Self-Care Through Reflection
farm1980
Self-CareArticle.pdf
ABSTRACT
BACKGROUND: There is resurgent interest in the concept and practice of self-care as a means to
improve the health, wellness and wellbeing of individuals, and as an avenue to mitigate financial
pressures and growing demands on health and social care systems worldwide. An ongoing challenge
has been the lack of clarity on the specific nature and entire scope of self-care, coupled to a lack of a
universal or widely accepted framework that could support the conceptualisation and study of self-
care in its totality, in all settings and from different perspectives.
OBJECTIVES: To advance a comprehensive yet pragmatic and widely accessible framework to support
the conceptualisation of self-care in its totality, in order to facilitate the development, commissioning,
evaluation and study of self-care initiatives across a variety of settings.
METHOD AND FRAMEWORK DEVELOPMENT: A pragmatic review of the academic and lay literature
was undertaken to identify extant theories and conceptual models of self-care. Following a content
analysis, the models were characterised, and a configuration matrix was constructed to illustrate the
key components and main themes of each model. These themes were organised into a number of
domains which were grouped together into cardinal dimensions of self-care. The dimensions of self-
care were consolidated in an inclusive framework and visually depicted on a schema to illustrate their
inter-relationship.
RESULTS: We identified a total of 32 candidate models, theories and frameworks of self-care.
Characterising these models led to the identification of various themes and domains. These were
found to naturally group into four cardinal dimensions of self-care: (1) Activities, (2) Behaviours, (3)
Context, and (4) Environment. A new model was synthesised to illustrate the relationship between
each dimension on a configuration matrix resulting in the creation of the Self-Care Matrix (SCM).
CONCLUSION: The Self-Care Matrix (SCM) is a useful framework that can be used to conceptualise
and frame the totality of self-care and its various interlinked elements. SCM is intended for use by all
stakeholders who are interested in the study, development, commissioning and evaluation of self-care
initiatives.
©SELFCARE 2019 38www.selfcarejournal.com
SelfCare 2019;10(3):38-56
A RT I C L E
Advancing the study&understanding of self-care
THE SELF-CARE MATRIX: A UNIFYING FRAMEWORK FOR SELF-CARE
AUSTEN EL-OSTA1*, DAVID WEBBER2, SHAMINI GNANI1, RICKY BANARSEE1, DAVID MUMMERY1,
AZEEM MAJEED1, PETER SMITH3**
1The Self-Care Academic Research Unit (SCARU), Department of Primary Care & Public Health, Imperial College London, UK 2International Self-Care Foundation (ISF), London UK
3The Self-Care Forum UK, London UK
*Corresponding author, **Supervisory author.
Key words: Self-care, Theory, Framework, Conceptual model, The Self-Care Matrix, SCM
INTRODUCTION
The global epidemic of long-term noncommunicable diseases (NCDs) and so called ‘lifestyle
diseases’ observed today is a direct result of our inability to self-care1,2. Consequently, policymakers
and commissioners of health services in England and elsewhere are increasingly looking at self-care
initiatives as a potential means of promoting health and wellbeing in individuals and communities,
whilst reducing costs and demand on scarce national healthcare resources.
There are many potential policies which support self-care activities and the sustained adoption
of positive lifestyle behaviours in everyday life. However, because existing self-care interventions
are usually linked to a general disease area or the management of a specific condition3, there is
scant evidence on the cost-effectiveness of self-care interventions across different settings4-6. An
additional barrier to the widespread adoption of self-care initiatives is the lack of a suitable model
to support the conceptualisation of self-care in its totality, explaining the relationship between self-
care activities and behaviour change in the context of resource utilisation, and how self-care praxis
can be modulated by external forces and the wider environment.
A recent study identified over 136 definitions of self-care7, with various terms including ‘self-
management’, ‘self-efficacy’, ‘self-treatment’ and ‘collaborative care’ often used interchangeably8-10
depending on the correlating theories and the academic field of interest7,11-16. Consequently, various
definitions of self-care have emerged as a result of differing perspectives between healthcare
professionals and the general public, and between health professionals in different disciplines7.
Various instruments have been used to assess proxy measures of self-care capacity and capability17-19,
including the Patient Activation Measure (PAM)20-22. However, health and social support concepts
such as self-care are generally less amenable to direct measurement and evaluation due to a lack of
efficient indicators23-26 and the wide potential range of measurables. Because self-care is intimately
linked to behaviour change theory which merges the fields of sociology and psychology and refers to
a mutation in human health behaviour29,30, any measurement related to self-care, either as a concept
or a set of actions or behaviours, is also dependent on the specific impairment perspective27,28. Thus,
whereas several existing frameworks and models can be used to explore the relationship between self-
care and behaviour change31-48, there is currently no univocal definition of self-care, no instrument
that can measure the totality of self-care indicators directly, and no candidate model or unifying
framework that can be used to explicate self-care in its totality.
Conceptualising self-care
Godfrey identified various models of self-care from the academic literature13, but her seminal
analysis excluded the study of other widely accepted but non-academic conceptual models of self-
care. For example, there exist in the lay literature a number of alternative yet non-mutually exclusive
mid-level descriptions and conceptual models to support the study and application of self-care in
various settings. These include: (1) the widely used Seven Pillars of Self-Care Framework49 which
describes the main activities and elements of self-care relevant to the individual self-carer, and
©SELFCARE 2019 39
THE SELF-CARE MATRIX: A UNIFYING FRAMEWORK FOR SELF-CARE
(2) the Self-Care Continuum50 which describes the placement of an individual along a continuum
of care in the context of resource utilisation. However, neither model from academic or lay
literature was developed specifically for the purpose of conceptualising self-care in its totality, or
could explain the link between self-care activities, behaviour change and resource utilisation in
the context of the prevailing culture and the external environment. The lack of a conceptual and
unifying framework that attempts to capture the totality of self-care may impede the development
and deployment of self-care initiatives in the contemporary setting.
Aim
To characterise and consolidate existing models of self-care theory and practice gleaned from both
academic and lay literature to advance a comprehensive yet pragmatic framework that facilitates
the conceptualisation of self-care in its totality and its study across all settings.
METHODS
Pragmatic review of the literature
A pragmatic review of the literature was conducted to identify published theories linked to self-care
and relevant models and frameworks used to conceptualise self-care across various settings. We
conducted searches based on titles on all relevant databases including MEDLINE; Embase; HIMIC;
Global Health; and PsychINFO through Ovid. The initial search identified 752 publications for the
period 1983-2018. Additionally, we searched on CINAHL, Scopus and Cochrane databases which
revealed 436, 563 and 68 publications respectively. The search in all databases used the terms: self
care, self monitoring and self management to identify the relevant articles. The results of each
category were combined using Boolean terms ‘AND’ and ‘OR’ to narrow down the search findings
after linking with keywords like “model*”, “framework*” and “scheme*”. We also included relevant
models and frameworks gleaned from non-academic literature including websites of various non-
governmental organisations, charities and other entities engaged in the self-care discourse such
as the World Health Organisation (WHO), Kaiser Permanente, the Self-Care Forum UK and the
International Self-Care Foundation.
Characterising self-care models and theories
An initial review of single-disease specific models and frameworks aimed at explaining self-care
theory and praxis was undertaken, which resulted in a list of 631 manuscripts. After scanning
this list, a total of 44 papers were found to pertain to self-care models, frameworks, concepts or
theories. This initial list included various examples of how self-care links with behaviour change
theory (n=12). The latter were excluded, and the final list (n=32) was used to characterise various
aspects of each self-care model.
