Patient Education and Counseling 104 (2021) 689–702

Contents lists available at ScienceDirect

Patient Education and Counseling

journal homepage: www.elsevier.com/locate/pateducou

Empowerment-oriented strategies to identify behavior change in

patients with chronic diseases: An integrative review of the literature
Hannah Cardoso Barbosaa , João Antônio de Queiroz Oliveiraa , Josiane Moreira da Costab ,
Rebeca Priscilla de Melo Santosc, Leonardo Gonçalves Mirandab ,
Heloisa de Carvalho Torresd , Adriana Silvina Paganoe,
Maria Auxiliadora Parreiras Martinsa,*
a
Faculdade de Medicina, Universidade Federal de Minas Gerais, Minas Gerais, Brazil
b
Faculdade de Farmácia, Universidade Federal de Minas Gerais, Minas Gerais, Brazil
c
Instituto de Ciências Biológicas, Universidade Federal de Minas Gerais, Minas Gerais, Brazil
d
Escola de Enfermagem, Universidade Federal de Minas Gerais, Minas Gerais, Brazil
e
Faculdade de Letras, Universidade Federal de Minas Gerais, Minas Gerais, Brazil

A R T I C L E I N F O A B S T R A C T

Article history: Background: Chronic diseases in the Americas account for about 80 % (5.2 million) of all deaths.
Received 26 November 2019 Instruments are needed to enhance knowledge, skills, behavior change and self-care attitudes drawing on
Received in revised form 24 December 2020 patient autonomy.
Accepted 11 January 2021
Objective: To identify empowerment-oriented strategies focused on behavioral change in patients with
chronic diseases.
Keywords: Patient Involvement: None.
Health behavior
Methods: This is an integrative review of articles published from any period until June 2020 by journals
Patient education as topic
Power (psychology)
indexed in the following databases: National Library of Medicine National Institutes of Health (PubMed),
Chronic disease Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Biblioteca Virtual em Saúde (BVS).
Self-care Results: Out of 1,287 articles, 25 met our selection criteria. Reported health interventions were based on
Health education self-management and behavior change, shared decisions and a personalized collaborative process, peer
support and self-confidence, as well as strategies involving educational media and health literacy.
Discussion: Over 80 % of health interventions were patient-centered and focused on patient knowledge
and skill development towards personal goal setting, including effective problem-solving strategy
development. Behavior change is not only an outcome of education, but also implicates revisiting values,
attitudes, and experiences. Knowledge is important to facilitate decision-making leading to positive
outcomes in chronic disease management.
Practical Value: Empowerment-oriented strategies are important tools for providing trust and motivation
to people with chronic diseases. Healthcare professionals should support and encourage patient
empowerment as a strategy for behavior change and able to offer qualified care for shared decision
making. Thus, patients will be able to participate more actively in their own health condition
management and to make decisions to promote self-care.
© 2021 Elsevier B.V. All rights reserved.

Contents

1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 690
2. Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 690
2.1. Study design . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 690
2.2. Search strategies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 691

* Corresponding author at: Faculdade de Farmácia, Universidade Federal de Minas Gerais, Av. Antônio Carlos, 6627, Campus Pampulha, Belo Horizonte, Minas Gerais, CEP
31270-901, Brazil.
E-mail address: auxiliadorapmartins@hotmail.com (M.A. Parreiras Martins).

https://doi.org/10.1016/j.pec.2021.01.011
0738-3991/© 2021 Elsevier B.V. All rights reserved.
H. Cardoso Barbosa et al. Patient Education and Counseling 104 (2021) 689–702

2.3. Inclusion criteria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 691

2.4. Exclusion criteria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 691
2.5. Data extraction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 691
3. Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 691
4. Discussion and conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 692
4.1. Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 692
4.1.1. Self-management and behavior change . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 699
4.1.2. Shared decision-making and personalized collaborative process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 699
4.1.3. Peer support and self-confidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 700
4.1.4. Strategies involving educational media . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 700
4.1.5. Health literacy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 700
4.2. Strengths and limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 700
4.3. Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 701
4.4. Practice implications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 701
Funding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 701
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 701

