Minireview / Open Access
DOI: 10.31488 /heph.142
Proposal of a Regional Model Building towards Self Management Supporting Systems of Pain in Japan
Tomoko Tachibana
Chief Senior Researcher, Center for Public Health Informatics, National Institute of Public Health
*Corresponding author: Tomoko Tachibana, MD, MPH, PhD ,2-3-6 Minami, Wako city, Saitama prefecture 351-0197, Japan, Tel: +81-48-458-6206; Fax: +81-48-469-0326; E-mail: tachibana.t.aa@niph.go.jp
Abstract
In recent years, the number of patients with chronic diseases has been increasing. We have been proposing measures to enhance social support for people who have “chronic health problems” including sequelae and disabilities and live a social life.In this study, I focused on the treatment of pain, which is one of the chronic health problems.Then, I proposed a study plan for the construction of the "regional model" necessary for the realization of regional self-management support systems in Japan.The significance of the proposal was compared with the experience abroad from a behavioral perspective. CDSMP, one of the Self-Management Education (SME) programs in the United States, has been recognized to have the effects of "reducing pain," "improving self-efficacy," "reducing visits to medical institutions," etc. The following advantages could be expected by realizing the plan proposed in this study: (1) Contribution to the chronic pain policy, (2)Maintenance of useful medical resources, (3)Contribution to promote work style reform of doctors.
Keywords: chronic condition, self-management supporting system, behavioral science, medical cost reduction
Introduction
In recent years, the global burden of disease has shifted to non-communicable diseases [1,2]. Developed countries are required to develop a support base for people who live in social life while having "chronic health problems" such as aftereffects and disabilities of chronic diseases and trauma [3].Therefore, in the United Kingdom, self-care is promoted, which is the philosophy of the National Health Service of England (NHS) Constitution, that "patients and citizens also support the system as a member [4]."So far, I have published the proposals for the necessary infrastructure development with the aim of promoting “sustainable and evidence-based health policies for a symbiotic society[5-8]” and “social security and work-style reform in anticipation of 2040[9-11].” Even in Japan, where the birthrate is declining and the population is aging, a regional medical strategy that can maintain useful medical resources and contribute to reforming doctors' working styles will be necessary.
In this study, I propose a plan to realize a strategy focused on the treatment of chronic health problems.For that purpose, first, "pain" is taken up as one of the chronic health problems. And about self-management of "pain," I propose a study plan to realize social life support (hereinafter referred to as "self-management support").Then, from the viewpoint of social medicine, the related behavioral medical methodologies are organized and the validity of the proposed plan is verified. The purpose of this study is to propose a reasonable and effective method of realizing self-management support that considers medical cost reduction in Japan, where the development of a regional comprehensive care system is progressing.
How to Develop Self-Management Support Measures
Countermeasures for "pain" in Japan
In Japan, the prevalence of chronic pain is 22.5%, 10% of patients with chronic locomotor tract pains have restrictions on studying and working, and there is a health problem of social loss of 370 billion yen [12].Chronic pain, which many people have, is one of the causes of lowering QOL, and it is a social issue that it is difficult to obtain understanding from others because the objective index is not established.Based on "Countermeasures for chronic pain in the future (recommendations) [13]" in September 2010, as a comprehensive pain countermeasure, "1) construction of medical system, 2) education and promotion, 3) information provision / consultation system, 4) promotion of research” are being implemented.As a result of this study, the "Pain Center," which provides multi-disciplinary cooperation across departments and provides a multifaceted approach including cognitive behavioral therapy, has been established and deployed nationwide since FY2013. The Pain Center is working to improve the medical level of chronic pain and to maintain and improve the QOL of patients with chronic pain.
Proposal of "Practical study on a support program for people with chronic health problems who have difficulty in living in relation to ‘pain’"
In this study, I propose a study plan to build a regional model to introduce and disseminate self-management by treating the above-mentioned "pain" as one of the chronic health problems in Japan.This study plan is proposed with a view to contributing to reforming the working style of doctors and achieving results such as medical cost reduction.
Study outline
Study title: A Practical Study on a Supporting Programs for Difficulty Living with the Chronic illness or injury
Summary of issues
Need for support for the chronic illness or injury with chronic pain
Most of the chronic illness or injury people live in the area with difficulty due to chronic pain (hereinafter referred to as chronic pain). As the chronic illness or injury population increases in the future, it is necessary to support self-management of chronic pain so that everyone can live their own life in the community.