Framework synthesis
A qualitative content analysis approach was used to identify the key assumptions, characteristics,
themes and domains of self-care pertaining to each model. Further to characterising each model,
©SELFCARE 2019 40
THE SELF-CARE MATRIX: A UNIFYING FRAMEWORK FOR SELF-CARE
we identified a number of themes and perspectives which could be conveniently grouped into
various domains. These domains were found to naturally group together under four cardinal
‘dimensions’ of self-care.
The inter-relationship between each self-care dimension was considered. A visual depiction
of each dimension was juxtaposed on a matrix resulting in a schema of the newly synthesised
framework that could be used to conceptualise self-care theory and practice in its totality. The
resulting unifying framework (the Self-Care Matrix) was assessed for congruence by determining
the extent to which it supported the formal study of self-care as an applied field of research, whilst
providing a logical connection between each dimension.
RESULTS
Characterising existing models and concepts of self-care
Our pragmatic review of lay and academic literature identified a range of perspectives on self-care
in various contexts. We identified and characterised 32 different theories, models and frameworks
that attempted to describe self-care from different perspectives. Table 1 summarises the key points
of the most relevant theories and models of self-care, grouped as either prevention-focused
(n=9), rehabilitation-focused (n=16) or concerned with both prevention and rehabilitation (n=7).
Theories ranged from academic theories illustrating the antecedents (i.e. aspects necessary for the
performance) and the consequences (i.e. results of the performance) of self-care, to more applied
concepts that supported the understanding of self-care in the context of resource utilisation, or
applied interventions for behaviour change in autonomous or assisted care settings.
The four cardinal dimensions of self-care
Content analysis and characterisation of each model resulted in the identification of various themes
and domains of self-care which could be naturally grouped under four dimensions of self-care
(table 2). The four cardinal dimensions of self-care identified were: (1) Self-Care Activities, (2) Self-
Care Behaviours, (3) Self-Care Context, and (4) Self-Care Environment (table 2). Each dimension
pertains to a different aspect of self-care as follows:
1st Dimension: Self-care activities (micro-level: person-centred)
The first dimension is concerned primarily with individual activities, capacities and capabilities,
and what people know and do to self-care. At this micro-level, self-care is considered from a
person-centred perspective. Suitable interventions may be developed to improve and promote
health maintenance, monitoring and self-management of common, every-day or long-term
conditions. The Health Belief Model, Orem’s Self-Care Deficit Nursing Theory51-53, and the
widely used Seven Pillars of Self-Care model54 are suitable candidate models that can be used
to explore this cardinal dimension. The first dimension of self-care is necessarily concerned
with the ‘self ’, is person-centric and activities therein relate directly to what individuals can do
for themselves, as well as the knowledge required to inform suitable self-care choices, such as
health literacy and self-awareness.
©SELFCARE 2019 41
THE SELF-CARE MATRIX: A UNIFYING FRAMEWORK FOR SELF-CARE
2nd Dimension: Self-care behaviours (meso-level: Individual and group focused)
The second dimension is concerned with the principles and actions that support and motivate
individuals to engage in positive self-care behaviours and achieve the sustained adoption of
health-seeking behaviours and lifestyles choices. Interventions operating at this meso-level include
efforts to improve PAM scores, the use of digital health technology including nudges, gamification
an incentivisation strategies to promote the sustained adoption and maintenance of desirable
lifestyle choices and habits. Associated theories include the Middle Range Theory of Self-Care55
which addresses health promoting practices within the context of the management of a chronic
illness. The widely used trans-theoretical model of behaviour change and the Behaviour Change
Wheel48 are suitable candidate models that adequately describe activation and behaviour change
elements relevant to self-care. The second dimension is focused on the individual, but may also
extend to the social network as it describes the prevailing ‘lifestyle’ habits, normative attitudes
and routine interactions with the immediate environment, including interface with technology and
decision support tools.
3rd Dimension: Self-care context and reliance on resources (meso-level: patient-
centred, health system focused)
The third dimension considers the extent to which an individual is reliant on external resources
in the home, community, assisted care or professional healthcare settings. Interventions at this
meso-level are often health system-focused, whereby an individual, a demography or a segment
of society is routinely considered from a ‘statist’ or medicalised patient-perspective as opposed
to a person-centred perspective. Interventions at this level are often concerned with modulating
resource utilisation, including access to services, clinical pathways and/or the extent of
integration of care. The widely used Self-Care Continuum54 and the Kaiser Permanente Pyramid
of Self-Care model56 are suitable candidates for this dimension as they dynamically illustrate the
inverse relationship between individual autonomy and reliance on external resources or need for
increasing support.
4th Dimension: Self-care environment, barriers and drivers to self-care (macro-level:
policy-driven, health system focused)
The fourth dimension is concerned with existing drivers and barriers to self-care in relationship
to the operating fiscal and policy environment, and in the context of the prevailing culture and
normative attitudes that inform self-care praxis in the wider community. This dimension takes into
account the built and natural environment and other mediating factors. At this macro-level, drivers
and barriers to self-care operate at scale or at population level. The fourth dimension is thus related
to the public health landscape and informs the ‘country narrative for self-care’, which is largely
influenced by the prevailing cultural and societal attitudes and perceptions concerned with health
and wellbeing. Suitable candidate models that could be used to study this self-care dimension
include Public Health Theory, Public Management Theory, Public Policy Theory and any existing
Health in All Policy (HiAP) prescriptions, including directives for the built environment.
©SELFCARE 2019 42
THE SELF-CARE MATRIX: A UNIFYING FRAMEWORK FOR SELF-CARE
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io n
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g m
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om
R os
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s H
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B el
ie f
M od
el a
nd P
en de
r’s H
ea lth
P ro
m ot
io n
M od
el . E
m ph
as is
es t
he im
po rt
an ce
o f
se lf-
ca re
p ra
ct ic
es r
el at
ed
to n
ut rit
io n,
p er
so na
l h yg
ie ne
, e nv
iro nm
en ta
l s an
ita tio
n,
in te
rp er
so na
l c om
m un
ic at
io ns
, s pi
rit ua
lit y,
s ex
ua lit
y, e
du ca
tio n,
re
st a
nd r
ec re
at io
n an
d pr
ot ec
tio n
of f
am ily
m em
be rs
.
Th e
m od
el is
b as
ed o
n a
th or
ou gh
li te
ra tu
re r
ev ie
w o
n he
al th
pr
om ot
io n
an d
w el
l- be
in g
in t
he c
on te
xt o
f ag
ei ng
.
A ss
um es
t ha
t th
e fo
un da
tio na
l a sp
ec ts
o f
se lf-
ca re
a re
t he
bu
ild in
g bl
oc ks
o f
ou r
co nc
ep tu
al iz
at io
n of
s el
f- ca
re .
Se lf-
ca re
c an
b e
le ar
ne d
an d
ap pl
ie d
to im
pr ov
e ov
er al
l h ea
lth
an d
w el
lb ei
ng . I
t co
ns id
er s
ho w
s el
f- ca
re m
ay b
e ap
pl ie
d fr
om
di ff
er en
t pe
rs pe
ct iv
es t
o sa
tis fy
p hy
si ca
l, ps
yc ho
lo gi
ca l,
em ot
io na
l, sp
iri tu
al , p
er so
na l,
pr of
es si
on al
n ee
ds .