1. Introduction self-care, coping skills, and the individual's ability to achieve

Chronic diseases (CD) have become a serious health problem
[1]. In the Americas, CD are responsible for about 80 % (5.2 million)
of all causes of deaths, many of them being preventable and 35 % of
which being caused by the four main CDs: chronic respiratory
diseases, cardiovascular diseases, cancer, and diabetes [2]. CDs
require a specially adapted approach to both condition manage-
ment and promotion of effective treatment strategies [3]. CD
treatment often involves drug therapy of continuous use for
disease control [4,5], lifestyle changes such as dietary measures,
physical activity and weight loss, in order to reduce mortality and
improve quality of life [1,2,6].
Increase of life expectancy of the population along with
negative changes in lifestyle, poor dietary habits, physical
inactivity and stress have contributed to the growing incidence
of non-communicable chronic diseases (NCCDs), which constitute
a serious public health problem [1,2,7]. Fostering integral care
facilitates behaviors towards improvements in rational use, safety,
and effectiveness of drug therapy [8–10]. In this regard, in March
2017, the World Health Organization (WHO) launched the third
global challenge for patient safety in an effort to reduce serious and
preventable drug-related harm in all countries by 50 % and raise
awareness among patients about the risk associated with the
inappropriate use of medicines [7].
Self-care is considered an integral component of NCCD
management [11], which allows individuals to identify symptoms
and choose better strategies to enhance their healthcare.
Empowerment in chronic conditions refers to the individual's
autonomy to make daily decisions towards self-care, acknowledg-
ing the importance of shared responsibility between patients and
healthcare professionals, whereby the former are responsible for
both their choices and ensuing consequences on healthcare
[12,13]. There is a variety of theoretical frameworks to build on
in empowerment-oriented interventions towards changes in
health behavior. Their objectives are similar, even though the
methods employed are specific. Our study draws on the concept of
empowerment supported by the social cognitive theory proposed
by Bandura, which has been related to behavior change, especially
in people diagnosed with NCCDs [14,15].
Shared decision-making is a patient-centered approach that
encourages the incorporation of the patient into the decision
process along with the healthcare team working together to
elaborate a therapeutic plan [16]. This co-responsibility is the
result of communication between the health professional and
the patient, leading to mutual sharing of information regarding the
chronic condition, which can result in better clinical outcomes.
Empowerment may contribute to an increased sense of control,
behavior changes [14,15,17]. Patient-centered care planning
considers self-management as a fundamental principle for NCCD
control management. Patient-centered care can be enhanced by
empowerment models adopted by health professionals and
healthcare systems [18].
Interventions aimed at promoting healthy lifestyles should be
adapted to the needs of individuals with NCCDs, taking into
account their social, economic, and cultural milieu [18,19]. Further
important factors include health literacy, perceptions, world view,
and personal motivations interfering in the accomplishment of
behavior changes [20]. Previous studies have reported positive
contributions of educational interventions to the treatment of
NCCDs, such as increased patient satisfaction, enhanced knowl-
edge about treatment, improved adherence to drug therapy and,
consequently, a reduction in complications [21–24]. Strategies
fostering behavioral changes and self-care activities trigger better
patient healthcare outcomes [25,26].
One of the challenges for health professionals is to identify
educational practices aimed at individuals with NCCDs to provide
knowledge, skills, and attitudes that promote self-care, consider-
ing the autonomy of each individual [27]. Currently, there is a
shortage of instruments to guide practices with an approach to
empowerment and patient self-care, and health professionals are
not always aware of and mobilized about the importance of this
educational approach [28]. There is a knowledge gap regarding
empowerment-oriented health interventions, which points to the
need to identify strategies designed for patients with NCCDs, using
methods that could improve knowledge, skills, behavior changes,
and self-care attitudes, taking into account the autonomy of each
individual. A comprehensive approach to these interventions may
guide healthcare professionals to help people with NCCDs
develop self-established life goals. Thus, we sought to identify
empowerment-oriented health interventions and their effect on
outcomes related to behavior changes in patients with NCCDs.
2. Methods
2.1. Study design
This study is an integrative review of literature with a
comprehensive methodology differing from other types of
review in that it includes multiple questions or research
hypotheses. It covers both experimental and non-experimental
studies in order to broaden the understanding of the phenome-
na of interest. Moreover, it is a useful tool in the healthcare field
as it reviews scientific evidence from the field of education and
psychology [29].

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H. Cardoso Barbosa et al. Patient Education and Counseling 104 (2021) 689–702

2.2. Search strategies
The steps followed were: identification of the proposed theme,
search for potentially eligible studies, exclusion of duplicate
articles, selection of articles according to inclusion and exclusion
criteria, data extraction, evaluation of selected articles, and
interpretation of results.
The databases used to perform the bibliographic search were
the National Library of Medicine - National Institutes of Health
(PubMed), Cumulative Index to Nursing and Allied Health
Literature (CINAHL), and Virtual Health Library (VHL). The
descriptors were selected from the Health Science Descriptors
(DeCS) of the VHL and MeSH Database. The query was not filtered
by language; nor was a time period set. Retrieved articles were
exported to bibliographic indexing software, and duplicates were
manually removed. Search strategies with the selected descriptors
are depicted in Box 1.
2.3. Inclusion criteria
Our inclusion criterion was articles reporting an approach to
health empowerment interventions aimed at behavior change in
patients with NCCDs focused on patients or healthcare professionals.
2.4. Exclusion criteria
The exclusion criteria were: studies involving a population <18
years of age, studies with animals, studies on sexually transmitted
diseases, and systematic reviews. Studies of protocols that did
not present partial results or qualitative results of reported
interventions were also excluded.
2.5. Data extraction
Data extraction and the selection of articles were performed
separately by two researchers (HCB, RPMS) by reading the title and
summary of each study. Data were compiled using a spreadsheet
editor to identify potentially eligible studies. Discrepancies were
evaluated by a third researcher (LGM). Potentially eligible studies
were read in full and studies in which no intervention results were
identified were excluded. Data extracted from the articles were:
title, year of publication, authors, NCCD targeted, study design,
country, participants’ number and age, and intervention type and
duration.
3. Results
Initially, 1287 articles were found, 25 of which were included in
the final analysis (see Fig. 1).
Studies analyzed by publication period were mostly distributed
between 2016 and 2020 (16; 64.0 %) [28,30–44] (Table 1). Diabetes
mellitus was the most frequent NCCD in the studies (12; 48.0 %)
[28,32,36–38,41,45–50]. The main country of publication was the
United States of America (8; 32.0 %) [30,32–34,36,43,48,51].
Concerning the design of the studies, thirteen were randomized
clinical trials (13; 52.0 %) [28,30–32,36,39,40,42,43,45,48,50,51].

Box 1. Search strategies by database.