Need for self-management program development for chronic pain in the chronic illness or injury
Self-management education (SME) is one of the methods to support self-management of chronic symptoms and diseases. The efficacy has been established, and it may be useful for self-management of chronic pain in the chronic illness or injury. However, in Japan, the use of SME is limited to programs such as diabetes and chronic obstructive pulmonary disease. In the future, it is necessary to focus on the “symptoms” across the disease and promote the program development of chronic pain.
Necessity of training companions for self-management
As the number of single-person and married-family chronic illness or injury households and chronic illness or injury people with dementia is increasing, it may be difficult to continue the self-management program for chronic pain alone. Therefore, there is a need for a companion, such as a familiar inhabitant, who supports self-management for chronic pain.
Details of assignment
Need for support for the chronic illness or injury with chronic pain
With the development of medicine and environmental hygiene, today, the number of acute infectious diseases has become extremely small, while lifestyle-related diseases and chronic diseases such as diabetes and hypertension have increased dramatically, and the importance of measures against chronic diseases is increasing. "Chronic pain" was cited as one of the issues that should be promoted in the future at the "Examination Committee for further enhancement of chronic disease countermeasures (August 2009) " by the Ministry of Health, Labor and Welfare.
The prevalence rate of chronic pain (more than twice a week or more than one week a month, hereinafter referred to as chronic pain) in Japan is 22.5%, and the social loss is 370 billion yen. Many of the diseases that cause chronic pain are associated with "aging," and many chronic illness or injury people complain of "back pain, stiff shoulders, and pain in limb joints [14]." On the other hand, 68.6% of 8,924 men and women aged 20 and over all over Japan who have chronic pain responded that “pain should be endured [15].” Furthermore, because of the misunderstanding that “the pain of the chronic illness or injury” is “common things with aging[16],” many chronic illness or injury people give up.
In the comprehensive local care system as a national policy, “to maintain the dignity of the chronic illness or injury and to support the independent living, you can continue to live your own life until the end of your life in the area where you are used to living as much as possible”. As the chronic illness or injury population increases in the future, it is necessary to support self-management of chronic pain so that everyone can live their own life in the community.
Need for self-management program development for chronic pain in the chronic illness or injury
A self-management education is one of the methods for self-management of symptoms and chronic diseases. Developed in the late 1980s at Stanford University in the United States, it is now available in 22 countries around the world and its effectiveness has been established. In Japan, applicants are also practicing in Kumamoto and Kanazawa [17,18]. This technique may also be useful for self-management of chronic pain in the chronic illness or injury. However, in Japan, self-management education is only for programs such as diabetes. It is necessary to develop a “chronic pain self-management program for the chronic illness or injury” so that the chronic illeness or injury people can self-control their chronic pain and lead their own way of life in the community.
Necessity of training and expansion of self-management companion
In Japan, the number of single-person and single-family chronic illness or injury households and chronic illness or injury people with dementia is increasing, and it is expected that the aging society will continue to progress [19]. In the present study, the applicants developed a self-management program to enable chronic illness or injury people to self-manage chronic pain and lead their own lives, while at the same time I will consider measures to support self-management for chronic pain by those who are familiar to us and who will be run by them.
From the 2014-2016 fiscal year, a verification experiment on self-management support conducted by the Japan Institute of Management has examined the contents of support available for patients with chronic diseases and the image of users who will support self-management. However, most of these have been applied to the elderly who have diseases such as cerebrovascular disease and chronic heart failure, triggered by admission to an acute hospital. There are few cases where it is applied to elderly people in areas with frail conditions.
Therefore, we will train and expand companions in the region so that the chronic illness or injury can continue to carry out the “chronic pain self-management program for the chronic illness or injury” developed in this study. Specifically, in the model area, training for self-management will be provided to local volunteers who are engaged in health promotion activities in the area, and train companions. Furthermore, since chronic pain in the chronic illness or injury is a national problem, in order to expand the number of companions, disseminate the “chronic pain self-management program for chronic illness or injury people” and training of companions in various regions. There is a need.
Efforts of this study to solve problems
To solve the above problems, this study will tackle the following steps.
Development of “chronic pain self-management program for chronic illness or injury people” in model areas
Foster supporters in the “chronic pain self-management program for the chronic illness or injury” in model areas
Implementation of the “chronic pain self-management program for the chronic illness or injury” in the model area and measurement of the effects on the companion and the chronic illness or injury
Consider measures to spread “chronic pain self-management program for chronic illness or injury people” and accompany supporter training nationwide
Study method, contents
1-1. “Survey on self-management of chronic pain for the chronic illness or injury” in a model area
In a model area (Wako City, Saitama Prefecture, Japan), with the cooperation of the Wako City Council of Social Welfare, conduct an investigation on the condition of chronic pain, the status of self-management, and ideas for improvement in the chronic illness or injury.