Ta bl
e 1:
C ha
ra ct
er is
ti cs
o f
32 g
en er
ic t
he or
ie s,
m od
el s
an d
fr am
ew or
ks a
ss oc
ia te
d w
it h
se lf
-c ar
e
Pr ev
en ti
on -f
oc us
ed
43
THE SELF-CARE MATRIX: A UNIFYING FRAMEWORK FOR SELF-CARE
Ta bl
e 1:
c on
ti nu
ed
‡‡ ye
ar M
od el
/ T
he or
y /
Fr am
ew or
k D
es cr
ip ti
on U
se s
Th eo
re ti
ca l b
ac kg
ro un
d /
R at
io na
le
R eh
ab ili
ta ti
on -f
oc us
ed
Th e
m od
el is
a r
ep re
se nt
at io
n of
a p
er so
n’ s
gr ow
th
th ro
ug h
lif e
w ith
a s
pe ci
fic f
oc us
o n
th e
in di
vi du
al ’s
qu es
t fo
r au
to no
m y,
t hr
ou gh
p hy
si ca
l a nd
p sy
ch ol
og ic
al
in te
gr ity
.
Th e
th eo
ry e
xp la
in s
th at
a n
in di
vi du
al r
eq ui
re s
nu rs
in g
– in
ot
he r
w or
ds ‘h
el p’
– w
he n
a se
lf- ca
re d
efi ci
t ex
is ts
a s
a re
su lt
of s
el f-
ca re
d em
an d
ex ce
ed in
g se
lf- ca
re a
ge nc
y.
Th e
m od
el is
a m
od ifi
ca tio
n an
d ex
te ns
io n
of t
he H
ea lth
Be
lie f
M od
el . I
t fo
cu se
s m
or e
on h
ow t
o pr
om ot
e se
lf- ca
re
as o
pp os
ed t
o un
de rs
ta nd
in g
he al
th b
eh av
io ur
c ha
ng e.
A c
on ce
pt ua
l m od
el b
as ed
o n
th e
dy na
m ic
s of
c ar
e w
hi ch
st
em f
ro m
t he
p er
so na
l e xp
er ie
nc e
of d
ev el
op m
en ta
l di
sa bi
lit y.
In fo
rm s
ed uc
at io
na l p
ro gr
am t
ha t
ai m
s to
in cr
ea se
t he
pr
ac tic
e of
s el
f- m
an ag
em en
t ac
tiv iti
es a
m on
g pa
tie nt
s w
ith o
ne o
r m
or e
ch ro
ni c
di se
as es
a nd
/o r
co m
or bi
di tie
s.
C on
si de
rs f
ou r
m od
es o
f se
lf- ca
re d
ep en
di ng
o n
di ff
er en
t co
nd iti
on s
th at
e nt
ai l d
iff er
en t
ac tio
ns a
nd m
ea ni
ng s.
T he
m
od es
in cl
ud e
re sp
on si
bl e
se lf-
ca re
, f or
m al
ly g
ui de
d se
lf- ca
re , i
nd ep
en de
nt s
el f-
ca re
a nd
a ba
nd on
ed s
el f-
ca re
.
Pr ov
id es
a n
ap pr
oa ch
t o
un de
rs ta
nd in
g an
d pr
ov id
in g
se lf-
ca re
s up
po rt
f or
p eo
pl e
w ith
lo ng
-t er
m c
on di
tio ns
.
Ill us
tr at
es t
he li
nk s
be tw
ee n
pe op
le s
uf fe
rin g
fr om
lo ng
- te
rm c
on di
tio ns
t o
th ei
r su
pp or
t ne
tw or
k in
cl ud
in g
he al
th
pr of
es si
on al
s, c
om m
un ity
a nd
v ol
un ta
ry g
ro up
s, n
on -
he al
th p
ro fe
ss io
na ls
a nd
p er
so na
l c om
m un
iti es
.
A c
om pr
eh en
si ve
c on
ce pt
ua l m
od el
t ha
t ar
tic ul
at es
t he
in
di vi
du al
, f am
ily , c
om m
un ity
, a nd
h ea
lth c
ar e
sy st
em le
ve l
in flu
en ce
s th
at im
pa ct
s el
f- m
an ag
em en
t be
ha vi
ou rs
.
G ro
w th
M od
el o
f Se
lf- C
ar e66
Se lf-
C ar
e D
efi ci
t N
ur si
ng
Th eo
ry 51
-5 3
M od
el o
f Se
lf- ca
re in
C hr
on ic
Ill
ne ss
es 67
C on
ce pt
ua l M
od el
f or
C ar
e in
D ev
el op
m en
ta l D
is ab
ili ty
Se
rv ic
es 68
C hr
on ic
D is
ea se
S el
f- M
an ag
em en
t69
M od
el f
or s
el f-
ca re
( of
h om
e- dw
el lin
g el
de rly
)70
W ho
le S
ys te
m In
fo rm
in g
Se lf-
M an
ag em
en t
En ga
ge m
en t
(W IS
E) 71
So ci
al N
et w
or ks
, W or
k an
d ne
tw or
k- ba
se d
R es
ou rc
es f
or
th e
M an
ag em
en t
of L
on g-
te rm
C on
di tio
ns 72
Pa ed
ia tr
ic S
el f-
M an
ag em
en t73
10 11 12 13 14 15 16 17 18
It is
e m
pl oy
ed a
s a
m et
ho d
to e
na bl
e nu
rs es
t o
de ve
lo p
nu rs
in g
ca re
p la
ns b
as ed
on
t he
p at
ie nt
’s ab
ili ty
t o
m ee
t sp
ec ifi
c se
lf- ca
re n
ee ds
.
C an
b e
us ed
a s
a ba
si s
to c
oo rd
in at
e nu
rs in
g ca
re b
y m
ai nt
ai ni
ng n
ur se
-p at
ie nt
re
la tio
ns hi
ps , d
es ig
ni ng
a nd
m an
ag in
g nu
rs in
g ca
re a
nd r
es po
nd in
g to
p at
ie nt
s’
ne ed
s an
d de
si re
s fo
r nu
rs in
g as
si st
an ce
.
Th e
pr om
ot io
n of
s el
f- ca
re a
nd s
el f-
m an
ag em
en t
be ha
vi ou
rs a
m on
g ch
ro ni
ca lly
il l p
at ie
nt s.
Th e
m od
el is
e m
pl oy
ed in
n ur
si ng
c ar
e fo
r th
e tr
ai ni
ng o
f pe
op le
w ith
d ev
el op
m en
ta l
di sa
bi lit
ie s.
C an
b e
us ed
t o
as si
st s
pa tie
nt s
in g
ai ni
ng
sk ill
s an
d co
nfi de
nc e
fo r
ap pl
ic at
io n
on
a da
ily b
as is
f or
t he
p ur
po se
o f
ch ro
ni c
di se
as e
se lf-
m an
ag em
en t.
Th e
m od
el w
as e
nv is
io ne
d as
a w
ay f
or
he al
th p
ro fe
ss io
na l a
nd n
ur si
ng r
es ea
rc h
to u
nd er
st an
d ho
w a
p at
ie nt
’s hi
st or
y an
d vi
ew s
of t
he f
ut ur
e in
flu en
ce h
is /h
er s
el f-
ca re
b eh
av io
ur .
C an
b e
us ed
t o
de ve
lo p
se lf-
ca re
a nd
se
lf- m
an ag
em en
t in
te rv
en tio
ns a
t th
re e
di ff
er en
t le
ve ls
: t he
p at
ie nt
-l ev
el , t
he
pr ov
id er
-l ev
el a
nd t
he w
id er
s ys
te m
-l ev
el .
In fo
rm s
th e
de ve
lo pm
en t
& d
el iv
er y
if se
lf- ca
re s
up po
rt s
ys te
m s
by v
ie w
in g
co m
m un
iti es
a nd
n et
w or
ks a
nd ‘e
xp er
t pa
tie nt
s’ a
s a
ke y
m ea
ns o
f su
pp or
t fo
r m
an ag
in g
lo ng
-t er
m c
on di
tio ns
.
