SOC.Sci. Med. Vol. 29, NO. 2. pp. 213-219. 1989 0277-9536189$3.00 + 0.

00
Printedin Great Britain. All rights reserved Copyright c 1989 Pergamon Press plc

A CLINICAL TRIAL OF A SELF-CARE APPROACH

TO THE MANAGEMENT OF CHRONIC HEADACHE
IN GENERAL PRACTICE
2* BARRYFATOVICH,~RAY JAMES’ and
ROBINWINKLER,‘+ PETERUNDERWOOD, DENNIS GRAY’
‘Clinical Unit, Department of Psychology, University of Western Australia, Nedlands, 6009, Western
Australia, 2Department of Community Practice, University of Western Australia, Nedlands, 6009,
Western Australia and )Health Commission of New South Wales, Box 118, Byron Bay, 2481, New South
Wales, Australia

Abstract-This paper reports a trial which assessed the clinical effectiveness of adding a behavioural
self-management programme to the existing management of chronic headache by general practitioners
(GPs). Eighty-seven chronic headache sufferers, referred to the study by 35 GPs, were randomly allocated
to either a self-care group or a GP-control group. Headaches, drug usage, visits to health-care providers
and time off work were self-monitored daily by all subjects for 4 weeks prior to intervention, for 4 weeks
during intervention, and for 4 weeks immediately after intervention. Additionally, self-monitoring was
carried out for two further 4-week periods, one at 6 months and one at 12 months post intervention.
Headache records showed that the self-care program significantly enhanced GP management. This effect
was well maintained. However, drug usage, visits to health-care providers and time off work did not differ
significantly between the treatment and control groups. ‘No-show’ rates, defined as those referred by a
GP but who did not attend, were high-largely due to time requirements of the self-care program.
However, drop-out rates, defined as those who left the self-care groups were low. It was concluded that
this behavioural self-management program was a clinically effective adjunct to general practice manage-
ment of headache but its use is likely to be limited due to problems of patient enrollment.

Key words-self-management, chronic headaches, compliance, general practice management

INTRODUCTION behavioural self-management programme adminis-

tered by a psychologist, with those being treated by
It has been claimed that self-care approaches repre-
their GP. Recently, Kiely and McPherson [2] re-
sent a solution to several topical problems of contem-
ported a study comparing patients who had received
porary medicine including iatrogenic illness, excessive
a self-administered stress package at GP consultation
reliance on medical expertise, and rising health-care
with those who had received a GP consultation alone.
costs. There have, however, been few empirical
While Earl1 and Kincey’s study failed to show any
studies of the clinical effectiveness of self-care ap-
benefit from the self-management programme, Kiely
proaches in the management of common disorders.
and McPherson’s study showed some reduction of
In part, this is due to the vagueness of self-care
both symptoms and consulting rates in those who had
concepts and procedures. However, the self-manage-
used the package. However, Kiely and McPherson’s
ment procedures developed within behaviour modifi-
conclusions need to be viewed with caution since
cation and behavioural medicine, such as relaxation
their study suffered from several methodological
and biofeedback, are clearly specified and have been
weaknesses and was based on very small numbers of
used extensively in the management of a wide range
patients.
of common medical disorders with positive effects.
Other relevant studies have compared psycho-
Unfortunately, however, these procedures have
therapy with GP consultation. These have also pro-
generally been used by psychologists in specialist
duced conflicting results. Brodaty and Andrews [3]
clinics and have rarely been compared to the
found brief psychotherapy produced no significant
effectiveness of existing medical procedures among
advantage compared with GP management of anxiety
patients from mainstream medical settings. This is
states. However, Espie and White [4] suggest that,
particularly so in the setting of primary care, where
particularly with regard to anxiety and stress dis-
the common, chronic disorders often dealt with by
orders, psychotherapy and psychotherapists can
behavioural self-management procedures typically
produce some significant clinical improvement in
first appear. patients referred by GPs.
Only two studies have compared psychologically
Different study methods, case selection, and cri-
based self-management therapies with primary care.
teria for improvement may explain much of
Earl1 and Kincey [1] compared patients attending a
the conflicting evidence. Moreover, all these studies
examined patients suffering from more general stress-
*Since the completion of this study, the principal investi- related disorders: it is possible that self-management
gator, Robin Winkler, died of a serious illness. programmes work well in primary care with some but
*To whom correspondence should be addressed. not with all disorders.

