Effects of a HAPA-based multicomponent intervention to improve self-management precursors of older adults with tuberculosis: A community-based randomised controlled trial

Highlights

• The HAPA-based multicomponent intervention can improve self-management precursors.

• Single health education is less effective than multicomponent intervention.

• Education and comorbidities are associated with self-management precursors.

Abstract

Objective

To evaluate the effectiveness of a multicomponent intervention based on the Health Action Process Approach (HAPA) model to improve the self-management precursors of older adults with tuberculosis (TB).

Methods

A cluster-randomised controlled trial was conducted. Older adults with TB in the intervention communities received HAPA-based multicomponent interventions at the beginning of treatment and in the first and sixth months after treatment initiation, and those in the control communities received health education alone. Self-management precursors were measured at baseline and 1 week after each intervention.

Results

Among 262 randomized patients, 244 (93%) completed the trial. Compared with the control group, self-management precursor scores for the intervention group increased significantly over time (β_group*time = 2.92, p < 0.001) in the following 3 precursors: behaviour belief (β_group*time = 0.35, p < 0.001), behaviour plan (β_group*time = 0.72, p < 0.001), and self-efficacy (β_group*time = 1.85, p < 0.001). Education was significantly associated with behaviour belief (β = 0.18, p < 0.05). Chronic comorbidity was significantly associated with behaviour plan (β=−0.26, p < 0.05).

Conclusion

Compared with single health education, the HAPA-based multicomponent interventions significantly improved the self-management precursor of older adults with TB.

Practice implications

This HAPA-based multicomponent intervention strategy may be a promising self-management mode for the routine health care of TB patients.

Introduction

Tuberculosis (TB) has exceeded HIV as the most lethal infectious disease globally with approximately 10.0 million new cases in 2017. China is one of the 22 countries with a high burden of TB, and the number of new TB cases ranks second worldwide [1]. The World Health Organization (WHO) has reported that the burden of TB in China is shifting to elderly individuals [2]. China has an increasing elderly population that requires more health care resources because their burden of TB also increases.

Self-management is commonly defined as tasks that individuals undertake to manage the medical, role, and emotional management of their health conditions [3]. For patients with TB, self-management entails adhering to medication and treatment, maintaining a healthy diet and the appropriate amount of exercise, maintaining a good mental state, and building personal capacity to navigate challenges and solve problems [[4], [5], [6]]. Positive health outcomes have been demonstrated by self-management programmes for some chronic conditions, including heart failure, diabetes, arthritis, and hypertension [[7], [8], [9], [10]]. However, few studies on self-management among patients with TB have been published. Most studies have focused on only developing mobile or network-based interventions, such as mobile phone short message services, mobile applications, and web portals [[4], [5], [6]]. Many such interventions have not been successfully implemented and adopted within routine health care due to the complexity of telehealth and technical incompetence of the users [11]. Thus, it is necessary to explore more feasible and effective self-management interventions for older adults with TB.

Current self-management interventions for various chronic diseases have been based on different theoretical frameworks that can be divided into continuum models and stage models. In continuum models, the process of health behaviour change is considered continuous, and the goal is for individuals to follow a fixed route toward action, including the theory of planned behaviour, social-cognitive theory, and protection motivation theory [[12], [13], [14]]. However, the traditional continuum models have been criticised for the so-called intention-behaviour gap (ie the failure of intention to predict behaviour) [15]. A model that explicitly includes postintentional factors to overcome this gap is the Health Action Process Approach (HAPA) model. The HAPA model has demonstrated utility in predicting and directing behaviour in a number of health domains, including health screening, physical activity, and medication adherence [[16], [17], [18]], and has been advocated as a framework for designing health promotion interventions [19,20]. Additionally, studies targeting different health behaviours have demonstrated the overall applicability of the HAPA model in distinct samples of older adults [16,21]. These suggest that HAPA theory, a comprehensive and well-tested conceptual model, is suitable to guide self-management interventions for older adults with TB.

The HAPA model suggests that behavioural changes involve 2 phases: a motivational phase and volitional phase [16,17]. In the motivation phase, positive outcome expectations (behaviour beliefs; eg ‘If I take my prescribed medication, TB will be cured’) and confidence in one’s capability to undertake desired behaviours (self-efficacy; eg ‘I am capable of adhering to my prescribed medication regimen even if it is difficult’) are posited to be major influence factors of intention. In the volitional phase, intention must be translated into action through action planning (behaviour plans; eg ‘I plan to take prescribed medication 3 times a day’), influenced by perceived maintenance of self-efficacy [18]. Therefore, according to the HAPA model, behaviour beliefs, self-efficacy, and behaviour plans are 3 vital precursors to the actual self-management behaviours performed. Most researches have not sufficiently focused on self-management precursors. Studies have shown that behaviour beliefs, self-efficacy, and behaviour plans have significant mediating effects between intervention and self-management [22,23]. These 3 self-management precursors are critical targets for self-management intervention. Therefore, we developed a HAPA-based multicomponent intervention targeting self-management precursors and hypothesised that this intervention would significantly improve self-management precursors of older adults with TB.