C an
b e
us ed
t o
gu id
e de
ve lo
pm en
t of
ev
id en
ce -b
as ed
in te
rv en
tio ns
t o
im pr
ov e
se lf-
m an
ag em
en t,
a nd
in t
he d
es ig
n of
p ro
gr am
s ai
m ed
a t
pr ev
en tin
g th
e de
ve lo
pm en
t of
p oo
r se
lf- m
an ag
em en
t be
ha vi
ou rs
.
19 83
19 85
19 87
19 89
19 96
19 99
20 07
20 11
20 12
Th e
m od
el e
vo lv
ed f
ro m
a na
ly se
s of
k no
w le
dg e
an d
pr ac
tic e
th at
de
sc rib
e nu
rs in
g ac
tio n.
Ba se
d on
in te
rr el
at ed
c on
st ru
ct s
of s
el f-
ca re
a nd
t he
f ou
nd at
io n
of n
ur si
ng p
ra ct
ic e.
It a
ls o
fo cu
se s
on a
s ys
te m
s ap
pr oa
ch t
o he
al th
ca re
.
Su gg
es ts
t ha
t se
lf- ca
re b
eh av
io ur
s ar
e in
flu en
ce d
by p
re di
sp os
in g
va ria
bl es
( se
lf- co
nc ep
t, h
ea lth
m ot
iv at
io ns
, p at
ie nt
p er
ce pt
io n
of
se rio
us ne
ss , v
ul ne
ra bi
lit y,
e ffi
ca cy
), a
nd e
na bl
in g
va ria
bl es
( pa
tie nt
ch
ar ac
te ris
tic , p
sy ch
ol og
ic al
s ta
tu s,
r eg
im en
s ta
tu s,
c ue
s to
a ct
io n,
so
ci al
s up
po rt
, s ys
te m
c ha
ra ct
er is
tic ).
St em
s fr
om n
ur si
ng p
ra ct
ic e
an d
th e
ev al
ua tio
n of
h ea
lth s
er vi
ce s
pr ov
id ed
t o
in di
vi du
al s
w ith
d ev
el op
m en
ta l d
is ab
ili tie
s. A
ss um
es
th at
t he
n at
ur e
of c
ar e
ha s
a co
ro lla
ry t
ha t
is s
el f-
ca re
, t ha
t is
ap
pl ic
ab le
in b
ot h
ge ne
ra l t
er m
s as
w el
l a s
th os
e te
rm s
sp ec
ifi c
to
th e
fie ld
o f
de ve
lo pm
en ta
l d is
ab ili
ty .
Th e
pr og
ra m
g re
w o
ut o
f th
e A
rt hr
iti s
Se lf-
M an
ag em
en t
Th e
pr og
ra m
is g
ea re
d to
in co
rp or
at e
ed uc
at io
n on
a ll
ch ro
ni c
di se
as es
as
o pp
os ed
t o
ed uc
at io
na l p
ro gr
am s
fo cu
se d
on o
ne d
is ea
se o
nl y.
Ba se
d on
p rim
ar y
re se
ar ch
a m
on g
el de
rly p
op ul
at io
ns , l
ite ra
tu re
re
vi ew
s an
d qu
al ita
tiv e
re se
ar ch
u si
ng a
g ro
un de
d- th
eo ry
ap
pr oa
ch .
Ba se
d on
a w
ho le
s ys
te m
s ap
pr oa
ch t
o se
lf- ca
re .
Th is
a pp
ro ac
h ta
ke s
in to
c on
si de
ra tio
n th
e fo
rm a
nd c
on te
nt o
f so
ci al
n et
w or
ks , n
ot io
ns o
f ch
ro ni
c ill
ne ss
w or
k, n
or m
al is
at io
n pr
oc es
s th
eo ry
a nd
t he
w ho
le s
ys te
m s
in fo
rm in
g se
lf- m
an ag
em en
t en
ga ge
m en
t ap
pr oa
ch t
o se
lf- ca
re s
up po
rt .
It d
es cr
ib es
t he
r el
at io
ns hi
p am
on g
se lf-
m an
ag em
en t,
a dh
er en
ce ,
an d
ou tc
om es
a t
bo th
t he
p at
ie nt
a nd
s ys
te m
-l ev
el t
hr ou
gh
co gn
iti ve
, e m
ot io
na l a
nd s
oc ia
l p ro
ce ss
es .
44
THE SELF-CARE MATRIX: A UNIFYING FRAMEWORK FOR SELF-CARE
Ta bl
e 1:
c on
ti nu
ed
‡‡ ye
ar M
od el
/ T
he or
y /
Fr am
ew or
k D
es cr
ip ti
on U
se s
Th eo
re ti
ca l b
ac kg
ro un
d /
R at
io na
le
R eh
ab ili
ta ti
on -f
oc us
ed (
co nt
in ue
d)
A c
on ce
pt ua
l f ra
m ew
or k
de ve
lo pe
d to
u nd
er pi
n th
e tr
ai ni
ng o
f ce
rt ifi
ed c
om m
un ity
h ea
lth w
or ke
rs t
o de
liv er
h ea
lth c
ar e,
p re
ve nt
iv e
se rv
ic es
, a nd
h ea
lth
ed uc
at io
n fo
r un
de rs
er ve
d po
pu la
tio ns
t o
pr om
ot e
ch ro
ni c
di se
as e
se lf-
m an
ag em
en t.
A dd
re ss
es t
he p
ro ce
ss o
f m
ai nt
ai ni
ng h
ea lth
w ith
he
al th
p ro
m ot
in g
pr ac
tic es
w ith
in t
he c
on te
xt o
f th
e m
an ag
em en
t re
qu ire
d of
a c
hr on
ic il
ln es
s.
Th e
m od
el d
ec on
st ru
ct s
th e
ta sk
s as
so ci
at ed
w ith
ta
ki ng
p re
sc rip
tio n
dr ug
s; in
cl ud
in g
th e
kn ow
le dg
e,
sk ill
s an
d be
ha vi
ou rs
n ec
es sa
ry f
or p
at ie
nt s
to
co rr
ec tly
t ak
e m
ed ic
at io
ns a
nd s
us ta
in u
se o
ve r
tim e
in
am bu
la to
ry c
ar e.
Th is
f ra
m ew
or k
id en
tifi es
k ey
r el
at io
ns hi
ps a
m on
g se
lf- m
an ag
em en
t (p
at ie
nt b
eh av
io ur
s) , h
ea lth
f or
ce
(p at
ie nt
c ha
ra ct
er is
tic s)
, a nd
p at
ie nt
-d efi
ne d
go al
s in
th
e co
nt ex
t of
n ur
si ng
in fo
rm at
ic s.
A f
ra m
ew or
k th
at c
la rifi
es f
ac ili
ta to
rs a
nd b
ar rie
rs ,
pr oc
es se
s, p
ro xi
m al
o ut
co m
es , a
nd d
is ta
l o ut
co m
es o
f se
lf- a
nd f
am ily
m an
ag em
en t
an d
th ei
r re
la tio
ns hi
ps .
It id
en tifi
es k
ey r
el at
io ns
hi ps
a m
on g
se lf-
m an
ag em
en t
(p at
ie nt
b eh
av io
ur s)
, h ea
lth f
or ce
( pa
tie nt
ch
ar ac
te ris
tic s)
, a nd
p at
ie nt
-d efi
ne d
go al
s.
