Self-management of patients with chronic diseases during COVID19: a narrative review.

Flowchart of the process of searching and selecting the studies. The specifications relevant to the significance of self-management in chronic diseases. The specifications of relevant studies of self-management challenges during the COVID-19 pandemic. The specifications of studies relevant to the role of the healthcare team in the self-management of patients during the COVID pandemic.

This study is a narrative review conducted in 2019-2020. This study is focused on relevant works of chronic patient self-management during the corona pandemic from March 2019 to Jan 2021. To search Latin articles, databases including Google Scholar, PubMed, Science Direct, and Springer were used. The search strategy consisted of the combination of the following Boolean keywords and operators: (COVID-19 OR “Coronavirus 2” AND “chronic disease” OR “chronic condition” AND (“self-management”). Figure 1 shows the flowchart relating to the process of finding and selecting the studies included in this narrative. The articles were used in the study based on inclusion criteria including being relevant to the research objective, using structures framework including keywords including self-management, chronic disease, and COVID-19 in the abstract. Also, Latin articles with the availability of full text entered into the study. Figure 1 shows the flowchart of the search and selection process for the included studies. The exclusion criteria included works on diseases other than chronic diseases, repetitive works, and unavailable books. In the initial search based on the said keywords, 121 articles were collected. by studying the abstract and full text, 26 articles were selected based on inclusion and exclusion criteria, and elimination of repetitive and irrelevant cases. Two researchers who independently reviewed the titles have evaluated the data extracted and summaries of the articles found, considering the eligibility criteria. Disagreements were resolved by discussion, or in the event of no agreement by a four reviewers or researcher.

In this study, 26 qualified Latin articles were used. The results obtained from the reviewed studies were classified into 3 major domains 8 out of the 26 articles used in the study explained self-management in chronic diseases. Self-management in chronic patients is one of the best solutions to promote health and improve the quality of life ( Tab. I ). Sharif Ali et al presented a review on analyzing the positive effects of self-management on the emotional, behavioral, and social-mental domains, and the individual skills of diabetes patients [ 18 ]. Al Grant et al conducted a systematic and meta-analysis review on chronic patients such as diabetes, cardiovascular, and arthritis patients. In this study, they referred to the role of self-management to improve the quality of life and to reduce using healthcare system resources [ 19 ]. Banerji et al mentioned in a review that training self-management by healthcare cadre during the corona pandemic to diabetes patients plays a key role in the achievement of treatment purposes of these patients [ 20 ]. 10 out of 26 articles were focused on self-management challenges during the COVID-19 epidemic ( Tab. II ). According to the nature of chronic diseases and imposing unwanted and unpleasant conditions of the disease such as tolerating continuous pain and stress, and long-term treatment process causes necessity of frequent references to the healthcare systems, attachment of these systems to healthcare team to control the disease, and regular monitoring of self-management program [ 21 ]. However, the healthcare systems have reduced access to hospitals and visits for chronic patients during the corona epidemic because of managing the disease. This can make disruption in quality of life, and the treatment process of these patients [ 22 ]. For example, Banerji et al have conducted a study and referred to challenges such as a change in lifestyle, on-time unavailability of resources, and health team reducing the awareness of diabetes patients to control the disease and the mental effects of these restrictions [ 20 ]. Among entered studies, 9 articles were focused on the role of the healthcare team in the self-management of patients during the corona pandemic ( Tab. III ). The increased number of chronic diseases has made abundant challenges for the healthcare team. As the healthcare team tends to use specialized sources and facilities to support the patients and create high-quality life, providing information and making self-confidence in patients to take proper self-care behavior can be some part of the supportive plan of personnel for self-management of these patients. This can finally improve the quality of life, reduce anxiety and stress, and improve the adaptability and physical performance of patients under special conditions [ 23 ]. Hence, according to the outcomes of the COVID-19, the health team should provide programs and facilities for the patients and their families to support the self-management plans of chronic patients [ 24 ].