213
214 ROBIN WINKLER et
The present study focused on one class of dis-
order+hronic headaches. Headache was chosen as
the specific disorder to be studied because, (1) it is a
common complaint in primary care, (2) it is a chronic
disorder and therefore a self-care approach may be
particularly useful, (3) behavioural self-management
procedures have been developed for chronic
headache, (4) the authors had developed an effective
behavioural self-management programme [5]. A de-
scription of this program is given in greater detail
below. Here it is relevant to note that the programme
had been developed at the Clinical Unit of the
Department of Psychology at the University of
Western Australia over a period of 5 years, that it is
dependent upon regular group meetings of sufferers
led by a trained facilitator, and that the package
produced well-maintained clinical improvement com-
pared to placebo in terms of headache frequency and
intensity.
The first goal of the study was to determine
whether a behavioural self-management programme
for chronic headache, when added to present man-
agement practices in primary care, would provide an
additional clinical benefit. Previous studies have
framed their basic question as a comparison of
self-management versus primary care. Since in
the present study patients were not prevented from
seeing their family physician, it is more accurate to
phrase the basic question in terms of an addition to
existing treatment. Two further important questions
asked were: (1) would the additional procedures
produce an increase in patients’ confidence in dealing
with headaches through their own efforts?; and
(2) would there be a reduction in costs to the health
care system from these clinical and attitudinal
changes? If these questions are answered
affirmatively, then it can be argued that, for this
disorder, a self-care approach in primary care is
clinically effective, promotes a self-care attitude and
reduces costs.
In addition, it was felt necessary to address a
further set of questions to do with acceptance of the
self-care procedures by patients and doctors in pri-
mary care. Unlike many of the traditional procedures
used in primary care, self-care procedures require
additional time, effort and commitment from par-
ticipants. How will patients attending primary care
settings accept these demands. particularly when
measured in terms of participation and attendance?
In part, the answer to this question depends on such
factors as programme availability, the physician’s
attitude to self-care programmes, his or her willing-
ness and ability to refer, and the encouragement the
physician gives to the patient. In short, this study
examined both the effectiveness and acceptance of a
specifically focused self-care programme in a primary
care setting.
METHOD
This study depends upon a comparison between
two groups, patients attending a GP and also under-
taking a specific supervised self-care programme, and
a control group comprised of patients attending a GP
alone.
al
Self-care programme
The self-care programme was a structured, time-
limited programme emphasizing active patient par-
ticipation using stress management techniques in a
small group setting. It consisted of 10 sessions of
90min each, held twice weekly, with groups of 5-8
participants. The underlying theme of the programme
was ‘self-care’. It focused on two broad aspects of
self-care: first, teaching patients skills for use in the
control of headache episodes when they occurred
(relaxation training and cognitive restructuring) and,
second, the management of lifestyle factors that
precipitated or aggravated headache episodes (e.g.
assertion training and cognitive restructuring). The
groups also provided some social support for
patients. Facilitation of these goals was aided by
the headache diaries kept by the participants and by
the sharing of headache experiences in the group
discussions. The programme followed a detailed
manual [6] which is available from the authors.
To demonstrate the methods of the programme.
the following briefly describes a typical group at
work.
This group, consisting of 8 persons, met at 8 p.m. for the
third time at a local health centre. The facilitator (a health
educator) welcomed the group and invited patients to speak
of their headache experiences. As individuals responded,
other participants contributed, and particular problems
were brought up and discussed. Typical problems were
lifestyle factors (not enough time to take relaxation) or
non-assertiveness (having to make dinner with a headache)
which were handled by positive advice from the facilitator
and group. Next, group members examined their diaries
with particular reference to positive preventive activities.