Th is
m od
el u
pd at
es a
nd in
te gr
at es
t ha
t pr
op os
ed b
y R
ic ha
rd a
nd S
he af
. I t
ex pl
ai ns
t he
r el
at io
ns a
m on
g va
rio us
in te
r- re
la te
d co
nc ep
ts s
uc h
as s
el f-
ca re
, s el
f- ca
re a
ge nc
y, s
el f-
m on
ito rin
g, s
el f-
m an
ag em
en t,
s el
f- m
an ag
em en
t su
pp or
t, s
ym pt
om m
an ag
em en
t, a
nd
se lf-
ef fic
ac y
fr om
t he
n ur
si ng
p er
sp ec
tiv e.
Pr ov
id es
a n
in te
gr at
ed f
ra m
ew or
k fo
r un
de rs
ta nd
in g
ho w
p at
ie nt
s se
lf- m
an ag
e al
l a sp
ec ts
o f
ev er
yd ay
li fe
. Su
pp or
ts u
nd er
st an
di ng
o f
se lf-
m an
ag em
en t
by u
si ng
or
ig in
al d
at a
an d
a re
ce nt
c on
ce pt
a na
ly si
s to
p ro
po se
a
un ify
in g
fr am
ew or
k fo
r se
lf- m
an ag
em en
t st
ra te
gi es
.
A P
at ie
nt N
av ig
at io
n M
od el
fo
r C
hr on
ic D
is ea
se S
el f-
M an
ag em
en t
(T ra
ns fo
rm at
io n
fo r
H ea
lth )74
A M
id dl
e R
an ge
T he
or y
of
Se lf-
ca re
o f
C hr
on ic
Il ln
es s
55
H ea
lth L
ite ra
cy -i
nf or
m ed
M
od el
o f
M ed
ic at
io n
Se lf-
m an
ag em
en t75
A P
at ie
nt -f
oc us
ed F
ra m
ew or
k In
te gr
at in
g Se
lf- M
an ag
em en
t an
d In
fo rm
at ic
s76
A r
ev is
ed S
el f-
a nd
F am
ily
M an
ag em
en t
Fr am
ew or
k77
M od
el o
f Se
lf- ca
re a
nd
R el
at ed
C on
ce pt
s14
Th e
Ta xo
no m
y of
E ve
ry da
y Se
lf- M
an ag
em en
t St
ra te
gi es
(T
ED SS
)78
19 20 21 22 23 24 25
C an
b e
us ed
t o
ill us
tr at
e ho
w in
di vi
du al
s co
ul d
ov er
co m
e op
pr es
si ve
c on
di tio
ns
– w
he th
er t
he se
c on
di tio
ns a
re c
re at
ed
th ro
ug h
hu m
an d
es ig
n or
f ro
m s
itu at
io na
l ci
rc um
st an
ce s
– th
at le
ad in
d iff
er en
t w
ay s
to t
he s
ub ju
ga tio
n of
t he
h um
an s
pi rit
.
Fo r
us e
ac ro
ss a
v ar
ie ty
o f
ch ro
ni c
co nd
iti on
s du
rin g
th e
pr oc
es s
of m
ai nt
ai ni
ng
he al
th .
Th e
m od
el c
an b
e us
ed to
re vi
ew a
nd c
rit ic
iz e
cu rr
en t a
dh er
en ce
m ea
su re
s as
w el
l a s
to o
ff er
gu
id an
ce t
o fu
tu re
in te
rv en
tio ns
p ro
m ot
in g
m ed
ic at
io n
se lf-
m an
ag em
en t,
e sp
ec ia
lly
am on
g pa
tie nt
s w
ith lo
w li
te ra
cy s
ki lls
a nd
to
de m
on st
ra te
h ow
c ur
re nt
ly a
va ila
bl e
m ea
su re
s of
a dh
er en
ce a
re in
ad eq
ua te
.
It is
u se
d to
g ui
de c
hr on
ic il
ln es
s se
lf- m
an ag
em en
t in
te rv
en tio
ns t
hr ou
gh t
he
in te
gr at
io n
of s
el f-
m an
ag em
en t
an d
nu rs
in g
in fo
rm at
ic s,
t o
fo cu
s se
lf- m
an ag
em en
t re
se ar
ch a
nd p
ro m
ot e
et hi
ca l,
pa tie
nt -
em po
w er
in g
te ch
no lo
gy u
se b
y pr
ac tic
in g
nu rs
es .
It c
an b
e us
ed in
s tu
di es
a im
ed a
t ad
va nc
in g
se lf-
a nd
f am
ily m
an ag
em en
t sc
ie nc
e an
d al
lo w
f or
t he
d es
ig n
of s
tu di
es t
ha t
ca n
ad dr
es s
m or
e cl
ea rly
h ow
s el
f- m
an ag
em en
t in
te rv
en tio
ns w
or k
an d
un de
r w
ha t
co nd
iti on
s.
It c
an h
el p
nu rs
es , h
ea lth
ca re
p ro
fe ss
io na
ls
an d
co m
m is
si on
er s
of h
ea lth
t o
se le
ct ,
ap pl
y, a
nd a
ss es
s se
lf- ca
re c
ap ab
ili tie
s an
d ca
pa ci
tie s
in a
v ar
ie ty
o f
po pu
la tio
ns a
nd
co nd
iti on
s.
Pr ov
id es
a u
ni fy
in g
ta xo
no m
y th
at m
ig ht
re
so lv
e co
nc ep
tu al
c on
fu si
on w
ith in
t he
fie
ld o
f se
lf- m
an ag
em en
t sc
ie nc
e. It
h as
po
te nt
ia l t
o gu
id e
he al
th s
er vi
ce d
el iv
er y
an d
re se
ar ch
a nd
m ay
h el
p gu
id e
an d
ta ilo
r ca
re if
u se
d as
a m
ea su
re m
en t
fr am
ew or
k.
A ss
um es
d ev
el op
m en
t in
4 p
ha se
s: (
1) c
og ni
tiv e
ph as
e de
ve lo
ps
cr iti
ca l c
on sc
io us
ne ss
, ( 2)
In te
nt io
n ph
as e:
m ot
iv at
io na
l s ys
te m
is
ac tiv
at ed
t o
as se
ss c
ap ac
iti es
f or
t ra
ns fo
rm at
iv e
pr oc
es s,
(3 )
D ec
is io
n ph
as e:
in di
vi du
al a
ct ua
lis es
d ec
is io
ns t
ha t
w er
e m
ad e
to c
ha ng
e an
d m
ai nt
ai n
be ha
vi ou
rs t
ha t
pr om
ot e
ef fe
ct iv
e se
lf- m
an ag
em en
t, a
nd
(4 )
Tr an
sf or
m at
io n
ph as
e: s
el f/
gu id
ed e
va lu
at io
ns y
ie ld
e vi
de nc
e of
ac
tio ns
t ak
en in
di vi
du al
s to
im pr
ov e
pr oc
es s
m an
ag em
en t.
Ba se
d on
t hr
ee a
ss um
pt io
ns : (
1) g
en er
al s
el f-
ca re
a nd
il ln
es s-
sp ec
ifi c
se lf-
ca re
a re
d iff
er en
t, (
2) d
ec is
io n
m ak
in g
re qu
ire s
th e
ab ili
ty t
o th
in k
an d
un de
rs ta
nd in
fo rm
at io
n; a
nd (
3) s
el f-
ca re
a ct
iv iti
es f
or
m ul
tip le
c om
or bi
d co
nd iti
on s
m ay
c on
fli ct
s el
f- ca
re c
on si
de re
d fo
r ea
ch il
ln es
s se
pa ra
te ly
.