Data base, Search strategy

PubMed: ("Chronic Disease" OR "Chronic Diseases" OR "Chronic Illness" OR "Chronic Illnesses" OR "Chronically Ill" OR "Disease,
Chronic" OR "Diseases, Chronic" OR "Illness, Chronic" OR "Illnesses, Chronic") AND (Empowerment OR "Empowerment for Health"
OR "Patient Participation" OR "Activation, Patient" OR "Empowerment, Patient" OR "Engagement, Patient" OR "Involvement,
Patient" OR "Participation Rate, Patient" OR "Participation Rates, Patient" OR "Participation, Patient" OR "Patient Activation" OR
"Patient Empowerment" OR "Patient Engagement" OR "Patient Involvement" OR "Patient Participation Rate" OR "Patient
Participation Rates" OR "Power, Psychological" OR "Personal Power" OR Power OR "Power (Psychology)" OR "Power, Personal" OR
"Powers (Psychology)" OR "Powers, Psychological" OR "Psychological Power" OR "Psychological Powers" OR "Patient Power" OR
"Shared Decision-Making" OR "Patient Self-Efficacy") AND ("Health Behavior" OR "Behavior, Health" OR "Behavior, Health-Related"
OR "Behaviors, Health" OR "Behaviors, Health-Related" OR "Health Behaviors" OR "Health Related Behavior" OR "Health-Related
Behavior" OR "Health-Related Behaviors" OR "Self Care" OR "Care, Self" OR "Self-Care" OR "Health Education" OR "Education,
Health" OR "Self-Control" OR "Control, Self" OR "Regulation, Self" OR "Self Control" OR "Self Regulation" OR "Self-Regulation" OR
"Self-Monitoring")
BVS: ("Chronic Disease" OR "Enfermedad Crónica" OR "Doença Crônica" OR "Casos Crônicos" OR "Doença Degenerativa" OR
"Doenças Crônicas" OR "Doenças Degenerativas" OR "Moléstia Crônica" OR "Quadros Crônicos") AND (empowerment OR
empoderamiento OR empoderamento OR "Empowerment for Health" OR "Empoderamiento para la Salud" OR "Empoderamento
para a Saúde" OR "Patient Participation" OR "Participación del Paciente" OR "Participação do Paciente" OR "Power, Psychological"
OR "Poder Psicológico" OR "Poder Psicológico" OR "Poder (Psicologia)" OR "Poder Pessoal" OR "Patient Power" OR "Shared
Decision-Making" OR "Patient Self-Efficacy") AND ("Health Behavior" OR "Conductas Relacionadas con la Salud" OR
"Comportamentos Relacionados com a Saúde" OR "Comportamento Relacionado com Saúde" OR "Comportamento de Saúde"
OR "Conduta de Saúde" OR "Condutas de Saúde" OR "Self Care" OR autocuidado OR autoajuda OR "Health Education" OR
"Educación en Salud" OR "Educação em Saúde" OR "Educar para a Saúde" OR "Educação para a Saúde" OR "Self-Control" OR
autocontrol OR autocontrole OR "Self-Monitoring") AND (db:("LILACS" OR "IBECS" OR "campusvirtualsp_brasil" OR "BDENF" OR
"BBO" OR "SMS-SP" OR "CUMED" OR "MULTIMEDIA" OR "MedCarib" OR "colecionaSUS").
CINHAL: ("Chronic Disease" OR "Chronic Diseases" OR "Chronic Illness" OR "Chronic Illnesses" OR "Chronically Ill" OR "Disease,
Chronic" OR "Diseases, Chronic" OR "Illness, Chronic" OR "Illnesses, Chronic") AND (Empowerment OR "Empowerment for Health"
OR "Patient Participation" OR "Activation, Patient" OR "Empowerment, Patient" OR "Engagement, Patient" OR "Involvement,
Patient" OR "Participation Rate, Patient" OR "Participation Rates, Patient" OR "Participation, Patient" OR "Patient Activation" OR
"Patient Empowerment" OR "Patient Engagement" OR "Patient Involvement" OR "Patient Participation Rate" OR "Patient
Participation Rates" OR "Power, Psychological" OR "Personal Power" OR Power OR "Power (Psychology)" OR "Power, Personal" OR
"Powers (Psychology)" OR "Powers, Psychological" OR "Psychological Power" OR "Psychological Powers" OR "Patient Power" OR
"Shared Decision-Making" OR "Patient Self-Efficacy") AND ("Health Behavior" OR "Behavior, Health" OR "Behavior, Health-Related"
OR "Behaviors, Health" OR "Behaviors, Health-Related" OR "Health Behaviors" OR "Health Related Behavior" OR "Health-Related
Behavior" OR "Health-Related Behaviors" OR "Self Care" OR "Care, Self" OR "Self-Care" OR "Health Education" OR "Education,
Health" OR "Self-Control" OR "Control, Self" OR "Regulation, Self" OR "Self Control" OR "Self Regulation" OR "Self-Regulation" OR
"Self-Monitoring").

691
H. Cardoso Barbosa et al.
Fig. 1. Systematic search process for literature identification, review and exclusion (adapted from Prisma diagram). From: Moher D, Liberati A, Tetzlaff J, Altman DG, The
PRISMA Group (2009). Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement. PLoS Med 6(7): e1000097. doi:10.1371/journal.
pmed1000097.
More than half of the study interventions were applied in primary
healthcare and community settings (17; 68 %) [28,30–32,36,37,
40–43,46–48,50–53].
Interventions reported in the studies ranged from three days
[33] to 24 months [37,42]. The age of patients in the intervention
groups ranged from 18 to 90 years, and the mean age of
participants was 62.8 years. The number of participants ranged
from seven [53] to 6874 participants [40]. A wide variety of
techniques and tools were used including: games, audio and video
sessions, mobile applications, pamphlets, realistic simulations,
reflexive exercises, patient/caregiver training, peer supporters,
integrative group (theory of self-determination), cognitive behav-
ioral therapy, patient-centered care planning, poetry, guided
imagination, home visit, multiprofessional assistance, psycho-
social and psychoeducational support, positive reinforcement,
coaching telephone calls, role play, quitline cards and focus groups.
Table 1 shows the interventions applied in each study.
The interventions reported in the 25 selected studies presented,
in general, positive effects on the outcomes regarding NCCDs, such
as: enhanced empowerment and patient engagement in healthy
practices; increased treatment adherence and self-management
behaviors; reduction of negative emotional burden and manage-
ment of barriers and feelings; improved quality of life and healthy
habits; improvements in shared decision-making; and, in the case
of diabetes, reduction of glycated hemoglobin levels. The main
changes in behavior were directly related to: incorporation of
physical activity (17; 68.0 %) [28,31,32,34,37,38,40–42,44–47,50–
53]; stress management (17; 68.0 %) [28,31,33,35–39,41,42,44,
45,47,50–53]; healthy eating habits (16; 64.0 %) [28,31,32,34,37–
41,44,46,47,50–53]; improvements in communication skills (16;
64.0 %) [28,31–34,36,37,41–44,48,50–53]; shared decision-making
(13; 52.0 %) [28,31,32,34,36,42,45,45,46,47,50–53]; adherence to
drug therapy (10; 40.0 %) [31,38,41,42,44, 46,47,50–52]; weight
control (8; 32 %) [32,34,40,44,47,50,51,53] and smoking cessation
(8; 32 %) [30,34,35,38,42,43,47,51].
Self-confidence and autonomy were fostered in 23 (92.0 %) of
the selected studies [28,30–49,51,52]. Social support associated
with counseling contributed to motivational inspiration in 12
(48.0 %) of the studies [28,45,48,51,31–34,36,50,52,53]. Over half
of the studies reported interventions using support from
empowered peers [31,34,36–39,42,44,47,48,50,52,53]. Ten (40.0
%) studies adopted interventions focused on personalised care
planning with personal goals [28,32,34,35,40,42,45–48]. Only 4
692
Patient Education and Counseling 104 (2021) 689–702
(16.0 %) studies included patients with poor level of health literacy
[30,32,37,51].
Five (20.0 %) studies had their interventions guided by health
technologies, associating gaming with educational media. The
technologies included a virtual reality anti-smoking game with
destruction of virtual cigarettes [30]; video recordings by actors
impersonating realistic physician-patient interaction seeking to
empower participants to identify their main communication
problems [32]; DVD/CD-ROM with videos of counseling sessions
[43,51], and a digital mobile health application exploring
the impact of wellness, psychological empowerment, and inspira-
tion [35].
Regarding the healthcare team, in eight studies (32.0 %), the
process of care planning was conducted by a multidisciplinary
team [41,42,44,45,47,32,50,52] of community agents, dentists,
physicians, physical educators, psychologists, nurses, speech
pathologists, occupational therapists, acupuncturists, nutritionists
and physical therapists. Nine studies (36.0 %) involved physicians,
nurses, and other health researchers [28,31,33,34,36,38,40,46,51].
Two studies (8.0 %) presented interventions conducted by nurses
[49,53]. Two studies (8.0 %) showed interventions conducted by
pharmaceutical professionals and pharmacy technicians [43,53].
Six studies (24.0 %) comprised interventions aimed at training
health professionals [42,43,46,47,49,51] and 19 (76.7 %) studies at
training patients and caregivers [28,30–41,44,45,48,50,52,53].
4. Discussion and conclusion
4.1. Discussion
Our integrative review showed that interventions aimed at
patient empowerment prove an important strategy in the field of
NCCD management [12–15,17,54,55] because of their potential to
encourage autonomy and trust of individuals in shared decision-
making [28,30–32,35,36,42,45–47,49,51,56]. Empowered patients
can reflect on their contribution to the care process [28,30–32,
34–48,50–53,56–59], collaborate to develop coping and commu-
nication skills [34,37,41–44,48,50–53,59], and develop behavior
changes related to their NCCDs [28,30–36,39,41,42,44–49,51,
56–58]. Once empowered, patients see themselves as experts in
their own lives and therefore act as key decision-makers
throughout their treatment. Patients can manage their own health
conditions, including NCCDs.
H. Cardoso Barbosa et al. Patient Education and Counseling 104 (2021) 689–702