1-2. Self-management program Investigation of potential application to chronic pain in pioneering areas
Applying recommendations from the Japan Association for Self-Management of Chronic Diseases, and applying the opportunity of applicants to areas where we have pioneered self-management programs.
1-3. Development of “chronic pain self-management program for chronic illness or injury people”
Develop a “chronic pain self-management program for the chronic illness or injury” from the above 1 and 2 together with a practitioner (collaborator) of the self-management program.
1-4. Training companions of the “chronic pain self-management program for the chronic illness or injury” in model areas
In the model area (Wako City, Saitama Prefecture), the volunteers who are engaged in health promotion activities in the area introduced by the Wako City Council of Social Welfare developed the “Chronic pain self-management for chronic illness or injury people” developed in 3 above. Conduct training etc. to support the program.
2-1. Implementation and evaluation of “chronic pain self-management program for patients with chronic injury and family” in model areas
In a model area (Wako City, Saitama Prefecture), patients with chronic illnesses and their families who participate in local health promotion activities with volunteers, etc. trained in 1-4 above, and self-management practitioners (joint researchers) The “Chronic pain self-management program for patients with chronic injury and family” will be implemented. Once a week on the prospect of the 50 cases, get to participate several times in the seminar of 2.5 hours.
Evaluation ①: The following survey will be conducted before and after the intervention on the chronic injury patients and their families who participated in the “Chronic pain self-management program for chronic injury patients and their families”. Survey details: mental and physical conditions, knowledge of chronic diseases and chronic pain, QOL, self-efficacy of daily activities and working, etc.>
2-2. Evaluation of “chronic pain self-management program for patients with chronic injury and family” in the model area ②
In step 2-1 above, we conducted a focus group interview with companions who provided self-management support, and (1) qualitative effects of support, (2) program revision plan, (3) implementation challenges, and (4) measures for dissemination about the improvement of self-management support and the elements for promotion.
2-3. “Chronic pain self-management program for patients with chronic injuries and their families” and promotion of accompany runner ( ≓ supporter) training
Revised “Chronic pain self-management program for patients with chronic injuries and their families” based on the above 2-1. and 2-2. Going to the Stanford University in the
Expected results for study
Chronic phase illness patients with chronic pain, improvement of family self-management skills, expansion of social participation
Many patients with chronic illness and complaints complain of “backache, stiff shoulders, and pain in the joints of the limbs,” but many people with chronic illness have a misunderstanding such as “normal things with aging.” Family is giving up. In this study, by developing a “chronic pain self-management program for patients with chronic illness and family” and supporting it with local volunteers, patients with chronic illness and their families can live their daily lives well associated with chronic pain. As a result, it becomes possible to participate in society, which has been abandoned because of pain, and patients with chronic injuries and their families can live their lives in peace in the community.
Creating bases for a town where chronic patients with chronic illness and their families can live a safe life forever
Under the National Comprehensive Care System of National Policy, we aim to “build a comprehensive community care system in which housing, medical care, nursing care, prevention, and living support are provided in an integrated manner so that people can continue to live their lives in the community until the end of their lives.” It can be shown that it is feasible to set up a system in which the “chronic pain self-management program for patients with chronic injuries and their families” developed by this study is supported mainly by the companion runners called resident volunteers. Fostering supporters of this chronic pain management will play a part in the realization of an inclusive community that does not exclude anyone with chronic pain patients with chronic pain or residents with no family. Furthermore, by expanding the number of supporters nationwide based on successful cases in the model area, it will foster the locality for community development where chronic patients with chronic illnesses and their families can live a safe life forever.
Contribution to integrated health care and care prevention programs
Currently, the integrated implementation of health care and care prevention for patients with chronic injuries and their families is under way. At that time, by sharing the function of the activities of local resource groups / organizations, they can be promoted efficiently and effectively. Utilizing the “regional resource assessment tool” developed by the applicants to train and expand the companions of the “chronic pain self-management program for patients with chronic injuries and their families,” it becomes possible to carry out integrated care prevention.
Study target field (target area / facility) and its characteristics
Target field: Wako-shi, Saitama prefecture, Japan
Population 81 thousand (aging rate 17.5%)
As of March 31, 2017, Wako had a population of 81,151 (Basic Resident Register / Alien Registration). By age group, the young population (0-14 years) accounted for 14.0% of the total, the working-age population (15-64 years) accounted for 68.5%, and the chronic phase injury / family population (65 years and over) accounted for 17.5%. However, the aging rate is considerably lower than in Japan, and the working-age population is the largest in Saitama prefecture. Wako City has been working on prevention of long-term care since 2003, and in recent years it has also been working on self-supporting management at community care meetings, etc., and the value of the certification rate for long-term care is 9.7% as of March 2017, 18.3% nationwide - it is about half.Residents called health supporters act as instructors to hold various classes on health promotion, and the culture of extending healthy life expectancy by the residents is spreading.