The meeting concluded with a relaxation session
Design
Thirty-one GPs referred patients to the project.
Inclusion criteria were: (1) patients had suffered two
headaches per month for at least one year, (2) GPs
considered the headaches were made worse by stress,
(3) patients had no cervical osteoarthritis or whip-
lash, and (4) patients were willing to be contacted by
the university.
When GPs noted that patients met the study
criteria, the patients were asked whether they would
be prepared to enter a ‘community study investi-
gating headache’. If they were agreeable, the patient
names were then given to the researchers. Once a
sufficient number of patients had been obtained from
a geographical region (an area where, logistically, a
group of patients could get together), they were
randomly allocated to either an experimental group
(GP and self-care programme) or a control group
(GP and self-monitoring). No distinction was made
between tension and migraine headache in allocation
to experimental conditions since there is evidence
regarding the difficulty in distinguishing between the
two syndromes [7] and our previous research had
found both types of headache responded equally well
to the self-care programme [5].
The project team then contacted the patients to
invite participation. Those in the self-care condition
were then invited to attend a meeting at which a
self-care programme for headache was to be de-
scribed. Those in the GP-control condition were
 A self-care approach to chronic headaches in general practice
invited to attend a meeting at which they would be
asked to participate in a university research project
on headache which would involve daily monitoring.
Seven comparisons of self-care and GP-control con-
ditions were completed. In each comparison, patients
were free to attend their GP when they wished; thus,
care by GPs was common to both experimental
conditions.
Measures
Three outcome measures were used: (1) frequency,
intensity and duration of headache episodes (head-
ache activitybthe method of recording followed that
of Budzynski et al. [S], whereby patients kept daily
symptom diaries; (2) self-efficacy in controlling head-
ache symptoms and stress; and (3) cost of drugs and
visits to health-care providers. Results of each of
these three measures were analysed separately. The
main measure used was headache activity which was
averaged for the 4-week period of baseline, the last 4
weeks of the treatment period, the first 4 weeks post-
treatment, and for 4 weeks each at 6- and 1Zmonth
follow-up. Following Bandura [9], self-efficacy in
controlling headache symptoms and stress was
measured by asking patients to rate their confidence
(O-100%) in preventing, aborting and limiting
headache pain of defined intensities through their
own efforts, without drugs. The six-item self-efficacy
measure was given at the beginning of the baseline
period, at the end of 4 weeks after treatment, and at
6- and 1Zmonth follow-up. Confidence ratings on the
six self-efficacy items were totalled, as the items
correlated positively with each other and factor
analysis showed they were represented by a single
factor.
The patients recorded drugs taken (name and dose)
on a daily basis. To compute drug costs, drugs were
divided into anti-migraine drugs and others (pre-
dominantly analgesics). Costing of drugs was carried
out by a pharmacist and was calculated in terms of
cost to the Commonwealth Department of Health
and cost to the consumer. Some drugs are subsidized
by the government and some not. Drugs not covered
in the schedule of Pharmaceurical Benefits [lo] are
paid for in full by the consumer. Subsidized drugs
have a standardized price to the consumer, e.g. the
consumer may pay $4.00 (1983 price) for 100 tablets
of propranolol whereas the actual cost is $8.23. The
Department of Health reimburses the pharmacist
$8.23 minus $4.00, $4.23. This includes a dispensing
fee. Cost to the consumer for 100 tablets of pro-
pranolol if $4.00 and to the Health Department
$4.23. Drug costs were calculated in terms of the
amount consumed and not the amount purchased,
which was likely to be a larger figure. Visits to doctors
were costed using the Medical Benejits Schedule Book
[ 111published by the Commonwealth Department of
Health. This publication lists the refundable cost of
physician visits (GP, specialist, home visit) and
though less than the Australian Medical Associ-
ation’s recommended rates covers most of the visit
costs to the patient. Visits to other health providers
were costed according to the rate of a standard return
visit to a physiotherapist, since physiotherapists were
the most commonly used health providers after phys-
