Entwistle Vikki A, Cribb Alan, Owens John
Health Services Research Unit, University of Aberdeen, Health Sciences Building, Foresterhill, Aberdeen, AB25 2ZD, Scotland, UK.
School of Education, Communication and Society, King's College London, Waterloo Bridge Wing, Franklin-Wilkins Building, Waterloo Road, London, SE1 9NH, UK.
Health Care Anal. 2018 Mar;26(1):48-65. doi: 10.1007/s10728-016-0335-1.
There are various reasons why efforts to promote "support for self-management" have rarely delivered the kinds of sustainable improvements in healthcare experiences, health and wellbeing that policy leaders internationally have hoped for. This paper explains how the basis of failure is in some respects built into the ideas that underpin many of these efforts. When (the promotion of) support for self-management is narrowly oriented towards educating and motivating patients to adopt the behaviours recommended for disease control, it implicitly reflects and perpetuates limited and somewhat instrumental views of patients. It tends to: restrict the pursuit of respectful and enabling 'partnership working'; run the risk of undermining patients' self-evaluative attitudes (and then of failing to notice that as harmful); limit recognition of the supportive value of clinician-patient relationships; and obscure the practical and ethical tensions that clinicians face in the delivery of support for self-management. We suggest that a focus on enabling people to live (and die) well with their long-term conditions is a promising starting point for a more adequate conception of support for self-management. We then outline the theoretical advantages that a capabilities approach to thinking about living well can bring to the development of an account of support for self-management, explaining, for example, how it can accommodate the range of what matters to people (both generally and more specifically) for living well, help keep the importance of disease control in perspective, recognize social influences on people's values, behaviours and wellbeing, and illuminate more of the rich potential and practical and ethical challenges of supporting self-management in practice.
为何推广“自我管理支持”的努力很少能带来国际政策制定者所期望的那种在医疗体验、健康和幸福方面的可持续改善，原因是多方面的。本文解释了失败的根源在某些方面存在于支撑许多此类努力的理念之中。当对自我管理的支持（推广）狭义地定位于教育和激励患者采取疾病控制推荐行为时，它含蓄地反映并延续了对患者有限且有些功利的看法。它往往会：限制对尊重和赋能“伙伴合作”的追求；有破坏患者自我评估态度（进而未能注意到其有害性）的风险；限制对医患关系支持价值的认识；并掩盖临床医生在提供自我管理支持时面临的实际和伦理困境。我们认为，关注使人们能与其长期病症和谐共处（包括面对死亡）是更充分理解自我管理支持的一个有前景的出发点。然后我们概述了一种能力视角来思考美好生活能为自我管理支持的发展带来的理论优势，例如解释它如何能兼顾人们美好生活中（普遍和更具体层面）重要事务的范围，有助于正确看待疾病控制的重要性，认识社会对人们价值观、行为和幸福的影响，并揭示支持自我管理在实践中的更多丰富潜力以及实际和伦理挑战。