History of study or preparation status (preliminary study completed)
Regarding the theme of “Countermeasures for chronic pain” and “Self-management support” related to this study, literature study as a preliminary study has been completed.On the other hand, regarding the self-management program, the applicants have verified the effects of the chronic disease self-management program practiced in other areas [20].In addition, among the applicants, Dr.T and Dr.U are based in the pain management center and the mental care center, respectively, of the University Hospital in the vicinity of Wako City, which is the field of this study, and the academic management of the Japan Chronic Pain Society and guidelines for the treatment of fibromyalgia. They are medical doctors who supply medical treatments.
Protection of human rights and compliance with laws and regulations
This study will be conducted in accordance with the ethical guidelines for medical study for humans, with the approval of the ethical review committee of the applicant’s institution. Specifically.
How to obtain understanding from the study subject
Request study cooperation in writing and get informed consent. The contents of the explanation are as follows: Regarding study purpose, method, privacy protection, human rights protection, study cooperation is voluntary, there is no disadvantage even if you do not agree with the study cooperation, you can decline on the way, study materials strictly store and dispose of by cutting, and publicize the study results.
Presence or absence of invasion of study subjects and expected risks and disadvantages
It takes about 15 minutes to answer each questionnaire. The interview will take about one hour, and may cause some psychological and physical burden. Therefore, only those who have sufficiently explained and obtained consent will be requested to cooperate.
Safety management related to the protection of personal information of individuals to be studied
The respondent questionnaire and electronic data (stored on the CD) will be stored by the study chief (applicant) in a locked storage in his / her own laboratory. After the storage period of 5 years has passed, the data on the PC will be erased, and the data and media for which analysis has been completed will be cut off and then deleted.Anonymization processing is used for presentations at academic conferences and papers.
Method of information disclosure regarding study
As a result of this study, related academic conferences and papers will be presented in Japan and overseas. The analysis results will also be fed back to the city hall and related organizations that cooperated in collecting various data.
Other: No financial conflicts of interest to disclose.
Domestic situation regarding study
About self-management
From the 2014-2016 fiscal year, the Japan Management Association Study Institute conducted a verification experiment on self-management support to examine the content of support available for patients with chronic diseases and the image of users who will be used for self-management support. However, these are applied to chronic phase injury patients / family members having diseases such as cerebrovascular disease, chronic heart failure, and dementia, and are not applied to general chronic phase injury patient / family members.
As a summary of this proof experiment, the presence of an accompanist has motivated patients with chronic injury and family members who develop cerebrovascular disease to perform self-management, and caregivers have taken into account the history of cerebrovascular disease. Qualitative outcomes have been reported, such as the fact that collaboration with medical staff was inevitable to create an independent support-type care plan.
It is considered that the method of self-management support with the participation of the accompaniment person (resident volunteer) examined in this study will show the methodology to promote the above model project by the inhabitants.
About chronic pain
As a study related to chronic pain, cognition of patients with not only organic aspects but also psychosocial factors through a multidisciplinary collaboration system including clinical psychologists and physical therapists Pain centers that provide medical treatment using a diversified approach, including behavioral therapy, have been established nationwide from FY2011 (22 locations in total as of January 2019). Also, from fiscal 2017, a chronic pain medical care system construction model has been started at three locations nationwide in order to build a system in which pain centers and regional medical institutions cooperate to receive appropriate chronic pain medical treatment in the region. It has been expanded to eight locations in FY2018.
Characteristics of study, pioneering, ripple effect, etc.
The feature of this study is that the self-management program, which has been mainly for self-management of lifestyle-related diseases, will adapt to patients with chronic injuries and family chronic pain. In addition, instead of self-management by chronic phase illness patients / family, by fostering accompany supporters who support self-management, I also include patients with chronic phase illness /pain and residents without family. It can be said that aiming at the realization of local communities is important. Furthermore, by studying dissemination measures, it can be spread nationwide, and has pioneering implications for promoting integrated implementation of health services and care prevention.
Behavioral Significance
Behavioral medicine is defined as an interdisciplinary discipline that integrates knowledge and technology related to social culture, psychosociety, behavior, and biomedicine [21].The knowledge and technology of behavioral medicine are used not only for understanding people’s health and diseases, but also for preventing diseases, promoting health, elucidating etiology, diagnosis, treatment, and rehabilitation. For example, it is applied to behavioral therapy for psychosomatic disorders, cognitive behavioral therapy, therapeutic assistance / prevention of chronic physical diseases and lifestyle-related diseases, and establishment / maintenance of healthy behaviors.