The present study was conducted to analyze the status of self-management of chronic patients n the COVID-19. According to the results of reviewed articles, they were classified into 3 major groups. The role of self-management interventions has been increasing in the field of providing healthcare services for chronic patients. The results of a systematic review conducted by Panagioti et al. showed that self-management interventions in patients can improve health consequences and decrease the amount of using healthcare services. According to recent studies, it could be found that the definition of health has become more dynamic, and self-management is one of the key concepts in this field [ 25 ]. Self-management interventions applied from various methods and programs such as physical activity, educational interventions, and fitness programs among chronic patients have caused high ability of them for management of the disease [ 26 ]. Self-management is the best method for caring for chronic patients refers to the active participation of the patient in the management of disease and controlling the lifestyle [ 27 ]. Besides, self-management encompasses behaviors including food diet behaviors, pharmacological treatment, monitoring symptoms, sleeping, physical activity, fitness, growing the skills, setting goals, problem-solving, reducing stress, and using operating plans. Chronic patients use self-management as a part of their life, which can enhance the quality of life and can make patients feel healthy [ 24 ]. The most important consequences of self-management include an adaptation of chronic patients to the health problems related to their disease. This is because; the patients can diagnose the symptoms of the disease by self-management and awareness of relevant problems, and take effective measures to control them [ 28 ]. This can prevent more disabilities and development of the health of these individuals; because self-management in chronic diseases is not just focused on treatment and rehabilitation. It should be noted that achievement to desirable self-management is dependent on facilitating the health services, and meeting communicative barriers between the healthcare team and the patient. Also, it is dependent on providing more cooperation between patients and the healthcare team [ 29 ]. This issue has been changed into a challenge for the healthcare team and the patients, and the results have affected the self-management strategies [ 30-32 ]. According to the risk of COVID-19 prevalence in Canada in the in-person visits of patients to doctors' offices, online medical and health services are provided for the patients. For example, online triaging services are provided for COPD patients. Some limitations like cognitive and hearing disorders of patients, unavailability of technology, the lingual barriers, and problems of working with the system have reduced the quality of virtual healthcare compared to in-person healthcare. This problem is highly manifested in aged patients with COPD. Besides, quarantine and social distancing by the governments to reduce the prevalence of the virus has resulted in dysfunction in the management of patients with chronic neural disorders like epilepsy despite reducing the pulmonary infections caused by the disease. This is because; the patients suffer from anxiety and depression caused by decreased times of in-person visits with their doctors [ 22 ]. The restrictions have resulted in self-management behaviors such as nutrition, physical activity, and controlling chronic patients during the treatment process. This is because; these patients need special treatment and regular visits to various specialists to control their disease because of complicated clinical conditions. Hence, decreased access to healthcare services, medicine, and changes in their lifestyle can result in abundant problems for them [ 9 , 33 , 34 ]. Therefore, the healthcare team needs to control and support self-management programs due to the worry of these patients about the negative effects of the conditions on their health status and based on the significance of monitoring their health status [ 34 , 35 ]. During the corona pandemic, the healthcare team has to decrease in-person visits with chronic patients (especially diabetes patients) with COVID-19 and tries to train self-management to these patients. These patients have welcomed this method recently. However, it should be mentioned that some hospitals have caused the risk of high blood sugar by applying restrictive strategies in the activities of diabetic patients. The healthcare team, especially those with diabetic patients or newly diagnosed hyperglycemia with COVID-19, has to set their management strategies in such a way that the needs of patients are met and the personnel has been also protected [ 36 ]. Arlt et al. have mentioned that the healthcare team should pay attention to 3 elements including training, equipment, and empowerment to support chronic patient self-management. In the field of training : the patients should be trained sufficiently about coping with the changes in their health status, such as conditions caused by the corona pandemic in their life. Through this, the patients can be prepared to pass the crisis. Equipment : equipment aims to provide the needs of these patients such as medicine and medical equipment, which should be under careful supervision. Empowerment : empowerment means making patients ready to encounter critical conditions and take urgent interventions when needed. Also, the healthcare team tries to enhance the self-confidence and ability of the patients to take the self-management process properly [ 37 ]. The main limitations in this study include a few numbers of studies in this field because of the newness of the disease. Also, it could be mentioned that reviewed articles were Latin because no similar study existed in Persian. Hence, it would be better for further studies to emphasize chronic patient self-management during the COVID-19 pandemic.