Table 1
Intervention strategies addressed in the studies.

Authors Publication Country Chronic disease Study design Number of Main Intervention Main topics Main findings
year participants intervention setting covered
(male, n; %)
Danet Danet 2020 Spain Diabetes, Descriptive, 964 (182; A peer-led Primary care Emotional Main benefits of the
et al. [37] fibromyalgia and cross- 19 %) training program or management study are
heart failure sectional for improving community Improve communicative and
quantitative chronic patients’ settings communication emotional, allowing
assessment health skills a positive impact on
Healthy eating self-perceived
habits health.
Promoting
physical activity
Peer support
Empowered
peers
Pereira et al. 2019 Brazil Diabetes mellitus Exploratory, 27 (3; 11 %) Individual Primary care Adherence to The study showed
[38] and systemic descriptive interview, open, or drug therapy that people take care
blood pressure and intensive and a community The work of themselves
qualitative semi-structured settings Emotional because of fear of
study management complications,
Promotion of reinforced the need
self-confidence for guidance on the
and autonomy use of medication
Peer support and empowerment
Promoting of the chronic patient
physical activity for self-care.
Monitoring
blood pressure
Stress
management
Healthy eating
habits
Smoking
cessation intent
Bagheri et al. 2019 Iran Parkinson's Randomized 60 (11; 37 %) Family-centered Health Stress The family-centered
[39] disease controlled empowerment by center management empowerment
clinical trial self-control and and hospital Healthy eating model can
adoption of habits strengthen the
preventive Peer support family, as the
behaviors Promotion of fundamental axis of
self-confidence care, to endure the
and autonomy burden of care by
Motor skills focusing on
increasing
knowledge and
awareness and
managing problem-
solving.
Sayón-Orea 2019 Spain Metabolic Randomized 6874 (3406; Nutritional and Primary care Healthy eating Improvements in
et al. [40] Syndrome clinical trial 52 %) Behavioral or habits diet quality, energy
Intervention community Promoting intake, and
settings physical activity cardiovascular risk
Weight control factors were
on Energy- Promotion of observed in an
Reduced self-confidence energy-reduced
Mediterranean and autonomy Mediterranean diet
Diet adherence Personalised group.
care planning
Serpa et al. 2018 Brazil Diabetes mellitus Experience 18 (ND) Group Primary care Adherence to Understanding the
[41] and systemic report conversations, or drug therapy whole person in
blood pressure dynamics, community Glycemic integral care is a
occupational settings control great challenge for
therapy and art Monitoring the health
blood pressure professional to
Healthy eating manage patient’s
habits health and take
Improve responsibility.
communication
skills
Promoting
physical activity
Promotion of
self-confidence
and autonomy
Stress
management