Th e
m od
el p
ro vi
de s
a co
m pr
eh en
si ve
e xa
m in
at io
n of
t he
r an
ge o
f ta
sk s
th at
in di
vi du
al s
m us
t su
cc es
sf ul
ly p
er fo
rm t
o m
an ag
e th
ei r
m ed
ic at
io n
re gi
m en
.
Th e
Em po
w er
m en
t In
fo rm
at ic
s fr
am ew
or k
ca n
gu id
e in
te rv
en tio
n de
si gn
a nd
e va
lu at
io n
an d
su pp
or t
pr ac
tic in
g nu
rs es
’ e th
ic al
u se
o f
te ch
no lo
gy a
s pa
rt o
f se
lf- m
an ag
em en
t su
pp or
t. It
u se
s te
ch no
- en
ab le
d se
lf- m
an ag
em en
t in
te rv
en tio
ns t
o pr
io rit
is e
pa tie
nt n
ee ds
.
A s
w ith
t he
o rig
in al
f ra
m ew
or k,
t he
m od
el is
a ss
um ed
t o
be
re cu
rs iv
e in
t ha
t pr
oc es
se s
an d
ou tc
om es
in flu
en ce
f ur
th er
s el
f an
d fa
m ily
m an
ag em
en t.
Tw o
ne w
c on
ce pt
s ar
e ad
de d
to t
he p
re vi
ou s
m od
el , w
hi ch
a re
ex
te rn
al t
o in
di vi
du al
c on
tr ol
b ut
im po
rt an
t fo
r th
e ca
re o
f pe
op le
w
ith h
ea lth
p ro
bl em
s: s
el f-
m an
ag em
en t
su pp
or t
an d
di se
as e
m an
ag em
en t.
T he
y cl
ar ify
t he
d iff
er en
t ro
le s
an d
re sp
on si
bi lit
ie s
of
he al
th ca
re p
ro vi
de rs
a nd
t he
s ha
re d
re sp
on si
bi lit
y
Ba se
d on
t he
p re
m is
e th
at s
el f-
ca re
is a
p ro
du ct
o f
5 G
oa l-
or ie
nt ed
D
om ai
ns (
In te
rn al
, S oc
ia l I
nt er
ac tio
n, A
ct iv
iti es
, H ea
lth B
eh av
io ur
an
d D
is ea
se C
on tr
ol lin
g) , a
nd t
w o
ad di
tio na
l s up
po rt
-o rie
nt ed
do
m ai
ns (
Pr oc
es s
an d
R es
ou rc
e) .
20 12
20 12
20 13
20 14
20 15
20 18
20 18
45
THE SELF-CARE MATRIX: A UNIFYING FRAMEWORK FOR SELF-CARE
‡‡ ye
ar M
od el
/ T
he or
y /
Fr am
ew or
k D
es cr
ip ti
on U
se s
Th eo
re ti
ca l b
ac kg
ro un
d /
R at
io na
le
Pr ev
en ti
on a
nd R
eh ab
ili ta
ti on
f oc
us ed
A s
ys te
m at
ic m
et ho
d to
e xp
la in
a nd
p re
di ct
h ea
lth -
re la
te d
be ha
vi ou
r ch
an ge
. C on
si de
re d
a he
al th
- sp
ec ifi
c so
ci al
c og
ni tio
n m
od el
t ha
t w
as d
ev el
op ed
to
u nd
er st
an d
th e
fa ilu
re o
f tu
be rc
ul os
is s
cr ee
ni ng
pr
og ra
m s
in t
he U
S.
Th e
Se lf-
C ar
e C
on tin
uu m
d es
cr ib
es t
he p
la ce
m en
t of
an
in di
vi du
al a
lo ng
a c
on tin
uu m
o f
ca re
, a ss
um in
g pu
re
se lf-
ca re
o n
on e
en d
of t
he s
ca le
, t o
pu re
m ed
ic al
is ed
ca
re o
n th
e op
po si
te e
nd .
A p
at ie
nt s
eg m
en ta
tio n
an d
st ra
tifi ca
tio n
to ol
il lu
st ra
tin g
th e
po pu
la tio
n su
ita bl
e to
r ec
ei ve
h ea
lth p
ro m
ot io
n an
d pr
ev en
tio n
se rv
ic es
a lo
ng w
ith s
up po
rt f
or s
el f-
m an
ag em
en t
fo r
ch ro
ni c
ca re
p at
ie nt
s, w
he re
as h
ig h-
ris k
pa tie
nt s
re ce
iv e
di se
as e
an d
ca se
m an
ag em
en t.
A c
on ce
pt ua
l m od
el o
f th
e se
lf- ca
re p
ro ce
ss , d
efi ne
d as
m
ai nt
ai ni
ng h
ea lth
t hr
ou gh
t re
at m
en t
ad he
re nc
e an
d sy
m pt
om m
on ito
rin g.
Th eo
re tic
al c
on ce
pt ua
liz at
io n
of s
el f-
ca re
a nd
r el
at ed
co
nc ep
ts in
cl ud
in g
se lf-
m an
ag em
en t,
s el
f- ef
fic ac
y,
sy m
pt om
s m
an ag
em en
t an
d se
lf- m
on ito
rin g.
A v
is ua
l f ra
m ew
or k
th at
d es
cr ib
es t
he m
ai n
el em
en ts
o f
se lf-
ca re
r el
ev an
t to
t he
in di
vi du
al s
el f-
ca re
r. It
a pp
lie s
to p
eo pl
e of
a ll
ag es
a nd
a ll
st at
es o
f he
al th
.
Th is
m od
el c
on si
de rs
t he
n ee
ds o
f pe
rs on
s/ pa
tie nt
s in
t he
c on
te xt
o f
so ci
o- m
ed ic
al e
nv iro
nm en
t ar
ou nd
th
e pe
rs on
’s ne
ed s,
a nd
w ha
t in
te rm
ed ia
te a
nd fi
na l
ou tc
om es
o f
an in
iti at
iv e
co ul
d re
su lt
in im
pr ov
em en
t of
se
lf- ca
re c
ap ac
ity .
H ea
lth B
el ie
f M
od el
( H
BM )37
Th e
Se lf-
C ar
e C
on tin
uu m
49 ,7
9
K ai
se r-
Pe rm
an en
te P
yr am
id 56
,8 0
Si tu
at io
n Sp
ec ifi
c Th
eo ry
o f
Se lf-
C ar
e81
C on
ce pt
ua l M
od el
o f
Se lf-
C ar
e82
Th e
Se ve
n Pi
lla rs
o f
Se lf-
C ar
e49
Th e
in pu
t/ ou
tp ut
m od
el f
or
se lf-
ca re
83
26 27 28 29 30 31 32
It is
t he
m os
t w
id el
y us
ed m
od el
in
th e
de si
gn a
nd e
va lu
at io
n of
h ea
lth
be ha
vi ou
r in
te rv
en tio
ns .
Th e
ai m
o f
th e
co nt
in uu
m is
t o
em be
d se
lf- ca
re in
to e
ve ry
da y
lif e.
U se
d to
p ro
vi de
a d
et ai
le d
an al
ys is
of
c as
e fin
di ng
, r is
k st
ra tifi
ca tio
n an
d po
pu la
tio n
se gm
en ta
tio n
in r
el at
io n
to
re du
ci ng
e m
er ge
nc y
ad m
is si
on s.
U se
d to
m ai
nt ai
n ph
ys io
lo gi
c st
ab ili
ty ,
sy m
pt om
m on
ito rin
g an
d tr
ea tm
en t
ad he
re nc
e th
ro ug
h se
lf- m
an ag
em en
t.