The field of behavioral medicine study is now diverse and extends beyond basic and clinical study to public health activities for disease prevention and health promotion.In this paper, behavioral science on public health activities examined “(1) operant learning,” “(2) self-efficacy,” and “(3)psychological stress model” from the viewpoint of “why unhealthy behavior is formed and maintained.”
“(1) Operant conditioning [22]” is defined as a type of associative learning process through which the strength of a behavior is modified by reinforcement or punishment, or a procedure that is used to bring about such learning.An operant action is an action whose frequency changes immediately according to a change in the environment such as the appearance or disappearance of a stimulus immediately after the action occurs. Therefore, operant conditioning is learning to behave voluntarily while adapting to rewards and aversion stimuli, and is a basic theory of behaviorist psychology.This was the first experiment by Edward Thorndike in 1898, but in 1938 Ballas Skinner started a systematic study using mice and pigeons.The basic scheme of operant conditioning is as follows: preceding stimulus (A) [internal and external stimulus situation], action (B), result (C) ["Desirable result (C)" favors the stimulation situation. "Undesired result (C)" worsens the stimulus situation].Adachi [23] (2014) applied operant conditioning to an explanatory model of smoking behavior and cites “self-efficacy” as a quitter as an internal facilitator of stimulation control.
“(2)Self-efficacy” pays attention to what kind of result a person takes if he / she takes certain actions. The self-efficacy is the sense of self-efficacy (= “expectation of effect”) before the action is taken, and the prospect of the result of the action is “expected result.”Self-efficacy is largely associated with the performance and outcome of actions [24].There is general self-efficacy / individual self-efficacy, which influence each other. The most important resource for a switch that enhances self-efficacy is “self-successful experience,” and there are also “representative experience,” “linguistic persuasion,” and “emotional change.”An example of setting goals to increase self-efficacy is given [25].
“Self-efficacy” is also a theoretical model of the effect manifestation of “Chronic Disease Self-Management Program (CDSMP) [26],” which is one of the SME programs [20].CDSMP was developed in the late 1980s at Stanford University in the United States and is one of the world-wide spread SME programs. The goal of CDSMP is to “make it possible to live with sickness [27].”In CDSMP, “improvement of self-efficacy” is considered to be a more important mechanism of expression of effects, and its effects on various health conditions have been reported [28-31].
“(3) Psychological stress model” is based on the theory proposed by psychologist Lazarus and others. Lazarus simplified the psychological stress model, saying that stress is an interaction between the environmental demands of the “stresser” and the individual’s “stress response [32].”After that, various coping methods such as stress management techniques [33] have been proposed based on a psychological stress model [34,35].
Considerations
The method proposed in this plan applies the methodology of self-management education to the Japanese version and aims to develop it in cooperation with regional medical care.I have already made good progress in developing and evaluating self-management support programs for post-stroke epilepsy [36]. The proposed plan in this paper seems to be valid from a behavioral science perspective, and it could contribute to the promotion of chronic pain policy in Japan in the future.
Also, from the knowledge of self-care in the UK, if the proposed plan is realized, the following effects can be expected.
1.“Reducing medical expenses” and “reducing the number of times medical institutions are used” are expected.
2. In the UK, the advantage is that it can be practiced by non-professionals. In Japan, where the medical system is well-established and access to medical institutions is good, health and welfare staff should focus on “treatment” of chronic health problems and “by region” and “by type of illness.” It was thought that it could be a method that can contribute to reforming the working style of doctors.
Currently, due to the effects of pandemic measures by the Covid-19, strategies for financial difficulties have become an issue in many countries [37]. In order to maintain the quality of the super-aging Japanese regional medical system while avoiding its collapse, it is necessary to consider a proper balance between supply and demand. Methods that can be expected to contribute to the reform of doctors’ working styles by making effective use of useful medical resources and to reduce medical costs should be put into practice while conducting careful verification. It was thought that the proposal of this study would also contribute to “presentation of methods that can be expected to reduce medical costs” in anticipation of the emergence of the crisis of the spread of new coronavirus infection.
Conflicts of Interest
The author has no financial conflicts of interest to disclose concerning the study.
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Received: March 12, 2020;
Accepted: April 16, 2020;
Published: April 24, 2020.
To cite this article : Tachibana T. Proposal of a Regional Model Building towards Self-Management Supporting System of Pain in Japan. Health Education and Public Health.2020; 3:3.
© Tachibana T. 2020.