693
H. Cardoso Barbosa et al. Patient Education and Counseling 104 (2021) 689–702

Table 1 (Continued)
Authors Publication Country Chronic disease Study design Number of Main Intervention Main topics Main findings
year participants intervention setting covered
(male, n; %)
Luhr et al. 2018 Sweden Chronic heart Multicentre 118 (62, Self-management Primary care Personalised The intervention in
[42] failure and chronic randomized 79 %) intervention for or care planning this study was
obstructive controlled patients to community Positive assumed to influence
pulmonary disease trial understand and settings reinforcement the patient’s
manage the Improve preferences and
symptoms and communication experiences of
functional skills patient participation
limitations Shared in regular care of the
decision- patient’s long-term
making conditions, but no
Promoting effect was found in
physical activity the study
Adherence to
drug therapy
Smoking
cessation intent
Peer support
Promotion of
self-confidence
and autonomy
Empowerment
of health
professionals
Hudmon 2018 United Smoking Randomized 64 (ND) Training and Community Positive The engagement of
et al. [43] States of clinical trial promoting pharmacies reinforcement the pharmaceutical
America pharmacy-based Smoking professional and
referrals to the cessation intent pharmacy technician
tobacco quitline Improve in brief tobacco
communication cessation
skills interventions were
Promotion of effective and feasible
self- in the community
confidence and pharmacy setting.
autonomy
Empowerment
of health
professionals
Lin et al. [35] 2018 United Alcoholism and/ or Observational 190 (87; Mobile health Mobile Personalised Users whose well-
Kingdom smoking 46 %) application based health care planning being was improved
on cognitive- application Stress through the
behavioral management application were 1.72
therapy Smoking times more likely to
cessation intent stop smoking
Promotion of successfully.
self-confidence
and autonomy
Weigensberg 2018 United Diabetes mellitus Randomized 9 (4; 44 %) Integrative group Primary care Peer support Significant
et al. [36] States of clinical trial based on Self- or Improve reductions in
America Determination community communication perceived stress and
Theory settings skills depression, and
Glycemic increased overall
control well-being relative to
Shared other control
decision- participants.
making Reduction in
Stress perceived stress,
management regardless of the
Motivational intervention group
inspiration and was associated with
counseling reductions in
Promotion of glycated
self-confidence hemoglobin.
and autonomy
Cortez et al. 2017 Brazil Diabetes mellitus Randomized 127 (42; Empowerment Primary care Improve Glycated hemoglobin
[28] controlled 33 %) and self-care or communication levels and other
trial program community skills metabolic indicators
settings Personalised showed significant
care planning differences in the
Shared experimental group
decision- compared to the
making control group.
Stress
management
Healthy eating
habits

694
H. Cardoso Barbosa et al. Patient Education and Counseling 104 (2021) 689–702

Table 1 (Continued)
Authors Publication Country Chronic disease Study design Number of Main Intervention Main topics Main findings
year participants intervention setting covered
(male, n; %)
Motivational
inspiration and
counseling
Promoting
physical activity
Promotion of
self-confidence
and autonomy
Andrade et al. 2016 United Abuse of tobacco Randomized 60 (56; 93 %) Anti-smoking Primary care Smoking The anti-smoking
[30] States of and/ or alcohol clinical trial game or cessation intent based game
America community Promotion of improved the
settings self-confidence participants'
and autonomy immediate intention
Positive and motivation to
reinforcement quit smoking.
Hsiao et al. 2016 Taiwan Advanced renal Randomized 56 (31; 55 %) Empowerment Primary care Adherence to The empowerment
[31] insufficiency controlled and self-care or drug therapy group reported
trial program community Peer support significant increases
settings Improved in both age-based
communication and self-care
skills behaviors.
Personalised
care planning
Shared
decision-
making
Stress
management
Healthy eating
habits
Motivational
inspiration and
counseling
Prevention of
infections
Promoting
physical activity
Promotion of
self-confidence
and autonomy
Positive
reinforcement
Altshuler 2016 United Diabetes mellitus Randomized 80 (ND) Focus group Primary care Improve Participants reported
et al. [32] States of controlled associated with or communication learning specific
America trial realistic community skills ways to change their
simulation videos settings Weight control behaviors (eg, stating
Glycemic their opinions,
control asking more
Personalised questions).
care planning
Shared
decision-
making
Healthy eating
habits
Motivational
inspiration and
counseling
Promoting
physical activity
Promotion of
self-confidence
and autonomy
Positive
reinforcement
Spicer et al. 2016 United Abuse of tobacco Non- 112 (75; Substance abuse Railroad Improved Workers allocated in
[33] States of and / or alcohol randomized 67 %) prevention - industry communication the intervention
America clinical trial interpersonal skills group consumed 56
responsibility and Financial % fewer drinks and
values control consumed alcohol on
Stress 32 % fewer days than
management workers in the
control group.
Changes in smoking

695
H. Cardoso Barbosa et al. Patient Education and Counseling 104 (2021) 689–702

Table 1 (Continued)
Authors Publication Country Chronic disease Study design Number of Main Intervention Main topics Main findings
year participants intervention setting covered
(male, n; %)
Motivational behaviors were not
inspiration and significant.
counseling
Promotion of
self-confidence
and autonomy
Henry et al. 2016 United Cancer Qualitative 29 (23; 79 %) Focal group Health Peer support Barriers to patient
[34] States of targeting healthy center Improved engagement
America behaviors and hospital communication included emotional
skills aspects (e.g., anxiety,
Weight control depression, trauma),
Personalised symptoms (e.g.,
care planning fatigue, pain), lack of
Skin care information about
Shared neck cancer, and
decision- healthcare
making professionals’
Healthy eating authoritarian
habits approach in
Motivational counseling on cancer.
inspiration and Some common
counseling points were found in
Smoking barriers and
cessation intent facilitators according
Dental care to the type of
Promoting behavior.
physical activity
Promotion of
self-confidence
and autonomy
Positive
reinforcement
Miranda et al. 2016 Brazil Fibromyalgia Qualitative 11 (ND) Integrated University Improved Integrated
[44] community communication Community
therapy model for skills
the Stress Therapy (ICT) is an
empowerment of management efficient strategic
people living Healthy eating model for the
with fi habits empowerment of
bromyalgia Promoting people experiencing
physical activity fibromyalgia.
Weight control
Adherence to
drug therapy
Peer support
Promotion of
self-confidence
and autonomy
Emotional
management
Segal et al. 2015 Israel Diabetes mellitus Cohort 27 (19; 70 %) Empowerment of Hospital Glycemic There were no
[49] nurses environment control significant
Promotion of differences in safety
self-confidence parameters. Nurse-
and autonomy guided protocol is
non-inferior to
physician-guided
treatment in efficacy
and safety
parameters.
Battersby 2015 Australia Chronic Pragmatic 231 (54; Program based on Hospital Shared Quality of life for
et al. [45] obstructive randomized 23 %) cognitive, environment decision- people with multiple
pulmonary controlled behavioural, and making chronic diseases can
disease, coronary trial motivational Emotional improve with use of
artery disease, theory and management the Flinders Program.
cerebrovascular practice (Flinders Promoting
disease, chronic Program) physical activity
heart failure, Promotion of
diabetes, and self-confidence
musculoskeletal and autonomy
disorders Personalised
care planning
Motivational
inspiration and
counseling