En ab
le s
nu rs
es t
o us
e ev
id en
ce t
ha t
ta rg
et s
sp ec
ifi c
in te
rv en
tio ns
t o
in di
vi du
al iz
e ca
re t
ow ar
d ac
hi ev
in g
th e
m os
t re
le va
nt g
oa ls
.
U se
d as
a p
ra ct
ic al
t oo
l t o
he lp
co
m m
un ic
at e
an d
st ud
y se
lf- ca
re a
s a
m ul
tic om
po ne
nt a
nd in
te r-
re la
te d
se t
of
ac tiv
iti es
w hi
ch c
ou ld
b e
gr ou
pe d
in to
7
pi lla
rs , b
ut a
ls o
vi ew
ed h
ol is
tic al
ly .
W he
n co
up le
d to
a m
an ag
em en
t m
od el
/c yc
le li
nk in
g th
e m
ai n
ob je
ct iv
e,
th e
in pu
t/ ou
tp ut
m od
el f
or s
el f-
ca re
c an
b e
us ed
t o
fo rm
ul at
e po
lic y
re co
m m
en da
tio ns
o n
se lf-
ca re
.
Ta bl
e 1:
c on
ti nu
ed
A ss
um es
t ha
t su
st ai
ne d
be ha
vi ou
r ch
an ge
is d
et er
m in
ed b
y si
x va
ria bl
es , w
hi ch
a re
p er
ce iv
ed b
ar rie
rs , p
er ce
iv ed
b en
efi ts
, p er
ce iv
ed
se ve
rit y,
p er
ce iv
ed s
us ce
pt ib
ili ty
, s el
f- ef
fic ac
y an
d cu
e to
a ct
io n.
Th e
co nt
in uu
m f
ol lo
w s
a ‘li
fe -c
yc le
’ a pp
ro ac
h to
d is
ea se
p ro
gr es
si on
. It
w as
d ev
el op
ed b
y th
e Se
lf- C
ar e
Fo ru
m in
t he
U K
.
Th is
s ta
tis t
to ol
is b
as ed
o n
th e
co nc
ep t
of c
lin ic
al in
te gr
at io
n of
he
al th
p la
n, h
os pi
ta l,
ph ys
ic ia
ns a
nd m
ed ic
al g
ro up
.
In t
hi s
m od
el , s
el f-
ca re
m ai
nt en
an ce
is t
he f
ou nd
at io
n of
e ff
ec tiv
e se
lf- ca
re in
vo lv
in g
sy m
pt om
m on
ito rin
g as
a p
re re
qu is
ite f
or
sy m
pt om
r ec
og ni
tio n,
e va
lu at
io n,
t re
at m
en t
im pl
em en
ta tio
n an
d tr
ea tm
en t
ev al
ua tio
n in
t he
s co
pe o
f se
lf- ca
re f
or lo
ng -t
er m
co
nd iti
on s.
A ss
um es
t ha
t se
lf- ca
re is
t he
m os
t en
co m
pa ss
in g
co nc
ep t,
a nd
t ha
t sy
m pt
om r
ec og
ni tio
n an
d se
lf- m
an ag
em en
t fa
ll un
de r
th e
um br
el la
of
s el
f- ca
re , b
ut t
ha t
w he
n pe
rf or
m ed
b y
he al
th ca
re p
ro fe
ss io
na ls
it
is n
o lo
ng er
e xc
lu si
ve ly
w ith
in t
he d
im en
si on
o f
se lf-
ca re
.
Ea ch
o f
th e
se ve
n pi
lla rs
p ro
vi de
s a
su m
m ar
y de
sc rip
tio n
of lo
gi ca
l se
ts o
f se
lf- ca
re a
ct iv
iti es
a nd
e le
m en
ts , w
hi ch
p ro
vi de
a p
ra gm
at ic
, ho
lis tic
f ra
m ew
or k;
( 1)
K no
w le
dg e
& H
ea lth
L ite
ra cy
, ( 2)
M en
ta l
w el
lb ei
ng , S
el f-
aw ar
en es
s &
A ge
nc y,
( 3)
P hy
si ca
l a ct
iv ity
, ( 4)
H
ea lth
y ea
tin g,
( 5)
R is
k av
oi da
nc e,
( 6)
G oo
d hy
gi en
e, a
nd (
7)
R at
io na
l a nd
r es
po ns
ib le
u se
o f
pr od
uc ts
& s
er vi
ce s.
Th e
m od
el r
el ie
s on
s oc
io -m
ed ic
al e
nv iro
nm en
t an
d se
lf- ca
re
ca pa
ci ty
.
19 56
- 19
74 /
19 79
20 04
20 07
20 08
20 11
20 11
20 14
46
THE SELF-CARE MATRIX: A UNIFYING FRAMEWORK FOR SELF-CARE
Ta bl
e 2:
C ha
ra ct
er is
ti cs
o f
th e
fo ur
c ar
di na
l d im
en si
on s
of s
el f-
ca re
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47
Model synthesis
Figure 1 shows how the four cardinal dimensions of self-care can be juxtaposed on a matrix to
illustrate the relationship between them. In this new conception, the Self-Care Matrix (SCM) is a
synthesis of 32 existing models and frameworks which makes it possible to consider self-care in
its totality (figure 1). The two left panes of the schema congruently describe the level of focus and
the perspective relevant to each dimension of self-care. The schema also shows diagrammatically
how self-care activities, behaviours and activation, and reliance on resources (i.e. dimensions
1-3) are sequentially connected, whereas the self-care environment (i.e. dimension 4) exerts an
omnidirectional influence on all other three dimensions of self-care.
Figure 1: The Self-Care Matrix (SCM)
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THE SELF-CARE MATRIX: A UNIFYING FRAMEWORK FOR SELF-CARE
DISCUSSION
Self-care has been extensively defined and considered by various academic groups and
conceptualised from many different perspectives (table 1). The lack of a unified conceptual
framework that consolidates existing non-disease specific models and theories of self-care has
been a significant barrier to the development of suitable self-care interventions in the contemporary
setting. The strategic global development and adoption of a unified commonly-understood and
widely accepted conceptual model of self-care is desirable and can benefit all stakeholders. It is
also helpful to move towards understanding self-care as an applied field of research as opposed to
framing the concept as a purist academic pursuit.
To this end, we advance a comprehensive yet pragmatic model that supports the conceptualisation
of self-care in its totality, and that can be used by all stakeholders. The proposed Self-Care Matrix
(SCM) signals a new point of departure for self-care thinking that could inform the development,
commissioning and evaluation of self-care interventions.
The proposed Self-Care Matrix (SCM) thus provides a new point of departure for self-care thinking
that could inform the development, commissioning and evaluation of self-care interventions in the
contemporary setting by describing various aspects that could be grouped into four interlinked
dimensions.
Characterising the Self-Care Matrix
Our synthesis consolidated various perspectives gleaned from 32 existing models of self-care and
considered emergent themes and domains which naturally grouped into four cardinal dimensions
(table 2, figure 1). The SCM schema illustrates that each dimension operates at one of three
independent levels (micro, meso and macro-level). Dimensions 1 and 2 of the Self-Care Matrix
consider the individual from a person-centred perspective, while dimensions 3 and 4 frame the
individual or a segment of the population from the medicalised patient perspective or a broader
health system viewpoint.
Self-care involves a wide range of personal activities such as physical activity, healthy eating, good
hygiene and the avoidance of risks such as tobacco and excessive alcohol consumption. Although
it is recognised that these activities are inter-connected, they are often approached ‘vertically’ in
public health programmes and tend to be considered as separate activities. The Self-Care Matrix
thus provides a congruent system which covers all aspects of self-care, offers a logical connection
between them, and creates a framework on which metrics can be based and developed. In this
regard, SCM represents real-world conditions and provides a logical unifying framework for the
individual – and all other stakeholders – to make sense of all the different self-care elements and
their inter-connections.
