Self-management has become a popular term for behavioral interventions as well as for healthful behaviors. This is especially true for the management of chronic conditions. This article offers a short history of self-management. It presents three self-management tasks--medical management, role management, and emotional management--and six self-management skills--problem solving, decision making, resource utilization, the formation of a patient-provider partnership, action planning, and self-tailoring. In addition, the article presents evidence of the effectiveness of self-management interventions and posits a possible mechanism, self-efficacy, through which these interventions work. In conclusion the article discusses problems and solutions for integrating self-management education into the mainstream health care systems.

A structure for representation of patient outcome is presented, together with a method for outcome measurement and validation of the technique in rheumatoid arthritis. The paradigm represents outcome by five separate dimensions: death, discomfort, disability, drug (therapeutic) toxicity, and dollar cost. Each dimension represents an outcome directly related to patient welfare. Quantitation of these outcome dimensions may be performed at interview or by patient questionnaire. With standardized, validated questions, similar scores are achieved by both methods. The questionnaire technique is preferred since it is inexpensive and does not require interobserver validation. These techniques appear extremely useful for evaluation of long term outcome of patients with rheumatic diseases.The goal of the medical care system should be to improve or maintain health outcomes. Donabedian (1) and Williamson (2) have emphasized the need to distinguish between "process" and "outcome" measures in the evaluation of health care. The use of "process" indicators to assess outcome assumes that they relate directly to outcome; this is frequently not the case.Outcome measures, however, must be appropri-

An intervention designed specifically to meet the needs of a heterogeneous group of chronic disease patients, including those with comorbid conditions, was feasible and beneficial beyond usual care in terms of improved health behaviors and health status. It also resulted in fewer hospitalizations and days of hospitalization.

There is evidence that the psychological attribute of perceived self-efficacy plays a role in mediating health outcomes for persons with chronic arthritis who take the Arthritis Self-Management Course. An instrument to measure perceived self-efficacy was developed through consultation with patients and physicians and through study of 4 groups of patients. Tests of construct and concurrent validity and of reliability showed that the instrument met appropriate standards. Health outcomes and self-efficacy scores improved during the Arthritis Self-Management Course, and the improvements were correlated.We describe the development and testing of an instrument to measure patients' perceived self-efficacy (SE) to cope with the consequences of chronic arthritis. The need for such an instrument arose in the course of studying the effects of the Arthritis SelfManagement Course (ASMC). When evaluated in randomized studies, subjects who took the ASMC were found to have less pain and to be more active than controls (1). These results persisted, albeit attenuated, for 20 months after the course, without reinforcement. However, when the data were examined for anticipated associations between changes in behavior (ex- ercise, relaxation, and walking) and changes in health status (pain, disability, and depression), the expected associations were weak or were absent (2).These unexpected findings precipitated an interview with the participants and evaluation of their experiences in the course. Fifty-four participants were asked why they found the course helpful or not helpful. For half the people interviewed, pain and/or disability had decreased; for the other half, pain and/or disability had not changed or had increased. The former group attributed their benefits to an increased sense of influence over the consequences of arthritis; the latter group believed that they could do little to improve their situation (3).The findings from these interviews indicated that a sense of one's personal ability to affect the consequences of disease was strong in some subjects and relatively weak in others, and interacted with the course to create the health outcomes. This sense of ability to effect change (akin to confidence) is similar to the psychological concept of perceived SE (43). In a preliminary study using early instruments to measure perceived SE to cope with the consequences of arthritis, we found statistically significant correlations between perceived SE and health status (ref. 6 and unpublished observations). We therefore sought to develop a reliable and valid instrument for measuring perceived SE.Perceived SE, as postulated by Bandura (4), is one's belief that one can perform a specific behavior or task in the future. It refers to personal judgments of performance capabilities in a given domain of activity.Although it is related to other psychological concepts, such as locus of control, learned helplessness, and self-esteem, it differs in that it is behavior-specific.