696
H. Cardoso Barbosa et al. Patient Education and Counseling 104 (2021) 689–702

Table 1 (Continued)
Authors Publication Country Chronic disease Study design Number of Main Intervention Main topics Main findings
year participants intervention setting covered
(male, n; %)
Chan et al. 2014 Hong Diabetes mellitus Randomized 312 (178; Telephone Primary care Adherence to In patients with
[50] Kong clinical trial 57 %) support for or drug therapy diabetes mellitus
trained patients community Peer support who received
(Peer support) settings Improved integrated care, peer
communication support did not
skills improve
Weight control cardiometabolic
Shared risks or
decision- psychological well-
making being.
Stress
management
Healthy eating
habits
Motivational
inspiration and
counseling
Promoting
physical activity
Positive
reinforcement
Eckman et al. 2012 United Coronary artery Randomized 170 (66; Educational Primary care Improved Lower health literacy
[51] States of disease controlled 39 %) intervention or communication was not a barrier to
America trial emphasizing community skills improving disease
knowledge about settings Weight control specific knowledge
Coronary artery Shared and getting patients
disease and decision- empowered.
important life- making
style changes to Stress
improve health management
outcome Healthy eating
habits
Motivational
inspiration and
counseling
Promoting
physical activity
Positive
reinforcement
Adherence to
drug therapy
Weight control
Promotion of
self-confidence
and autonomy
Empowerment
of health
professionals
Smoking
cessation intent
Taddeo et al. 2012 Brazil Diabetes mellitus Qualitative 30 (ND) Empowerment of Primary care Personalised The practice of self-
[46] and systemic users with or care planning care is focused on a
blood pressure chronic diseases community Shared dialogical
settings decision- relationship, in
making which professionals
Healthy eating and patients must
habits understand that
Promoting success depends on
physical activity shared negotiation.
Promotion of
self-confidence
and autonomy
Adherence to
drug therapy
Empowerment
of health
professionals
Rolando et al. 2012 Cuba Obesity, diabetes, Review 114 (n = 26; Empowering of Primary care Personalised The coaching
[47] hypertension and 23 %) the patient with or care planning approach favors
asthma non - community Shared patient collaboration
communicable settings decision- and shared-decision
chronic diseases making making, unlike the
Stress usual approach of the
management authoritarian

697
H. Cardoso Barbosa et al. Patient Education and Counseling 104 (2021) 689–702

Table 1 (Continued)
Authors Publication Country Chronic disease Study design Number of Main Intervention Main topics Main findings
year participants intervention setting covered
(male, n; %)
Healthy eating healthcare
habits professional.
Promoting
physical activity
Weight control
Smoking
cessation intent
Adherence to
drug therapy
Peer support
Promotion of
self-confidence
and autonomy
Empowerment
of health
professionals
Hochhalter 2010 United Arthritis, lung Randomized 79 (27; 34 %) Patient Primary care Motivational Self-efficacy was a
et al. [48] States of disease, heart clinical trial engagement or inspiration and potential predictor of
America disease, diabetes, intervention for community counseling change in patient
hypertension, older adults with settings Improved activation and
depression, and multiple chronic communication health-related
osteoporosis illnesses. skills quality of life.
Peer support
Promotion of
self-confidence
and autonomy
Positive
reinforcement
Personalised
care planning
Twomey et al. 2010 Ireland Multiple sclerosis Qualitative 8 (ND) Fatigue Primary care Adherence to Results identified by
[52] management or drug therapy the participants as
program community Peer support positive were:
settings Improved improved lifestyle
communication and professional
skills changes, change in
Temperature point of view about
control fatigue and the
Shared development of
decision- social support.
making
Stress
management
Healthy eating
habits
Motivational
inspiration and
counseling
Promoting
physical activity
Promotion of
self-confidence
and autonomy
Freeman et al. 2007 United Chronic ulcer Case series 7 (ND) Patient support Primary care Peer support Through nursing
[53] Kingdom group (peer or Improved support there was
support) community communication improvement in self-
settings skills care and lifestyle
Weight control changes to prevent
Skin care recurrence of leg
Shared ulceration.
decision-
making
Stress
management
Healthy eating
habits
Motivational
inspiration and
counseling
Promoting
physical activity

Abbreviation: ND: No data.