Strength and limitations
A particular strength of SCM is that it emphasises the inter-relationship between the four dimensions
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THE SELF-CARE MATRIX: A UNIFYING FRAMEWORK FOR SELF-CARE
of self-care. This can help stakeholders identify the various discrete elements that could impact
self-care capacities and capabilities across a wide range of settings and scenarios (e.g. during urban
and environmental planning, or the development of public health initiatives or person-centred self-
care interventions). By way of illustration, many urban planners use Barton & Grant’s Settlement
Health Map84 as their conceptual framework. The Health Map has been widely referenced by the
WHO Healthy City programmes across the world, and is inspired by three sources: (1) theories of
the social determinants of health, (2) principles of human ecology, and (3) an understanding of the
disciplines of planning. The Health Map has clear antecedents in Hancock’s (1985) ‘mandala of
health’85, which linked health to human ecosystems and discussions on the social determinants of
health. Although the Settlement Health Map does not focus specifically on self-care, its concentric
circles of ecosystem, environment, community and lifestyle are entirely consistent with the four
dimensions of self-care expressed in the unifying Self-Care Matrix.
The principal limitation of our new conception is that the various models, theories, and frameworks
of self-care used to synthesise the Self-Care Matrix did not result from a systematic review of the
literature. However, our extensive pragmatic review identified the most widely used and accessible
conceptions of self-care gleaned from academic and lay literature and with reference to statutory
and non-governmental stakeholder groups concerned with the study and advocacy of self-care.
Integrating conceptual models with the evidence base
Because the Self-Care Matrix is a synthesis of existing theories and models, it is possible for
stakeholders to use an evidence-based approach to inform the development of suitable self-care
interventions for application across a wide range of settings. For example, SCM illustrates that the
second dimension of behaviour, activation and change is linked to, but ultimately separate from
the first dimension pertaining to self-care capacities, capabilities and activities. This delineation
makes it possible to integrate the evidence base for behaviour change in a way that fosters the
development of suitable self-care interventions through the application of knowledge from a broad
range of behaviour change theories31,32,36,44,48,86. Interventions at this level may be developed that
activate any number of pillars of self-care represented in the first dimension, whilst for example
using incentivisation and gamification techniques to ensure traction and lead to sustained behaviour
change in individuals represented in the second dimension.
Equally, the integration of the evidence base for the Self-Care Continuum54 represented by the third
dimension in SCM can be supported through a detailed analysis of case finding, risk stratification
and population segmentation. This could help make the economic case for the development and
funding of coherent self-care initiatives aimed at reducing reliance on resources56, and the funding
of social prescribing initiatives and workplace health promotion programmes that seek to promote
the routine adoption of healthy lifestyle habits and health seeking behaviours to improve overall
health and wellbeing.
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©SELFCARE 2019 51
Elucidating the relationship between the wider or external environment and how this can impact
self-care activities and behaviours in a segment of society can help drive fiscal and public health
policy prescriptions that could refocus health systems towards a Health in All Policy (HiAP)
approach87. For example, the WHO final report of the Commission on Social Determinants of
Health concluded that ‘social injustice is killing people on a grand scale’88, and identified key
commonalities between primary health care and the social determinants of health paradigms. This
places a central focus on health equity, which is relevant in all countries and contexts, regardless of
income level, and considers health as more than the absence of disease89. This evidence base can
be used to develop programmes which promote multi-sectoral action and the step-wise adoption
of progressive HiAP and other self-care ‘best-buys’ and policy prescriptions.
The Self-Care Matrix is therefore a suitable tool that could be used to model the impact that
an intervention could have on the various inter-related dimensions of self-care. To exemplify, the
schema shows that an intervention that causes a change in self-care activities (Dimension 1) would
not necessarily precipitate a change in an individual’s reliance on resources (Dimension 3) without
the mediation of factors concerned with activation and the sustained adoption of a desirable
lifestyle habits (Dimension 2). The schema also suggests that a change in the external environment
(Dimension 4) could exert a powerful and omnidirectional influence on all other three dimensions of
self-care. This analysis highlights the importance of resource mobilisation and policy development
work to promote a progressive commissioning landscape which encourages the piloting of suitable
evidence-based self-care interventions in the educational, applied care or community care settings.
Implications for policy makers and researchers
The emergence of long-term NCDs as a major health issue around the world has put the spotlight on
self-care90. Through self-care, people can delay or prevent many chronic diseases such as coronary
heart disease, strokes, diabetes and cancers, in which an unhealthy lifestyle is well established as a
key causative agent91. Many countries have incorporated aspects of self-care into policies through
innovative and notable practices92. However, all countries are a long way from implementing robust
and meaningful policy prescriptions designed to promote individual and population wide self-care
capabilities, whilst shifting professional practices and reorienting healthcare systems towards a
preventative ethos. The development of self-care as an academic subject and as a practical choice
for policymakers and health professionals presents important opportunities for the development of
sustainable policy prescriptions that support a coherent ‘cradle to grave’ approach to national and
international self-care narratives.
SCM can thus be used as a suitable lens by which to evaluate self-care interventions by considering
different components of self-care across four dimensions, and provides a common framework for
the study and development of policy prescriptions for self-care for application in the real-world
setting. Objective evaluation of self-care initiatives using the SCM approach could help foster a
culture of evidence-based commissioning for self-care interventions in the health and wellbeing
space.
THE SELF-CARE MATRIX: A UNIFYING FRAMEWORK FOR SELF-CARE
©SELFCARE 2019 52
Summary & Conclusion
The proposed Self-Care Matrix is a pragmatic and unifying framework that can be used to
conceptualise the totality of self-care and its various interlinked dimensions. SCM can be used as
a lens by which to view, identify, study and evaluate self-care elements in any health and wellbeing
intervention, independent of the disease category or setting. The mid-level descriptions and the
visual schema illustrating the inter-relationship between each of the four cardinal dimensions of
self-care render this model widely applicable and easily accessible to a wide audience, including
policymakers, commissioners of health and all other self-care stakeholders. The Self-Care Matrix
signals a new point of departure for self-care thinking and can be used as a common ground
between all stakeholders interested in advancing the study, practice, development, commissioning
and evaluation of self-care initiatives in the contemporary setting.
Correspondence to: Dr Austen El-Osta, The Self-Care Academic Research Unit (SCARU). Department of Primary Care & Public Health, Imperial College London, 323 Reynolds Building, Charing Cross Hospital, London W6 8RF.
Acknowledgements: Ms Evelina Barbanti (SCARU Research Assistant), Dr Ahmed Alboksmaty (SCARU Research Assistant), Ms Mashael Almadi (SCARU Research Assistant), Ms Farah Masood (SCARU Research Assistant) & Dr Marize Bakhet (SCARU Research Fellow) provided support in data acquisition and analysis.
Contributors: All authors provided substantial contributions to the conception (AEO, DW, SG, RB, DM, AM, PS), design (AEO, PS), acquisition of the data (AEO, EB, AA, MA, FM, MB), and the analysis and interpretation of the pragmatic review (AEO, DW). AEO, DW and PS did the decision making of the framework construction. AEO took the lead in planning the study with support from the co-authors and carried out the data analysis with support from AA, EB, DW and PS. AEO is the guarantor.
Funding: This article presents independent research in part funded by the National Institute for Health Research (NIHR) under the Collaborations for Leadership in Applied Health Research and Care (CLAHRC) programme for North West London. The views expressed in this publication are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care.
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