icians. Other providers consulted included nurses and
215
chiropractors. Fee variations among these various
providers are considerable and those charged by
physiotherapists were a conservative basis for cost
estimation.
The main statistical procedure used in the analysis
of results was analysis of variance. Analysis of
variance is a technique “that assesses the effects of
one or more categorical independent variables.. . ,
measured at any level upon a continuous dependent
variable . ” [lo]. Essentially, this is achieved by
comparison of group means to determine the proba-
bility that the groups were drawn from the same
population. In ‘n-way’ analysis of variance the main
effect of particular independent variables can be
assessed, as can their interactive effect. In this
study the major dependent variables were headache
activity, self-efficacy, and cost, and among the inde-
pendent variables were treatment type and occasion
of assessment.
RESULTS
Complete data from pre- to post-treatment period
was available for 87 patients (self-care, n = 42; GP-
control, n = 45). The mean age of those in the
self-care condition was 4OSyr (SD 13.5) and for
those in the GP-control condition, 38.2 (12S)yr.
Women outnumbered men in both conditions. There
was no significant age or sex difference between those
in the two conditions.
Data are presented in three categories: headache
activity, confidence in controlling headaches by
own efforts, and costs. The major criterion used for
clinical improvement was change in total headache
activity, as indicated by the composite measure of
frequency, intensity and duration.
Headache activity
In both experimental and control groups, headache
activity was first analysed for the Cweek baseline
period, the last 4 weeks of the treatment period and
the 4 weeks immediately after the treatment period.
Analysis of variance for the 87 subjects with complete
data showed no main effects for groups (F = 0.23,
P > 0.05), a significant main effect for occasions
(F = 21.62, P < 0.01) and a significant interaction
effect (F = 3.64, P < 0.05). These results indicate that
while the sample as a whole improved significantly,
through time those in the self-care condition im-
proved significantly more than those in the GP-
control condition.
At 12 months, complete data was available for 60
subjects (self-care = 33, GPtontrol = 27). Figure 1
shows headache activity for both conditions for these
subjects at each of the five 4-week recording periods.
Analysis of variance again showed no main effect for
groups (F = 0.99, P > 0.05), a significant main effect
for occasions (F = 11.50, P < 0.01) and a significant
interaction effect (F = 2.74, P < 0.05). Again, these
results show that the sample as a whole significantly
improved through time, but those in self-care con-
dition improved significantly more than those in the
GP-control condition. For six of the seven self-care
groups conducted, GP management plus self-care
reduced headache activity more than GP manage-
ment alone. Furthermore, more patients improved
216
f costs (twice as much or more from baseline onwards).
01 I I I I
d Baseline Treatment Post-
Treatment
6mQnths
Fig. 1. Headache activity at 12-month follow-up.
and fewer patients became worse in the
groups. In addition, patients were divided into those
experiencing < 50% improvement and those > 50%,
using the percentage change over base line, divided by
baseline data at the 12-month follow-up. Chi-square
showed significantly more patients improved by
50% or more in the self-care condition than in the
GP-control group (x2 = 7.64, P < 0.01). These results
indicate the substantial clinical effects of the self-care
groups. Analysis of variance indicated there was no
differential improvement for age or sex in either
treatment condition.
Patients’ self-assessments
Self-efficacy questionnaires were complete for five
of the seven groups, prior to treatment and at 4
weeks, 6 months and 12 months post-treatment.
Analysis of variance of self-efficacy for headache at
pre- and post-treatment (self-care n = 26; GP-control
n = 22) showed no effect for group (F = 0.01,
P > 0.05), a main effect for occasions (F = 27.43,
P < 0.01) and a significant interaction effect
(F = 19.67, P < 0.01). Subjects in both conditions
improved over time. but those in the self-care con-
dition improved significantly more.
Complete data was available for 17 patients in the
self-care condition and 9 in the GP-control condition
at the 12-month follow-up. Analysis of variance
showed a significant improvement in headache self-
efficacy for the sample as a whole over occasions
(F = 6.25, P < 0.01) and a significant interaction
(F = 3.26, P c 0.05). indicating greater improvement