698
H. Cardoso Barbosa et al.
Most studies involved patient-centered health interventions
and focused on empowering individuals, developing knowledge
and skills for them to set personal goals, and developing effective
problem-solving strategies [28,31,32,40,42,45–48,56]. Training
healthcare professionals in empowerment approaches contributed
to effectiveness of behavior change in patients, who provided
positive feedback on their active participation in the treatment
[28,32,54,55]. Six studies describing empowerment interventions
involving training of health professionals were reported in Segal
et al. [49] (nurses); Taddeo et al. [46] (physicians, nurses and
community agents); Luhr et al. [42] (nurses and physiotherapists);
Rolando et al. [47] (physicians, nurses, physical therapists, and
dieticians); Eckman et al. [51] (physicians and nurses); and
Hudmon et al. [43] (pharmacy technicians and pharmacists). This
type of training is crucial to achieving an effective standard of care,
using dialog-based, qualified listening, patient-centered, and
personalized education processes.
Most studies pointed out nurses and physicians as leaders of the
care process. This is due to the extensive presence of these
professionals in patient care, mainly in handling NCCDs [49]. Only
two studies discussed the need to promote the reliability of
pharmacists in the educational process regarding drug therapy
[43,53]. Ten articles acknowledged the importance of promoting
medication adherence for the management of CDs
[31,38,41,42,44,46,47,50–52], no highlight being given to the
relevant role of pharmacists in this process though. Studies with
multidisciplinary participation presented an integral vision of
patient care [41,42,44,45,47,52,56]. The performance of a multi-
disciplinary team is particularly important in the treatment of
NCCDs, because of their complexity, which requires diverse
knowledge and practices [18]. In addition to establishing
interdependence among health professionals, multidisciplinary
actions make the care process more effective and collaborative,
allowing for interventions with greater chances of success [60].
Our findings were divided into five main topics, as follows: self-
management and behavior changes, shared decision-making and
personalized collaborative process, peer support and self confi-
dence, and strategies involving educational media and health
literacy.
4.1.1. Self-management and behavior change
Health interventions have the potential to change patients'
behavior, helping them to manage their own disease and achieve
positive health outcomes. These behavior changes are intrinsically
related to changes in lifestyle [59], which include: healthy eating
habits, physical activity into one’s daily routine, and weight loss. In
the study performed by Altshuler et al. [32], patients improved
their skills, such as adherence to a healthy diet and adequate
frequency of glucose monitoring after interventions. Knowledge
about management of one’s own clinical condition leads to
changes in lifestyle, including weight control, physical activity, and
daily monitoring of blood pressure and glucose, thus preventing
deteriorating NCCDs.
Findings by Kremers et al. [59] showed that for behavior change
to be lasting and continuous, long-term intervention programs are
necessary, especially when they target lifestyle. For the evaluation
of weight control programs, an intervention program lasting more
than five years was necessary in order to promote sustainable
behavior change, bearing on the fact that habits become behaviors
as they are recurrently performed. In the study by Rolando et al.
[47] complications of a CD and failure to adhere to treatment are
linked to unhealthy behaviour.
In a systematic review, Soderlund et al. [57] employed the
motivational interview approach, which provided effective and
promising results for the self-management of physical activity in
patients with diabetes. The authors reinforced that to obtain
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Patient Education and Counseling 104 (2021) 689–702
significant results with the use of motivational inspiration,
interventions are best to target small steps in behavior change
and self-management, as major changes in behavior proved to be
less effective.
People with NCCDs play an important role in managing their
own health. However, this role is not always easy, as some of the
tasks involved can be complex and require self-confidence and
skill. Among them are taking medicines properly, monitoring
symptoms, maintaining healthy lifestyles, managing emotions,
solving practical problems, knowing when and how to seek
guidance from health professionals, and dealing with the impact of
the condition on their lives [56,59]. Behavior change does not occur
only through education, but also implicates values, attitudes, and
experiences. Daily knowledge acquisition is essential to promote
behavior that allows for proper maintenance of a clinical condition.
Behavior changes are best implemented immediately after
disease diagnosis, a time when the patient is more likely to
naturally assimilate recommended behavior change. This period is
known as the "learning moment". Another way to enhance patient
engagement for behavior change is to include psychological
stimuli in the intervention as a positive reinforcement [34].
4.1.2. Shared decision-making and personalized collaborative process
Shared decision-making represents the crux of effective
personalized support in the context of NCCDs, where individuals
are often the primary actor and decision-maker about their day-to-
day lifestyle choices and care [61]. Through shared decision-
making, health professionals, especially physicians, can help
patients understand the importance of their values and prefer-
ences in making health decisions. Patients should be educated
about the essential role they play in decision-making and receive
effective health interventions to improve the comprehension of
their options and the consequences of their decisions [62]. The
collaborative process of shared decision-making in patient
care involved dialogical exchange and identification of patients'
difficulties and barriers, definition of a set of goals or individual-
ized strategies to overcome difficulties, stimulation of self-
confidence, action planning, and evaluation of results [28,31,32,
34–36,42,45–48,56,57].
Behavior change may be hindered by barriers related to physical
limitations, lack of knowledge, cultural values, financial restric-
tions, inadequate logistics to obtain care, low motivation and lack
of social and emotional support [63]. Behavior change can be
affected by medical approach and healthcare team. Attentive staff
readily available to listen promotes a confident relationship,
motivating patients to remain engaged in healthy behaviors and
offering health information openly and without judgment [34]. An
authoritarian approach becomes a barrier to behavior change,
since patients have their own choices about their body and their
treatment which need to be considered.
Studies reporting interventions using a personalized collabora-
tive care process proved to be a promising and effective strategy.
They succeeded in achieving significantly better health outcomes
in biochemical tests (glycated hemoglobin [28], blood glucose [56],
lipid profile [28], blood pressure [28,56], and anthropometric
variables (body mass index) [28]). They also showed improvement
in attitudes, empowerment, and self-care behaviors [28,31,53,56].
Cortez et al. [28] and Coulter et al. [56] showed conflicting results.
Although they did not find any effects on cholesterol and body
mass index, they reported achievement of desirable results after
interventions, including glycemia, reduced blood pressure,
improvements in attitudes, self-care behaviors, and empower-
ment. Therefore, it is possible to conclude that the collaborative
process with shared decision-making has a positive potential
for NCCD management. In addition, among the positive and
statistically significant results in Coulter et al. [56] reduction of
H. Cardoso Barbosa et al.
depression symptoms and increased asthma control can be
highlighted.
It is noteworthy that behavior change is only one of the aspects of
empowerment which has a much broader approach also covering
patient participation, patient-centeredness, self-management,
shared decision and self-determination of life goals [64]. The
purpose of empowerment includes the support to help patients
recognizing what is personally meaningful and motivating for them,
and also why they should change their behavior, rather than simply
adhering to healthcare professionals’ recommendations. Use of
empowerment-based strategies should be undertaken in an
environment of a patient-centered approach where the healthcare
professionals take the role of an equal, a partner and guide, not a
leader or a patient’s decision-maker [12,14–17,62,64].
4.1.3. Peer support and self-confidence
Peer supporters having the same health conditions as patients
were trained to become trainers of further patients. The
prerequisites for a good peer supporter were being proactive
and informed, having good management of a chronic condition,
and volunteering [50,53]. Their role is to encourage health
promotion and self-care by sharing positive experiences, providing
suggestions and practical advice, promoting discussion groups,