In general, the healthcare team should identify the restrictions, problems, and concerns of self-management of patients, and evaluate the solutions and effective interventions to meet and control the barriers. They should also provide the best options to facilitate self-management of chronic patients during the corona pandemic. Besides, the health centers should be urgently equipped with relevant technologies of virtual healthcare including online and offline electronic consulting, providing educational sources through the website of the universities and social media, phone follow up, presenting educational papers, providing non-pharmacological methods like relaxation, and effective breathing practices to reduce anxiety. Multiple studies have proved the effectiveness of using technology (telemedicine) for the self-management of chronic patients during the COVID 19.

On 11 March 2020, the World Health Organization (WHO) announced the COVID-19 disease as a pandemic. The disease has caused a high mortality rate across the world to date. In the meantime, the risk of morbidity and mortality due to the COVID-19 is high in people with chronic diseases such as diabetes, hypertension, cardiovascular diseases, chronic obstructive pulmonary disease, and weakened immune system compared to the normal population [ 1-5 ]. Many efforts have been taken to produce the vaccine and definite treatment of the COVID pandemic in the world. These efforts have led to restricted access to the vaccine. According to academic evidence, specific drugs for COVID are not available. Hence, the best option here is trying to use preventive methods and to take self-management behaviors in chronic patients [ 1 , 6 ]. According to the declaration of the WHO, 35% of women and 29% of men suffer from chronic diseases such as cardiovascular diseases, chronic pulmonary diseases, or diabetes. Such prevalence of chronic diseases has left abundant negative effects on the workforce of different countries. Self-management is very important to save resources and improve the ability of patients. The results of interventions under the title of Chronic Disease Self-Management Program (CDSMP) made by the Stanford University of America in this country and more than 20 other countries (Canada, Australia, Argentina, England, Denmark, Spain, Coast Arica, and China) 40 years ago show that included individuals have acted successfully in the field of self-management of health [ 7 ]. The implementation of health instructions and protocols, such as social distancing and quarantine for reducing the spread of COVID-19 disease and transmission between carriers and healthy individuals has disrupted the treatment and self-management process of chronic patients. For example, the implementation of social distancing and quarantine has result in a significant reduction in regular visits of a patient with specialists to check their health status. Also, the pharmaceutical reserves have been decreased in some regions because of the closure of drug production plants. On the other hand, many patients have lost their insurance coverage because of unemployment caused by the corona pandemic and have encountered problems with treatment costs [ 8 , 9 ]. Besides, as the sources, equipment, and healthcare forces of states to control the COVID-19 pandemic, the chronic patients have trouble in access to healthcare services [ 10-12 ]. Health service providers are vital elements of societies, the health, and security of whom are significant not only for the continuous care of patients but also to control the prevalence of diseases. For example, the description presented by the health service providers of China based on their face-to-face experience on fighting COVID-19 was a responsibility to reduce pain and suffer from the patients and common effort to protect the country against the virus. This is because they believed in this sentence “everyone is responsible for the advent or collapse of his-her country”. Health service providers play a key role in the treatment of COVID-19 patients. The majority of these healthcare providers have little clinical experience working in the units of special infectious diseases. However, when healthcare systems are not ready to fight infectious disease, the health service providers help the system by gaining knowledge and skill and improving their communications in intensive training courses by accepting the risks and injuries caused by this disease. Health service providers need continuous medical training to cope with emergencies and to become ready under conditions like the corona pandemic. Healthcare systems must seek inter-professional, and inter-organizational cooperation to provide high-quality and efficient care because of the variety of organizational culture [ 13-17 ]. We aimed to assess the global impact of COVID-19 on self-management in chronic diseases and its challenges and evaluate the role of health care workers to support and improve patient care.

Funding sources: this research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. We would like to express our gratitude to Shiraz University of Medical Sciences Vice Chancellor for Research, Education and Research for approving this project.