other dimensions.Most fit indices reached the recommended threshold,and the average variance extracted values of the three dimensions were higher than 0.5.The values of the square root of the average variance extracted within each dimension were greater than the correlation between dimensions,and all heterotraitmonotrait values were below 0.85.3.The stage classification criteria and the intervention criteria of TBSMAccording to patient-centered multi-stage and multi-factor TBSM theory and TBSM behavior scale,corresponding cognition and intention items were set for 17 behaviors respectively,and questionnaires on TBSM cognition,intention and behavior were constructed and intervention criteria were formulated: first of all,patients can be judged to have completed this stage only if they reach full score in a certain stage.Otherwise,patients need to accept the intervention at this stage.Then,according to the scores of the three behavioral dimensions in this stage,further determine the behavioral dimensions that need intervention.If any(some)dimensions do not get full marks,intervention is needed for this dimension;otherwise,no intervention is needed.4.The self-management level and influencing factors of TB patients in Chongqing(1)Total score of self-management cognition of TB patients in Chongqing(10.749±4.979);the awareness rate of persistent treatment,supportive treatment and preventive transmission was 18.5%,32.9% and 32.0% respectively.The total awareness rate of self-management behavior was 7.5%.The total score of self-management willingness(13.026±4.906);the rate of adherence to treatment,support treatment and preventing transmission was 63.9%,48.9% and 50.9% respectively.The total willingness rate for selfmanagement behaviors was 31.5%.Total score of self-management behavior(51.324±12.792).The rates of behavior in the three dimensions of upholding treatment,supportive care,and preventing transmission were 13.9%,16.4%,and 21.5%,respectively.The overall selfmanagement behavior rate was 9.3%.(2)The results of path analysis showed that the self-management efficacy(β=0.690)and self-management intention(β=0.491)in the "individual behavior module";Health education(β=0.912)and psychological support(β=0.848)in the health service module;In the social environment module,family support(β=0.848)had a positive and direct predictive effect on self-management behavior.Knowledge(β=3.505)and self-management skill(β=5.334)in the module of individual behavior affect self-management behavior indirectly mainly through self-management efficacy;In the health service support module,health education(β=-1.539)indirectly affected self-management behavior mainly through avoidance,policy support(β=3.105),information support(β=1.440)and psychological support(β=2.714).(3)The epidemic level in the social environment module(β=-5.413)was mainly affected by cognition,family support(β=2.083)and peer support(β=4.091)was mainly affected by efficacy,and community committee support(β=1.186)was mainly affected indirectly by willingness and avoidance.5.A "patient-centered" intervention strategy for self-management of TB patients50 intervention strategies for self-management of TB patients were finally determined after two rounds of Delphi consultation.9 policy support strategies including "preintervention stage";5 strategies of "self-management cognitive stage";"Self-management willingness stage" strategy 6;"Self-management behavior stage" strategy 30.Conclusion1.The patient-centered multi-stage and multi-factor theoretical model of TBSM highlights the central role of patients in driving their own self-management behaviors.The individual behavior module is identified as a primary determinant influencing TBSM behavior,while professional support from healthcare institutions and the surrounding social environment serve as indirect influences on individual behavior.The comprehensive model effectively captures the factors relevant to TB patients’ self-management and provides valuable guidance for the development of intervention strategies.2.The SMTP demonstrates strong reliability and validity,making it a robust tool for assessing the level of self-management behavior among TB patients and evaluating the effectiveness of self-management interventions.3.Findings from the study conducted in Chongqing indicate that TB patients exhibited a relatively high subjective willingness to engage in self-management.However,there was a lack of accurate knowledge regarding self-management,and the overall level of selfmanagement behavior was suboptimal.Determinants of TBSM primarily included factors such as knowledge,self-management effectiveness,self-management skills,and avoidance coping within the individual behavior module.Additionally,the health service support module encompassed health education,policy support,information support,and psychological support,while the social environment support module consisted of family,peer,and community committee support.4.The patient-centered TBSM intervention strategies encompass a comprehensive range of interventions involving various stakeholders such as the Health Commission,CDC,healthcare institutions at different levels,family members,peers,and neighborhood committees.These strategies are designed to promote self-management behaviors among TB patients.In view of the final TBSM intervention strategy,the following policy suggestions are put forward:1.Strengthen the government’s sense of responsibility and create a sound policy supporting environment for TBSM.2.Health institutions at all levels work closely to provide a professional supportive environment for TBSM.3.Strengthen the internal factors of individuals and stimulate the internal motivation of self-management4.Strengthen the construction of professional TBSM team.5.Evidence-based health education in various forms should be carried out to give full play to its role as a bridge to self-management behavior. |
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