and supporting behavior change [31,34,36,50,52,53,56,59].
The experiences brought by patients as peers or family
members were well accepted in all studies employing this strategy
[31,34,36–39,42,44,47,48,50,52,53,56,59], bearing on the fact that
peer supporters were themselves patients, had a CD, shared similar
feelings about the disease and the need to perform self-care. The
insertion of family members in patient's care proved important to
improve treatment results [65]. Patients in peer support studies
reported benefits associated with this strategy, as they could
clearly internalize self-care messages and apply them in daily
routines, increasing knowledge about their own health conditions.
Psychosocial aspects also presented positive outcomes reported
by patients, such as improved self-esteem, physical well-being,
reduced anxiety and stress from living with a NCCD, and decreased
feelings of loneliness regarding their health situation. The
strengthening of self-confidence was very well achieved, using
peer support to encourage patients [31,34,36–39,42,44,47,48,56].
Therefore, mutual support and peer support groups are increas-
ingly recognized as an effective alternative to providing psychoso-
cial support.
4.1.4. Strategies involving educational media
Lin et al. [35] defined gamification as the use of elements and
game design in contexts not related to games, including the
context of health. This technique can bridge the original purpose of
a game and its use to help care to improve people's health. The use
of technologies may contribute for behavior change in healthcare.
Articles reporting playful activities as a form of intervention
showed satisfactory results, such as: improved self-confidence,
smoking cessation intent through an anti-smoking virtual reality
game [30], and reports of feeling that patients became more
capable of performing their own healthcare [32].
One challenge to interventions using discussion groups was
mobility issues reported by patients. In a systematic review, Buck
et al. [58] analyzed several interventions into three main groups:
education, support, and guidance. Face-to-face interventions were
prone to become less usual, giving rise to technology-mediated
interventions, as observed over the past 15 years, when
interventions have tended to use technology (e.g. telehealth) in
the management of heart failure.
Chan et al. [50] also proposed interventions to minimize
mobility barriers through telephone contacts by trained patients as
peers. The study targeted diabetes and the results were satisfactory
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Patient Education and Counseling 104 (2021) 689–702
and significant, including reduction in glycated hemoglobin,
reduced number of hospitalizations, improvement in psychic
suffering, adherence to drug therapy, and increased ability to self-
manage a NCCD. Unlike Chan et al., Buck et al. [58] found less
adherence to drug therapy when offering health interventions
with strict targets using phone calls or text messages. Therefore,
strict targets may impact results in studies that adopt technologies.
4.1.5. Health literacy
In low- and middle-income countries, there is a substantial
heterogeneity of socio-educational levels and part of the popula-
tion presents an inadequate level of health literacy. Diabetes is a
NCCD in which patients with poor levels of health literacy may
present poor control of the disease [66]. Health literacy can be
understood as the ability to obtain, process, and understand health
information. Health literacy is related to patients' ability to
interpret symptoms, manage self-care, and make decisions [67].
Several authors have pointed out that a model for NCCD care
can reach effectiveness if patients can understand their disease,
allowing them to feel in control and responsible for their health
condition, and goals are associated with the priorities of the
treatment and lifestyle of patients [28,31,32,35,52,54,56].
In our integrative review, few studies included patients with an
inadequate level of health literacy [30,32,37,51] and the results
varied greatly. The study performed by Andrade et al. [30], which
included people with insufficient health literacy, used qualitative
methods showing that apps development and technologies in the
treatment of patients offered viable and cost-effective alternatives
to improve adherence to healthy behaviors. Similarly, Altshuler
et al. [32] found that health attitudes and behavior were positive
when measured by patients’ self-reports. However, in a review
developed by Kremers et al. [59], health literacy disparities among
participants emphasized the need for development of programs
catering for different social groups. The randomized controlled
study developed by Eckman et al. [51] showed that low health
literacy was not a barrier to improving disease specific knowledge
and getting patients empowered. Coulter et al. [56] found
inconclusive results due to the low prevalence of patients with
limited health literacy in the reviewed studies.
Patient-centered care programs in patients with NCCDs are
advised to assess health literacy before establishing health
interventions. This can prevent patients with an inadequate level
of health literacy to overcome a barrier in the care process.
Characterizing health literacy in a population's study can help
understand the dimensions of knowledge that should be adapted
in the interventions for better patient self-management of
illnesses.
4.2. Strengths and limitations
This integrative review evaluated the main changes in behavior,
as a result of different types of interventions which proved
effective in patients living with high-prevalence NCCDs world-
wide. Empowerment-oriented strategies are important tools to
provide people with NCCDs with confidence and motivation.
Therefore, patients can take over the management of their health
condition and make decisions that promote self-care. The results of
this review support literature findings regarding individualized,
patient-centered interventions being related to improved lifestyle
changes. Moreover, self-management interventions for NCCDs
need to set goals that fit the needs of individuals, age, cultural
factors, health literacy, and psychosocial circumstances [67,68].
Some limitations of this integrative review can be pointed out.
Protocol articles were excluded despite their potential usefulness
to improve knowledge on the design of empowerment-oriented
interventions. The number of studies excluded by this criterion
H. Cardoso Barbosa et al.
may have been significant. Another limitation is leaving out
unpublished studies until the final date of research or studies
published in journals not indexed in the databases used in the
search process.
Most selected studies did not provide a clear description of the
theoretical framework supporting the empowerment approach
and interventions for behavior change. There is room for further
studies investigating the impact of behavior change interventions
supported by different theories, such as self-regulation, habitua-
tion-intention, transtheoretical model, social cognitive theory and
self-determination on specific outcomes in NCCDs (e.g. medication
adherence). In this sense, future investigations applying concepts
of behavioral economics bridging economics and psychology could
also be useful to understand the emotional burden of illness and
the influencing factors on health behaviors. The approach takes
into account the fact that people tend to make non-rational
decisions oriented to the present rather than to the future, which
may compromise the achievement of treatment outcomes [69].
4.3. Conclusions
Most interventions reported by the selected studies were
patient-centered and focused on the empowerment of individuals
with knowledge and skills to set personal goals and develop
effective problem-solving strategies. Health interventions were
promising, showing a significant impact when they were
associated with individualized models focused on the patient
and not on his (her) health condition, and when the care process
included a relationship between professional and patient generat-
ing a shared decision. To this end, healthcare professionals should
support patient empowerment as a strategy for behavior change
and able to offer qualified care for shared decision making.
4.4. Practice implications
The success of shared decision-making requires an adaptive
approach that accommodates patients' level of health literacy and
personal goals. Thus, patients will be able to participate more
actively in their own management of their health condition
and make decisions to promote self-care. Worldwide, health
agencies emphasize the importance of patient involvement in the
management of NCCDs. This is an important topic that deserves
international efforts to address the specific needs of patients with
NCCDs. The findings of this review may contribute to and guide
future studies of health interventions.
Funding
This study was partially funded by the Programa de Pós-
Graduação em Ciências da Saúde: Infectologia e Medicina Tropical
of Universidade Federal de Minas Gerais and by the Conselho
Nacional de Desenvolvimento Científico e Tecnológico (CNPq). HCT
and ASP are fellows of CNPq.
Declaration of Competing Interest
None.
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