Patient capacity and constraints in the experience of chronic disease: a qualitative systematic review and thematic synthesis.

BACKGROUND: Life and healthcare demand work from patients, more so from patients living with multimorbidity. Patients must respond by mobilizing available abilities and resources, their so-called capacity. We sought to summarize accounts of challenges that reduce patient capacity to access or use healthcare or to enact self-care while carrying out their lives. METHODS: We conducted a systematic review and synthesis of the qualitative literature published since 2000 identifying from MEDLINE, EMBASE, Psychinfo, and CINAHL and retrieving selected abstracts for full text assessment for inclusion. After assessing their methodological rigor, we coded their results using a thematic synthesis approach. RESULTS: The 110 reports selected, when synthesized, showed that patient capacity is an accomplishment of interaction with (1) the process of rewriting their biographies and making meaningful lives in the face of chronic condition(s); (2) the mobilization of resources; (3) healthcare and self-care tasks, particularly, the cognitive, emotional, and experiential results of accomplishing these tasks despite competing priorities; (4) their social networks; and (5) their environment, particularly when they encountered kindness or empathy about their condition and a feasible treatment plan. CONCLUSION: Patient capacity is a complex and dynamic construct that exceeds "resources" alone. Additional work needs to translate this emerging theory into useful practice for which we propose a clinical mnemonic (BREWS) and the ICAN Discussion Aid

The Efficacy of Resiliency Training Programs: A Systematic Review and Meta-Analysis of Randomized Trials

<div><p>Importance</p><p>Poor mental health places a burden on individuals and populations. Resilient persons are able to adapt to life’s challenges and maintain high quality of life and function. Finding effective strategies to bolster resilience in individuals and populations is of interest to many stakeholders.</p><p>Objectives</p><p>To synthesize the evidence for resiliency training programs in improving mental health and capacity in 1) diverse adult populations and 2) persons with chronic diseases.</p><p>Data Sources</p><p>Electronic databases, clinical trial registries, and bibliographies. We also contacted study authors and field experts.</p><p>Study Selection</p><p>Randomized trials assessing the efficacy of any program intended to enhance resilience in adults and published after 1990. No restrictions were made based on outcome measured or comparator used.</p><p>Data Extraction and Synthesis</p><p>Reviewers worked independently and in duplicate to extract study characteristics and data. These were confirmed with authors. We conducted a random effects meta-analysis on available data and tested for interaction in planned subgroups.</p><p>Main Outcomes</p><p>The standardized mean difference (SMD) effect of resiliency training programs on 1) resilience/hardiness, 2) quality of life/well-being, 3) self-efficacy/activation, 4) depression, 5) stress, and 6) anxiety.</p><p>Results</p><p>We found 25 small trials at moderate to high risk of bias. Interventions varied in format and theoretical approach. Random effects meta-analysis showed a moderate effect of generalized stress-directed programs on enhancing resilience [pooled SMD 0.37 (95% CI 0.18, 0.57) p = .0002; I² = 41%] within 3 months of follow up. Improvement in other outcomes was favorable to the interventions and reached statistical significance after removing two studies at high risk of bias. Trauma-induced stress-directed programs significantly improved stress [−0.53 (−1.04, −0.03) p = .03; I² = 73%] and depression [−0.51 (−0.92, −0.10) p = .04; I² = 61%].</p><p>Conclusions</p><p>We found evidence warranting low confidence that resiliency training programs have a small to moderate effect at improving resilience and other mental health outcomes. Further study is needed to better define the resilience construct and to design interventions specific to it.</p><p>Registration Number</p><p>PROSPERO #<a href="http://www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=CRD42014007185.VDLPvykbBiY" target="_blank">CRD42014007185</a></p></div

Additional file 1: of Patient capacity and constraints in the experience of chronic disease: a qualitative systematic review and thematic synthesis

Appendix: Complete Search Strategy for Data. Full Search Strategy used to complete the review. (DOCX 23 kb

Summary of Included Study Characteristics and Findings.

<p>Summary of Included Study Characteristics and Findings.</p

Summarized Effects of Resiliency Training in Meta-analysis.

<p>Summarized Effects of Resiliency Training in Meta-analysis.</p

Study flow diagram.

<p>Study flow diagram.</p

Resiliency training program operational framework.

<p>Resiliency training program operational framework.</p

Forest plot of generalized stress-directed resiliency training programs’ effect (SMD) on resilience, divided into subgroups based on whether a well-matched attention control was used.

<p>Forest plot of generalized stress-directed resiliency training programs’ effect (SMD) on resilience, divided into subgroups based on whether a well-matched attention control was used.</p

Effects of Removing Two Studies ([34] and Burton, unpublished) at High Risk of Bias from the Pooled Estimate of Generalized Stress-directed Training Program Effectiveness.

<p>Effects of Removing Two Studies (<a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0111420#pone.0111420-JoAnne1" target="_blank">[34]</a> and Burton, unpublished) at High Risk of Bias from the Pooled Estimate of Generalized Stress-directed Training Program Effectiveness.</p