for the self-care condition.
Patient also assessed their improvement in
headache activity at the If-month follow-up. Those
from the self-care groups rated their headaches as
significantly more improved over the previous year
than did those from the GP-control groups.
Changes in self-efficacy for headache scores (base-
line minus follow-up divided by baseline) were corre-
lated with drug-taking during the follow-up period in
order to determine whether increases in confidence
about ability to control headache symptoms without
drugs were accompanied by less taking of drugs
(defined by number of doses, all drug types com-
bined). At the 6-month follow-up, there was an
expected negative correlation (-0.44. P < 0.01) but
at the 12-month follow-up, the negative correlation
was not significant (-0.17, P > 0.05).
ROBIN WINKLER er al.
costs
Costs were assessed in terms of drug consumption
and visits to healh-care providers. Drug costs were
calculated in terms of cost to the Commonwealth
Department of Health and cost to the consumer from
each 4-week record from baseline to the 12-month
follow-up. Despite the random allocation, analysis of
variance showed that there was a significant effect for
groups indicating that subjects in the GP-control
condition from baseline to follow-up had higher drug
I
This was the case for government (F = 4.50,
12months
P < 0.01) and consumer (F = 4.11. P < 0.01) costs.
Only consumer costs changed significantly over the
five periods (F = 2.60, P < 0.05). But this was for the
sample as a whole. There were no differences in
self-care
changes in costs as a function of treatment condition.
Costs of visits to health-care providers (GPs,
specialists, others) were assessed in terms of visits for
headache and all visits using data from each 4-week
record from baseline to IZmonth follow-up. The
chronic patients in this sample did not make many
visits to health-care providers and there was consider-
able variation in visits made. Analysis of variance
showed only that cost of all visits combined over
provider and reason for visit declined significantly
over the year for the sample as a whole (F = 3.28,
P < 0.05).
No-shows and dropouts: patient acceptance
It is possible that patients who were referred to the
study and invited to participate, but did not do so,
may have introduced significant bias into the results.
To assess this and to assess the acceptability of
self-care in general practice the question of attrition
was investigated. Those who were referred to the
project but who did not participate until completion
were divided into two groups. Patients in the first
group were termed ‘no-shows’. These were patients
who were referred to the project, received a letter of
invitation and were phoned twice but did not attend
an initial organizational meeting. Patients in the
second group were called ‘dropouts’. Dropouts in-
cluded both: those who were present at an orientation
meeting but who did not attend or supply data
subsequently; and those who attended an orientation
meeting, attended at least one subsequent meeting
or supplied some data, but did not complete the
programme.
The number of no-shows and dropouts from each
experimental condition are presented in Table 1. It
can be seen that, (1) the number of no-shows was
high, (2) dropout rates were higher during baseline
for the self-care condition, (3) dropouts after the first
self-care group session were rare, (4) dropout rates
for the GP-control group were higher after the
beginning of the treatment period, primarily due
to the relative lack of contact with this group
(they were contacted by mail and telephone follow-
up, only when recording was required). There were
no significant differences in the dropout rates for
men and women or for patients of differing ages.
Dropout rates were not affected by the socio-
economic characteristics of the areas in which the
GPs practiced.
 A self-care approach to chronic headaches in general practice 217

Table I. No-shows and dropouts from self-care and GP controls

Self-care GP control Total
Total number contacted 113 107 l220
No shows 55 41 96
Present at orientation 58 66 124 (56%)
Dropout before programme 13 4 17
Present for programme 45 62 107 (49%)
Dropout from programme 3 17 20
Subjects for analysis 42 45 87 (80% of
after treatment period programme group,
39% of total)
*Some subjects were contacted twice, making the total number of contacts 321

In order to assess changes in headache improve-
ment for no-shows and dropouts, 24 subjects were
randomly chosen from the following groups (five
no-shows from each treatment condition, five drop-
outs during baseline from each treatment condition
and two dropouts during the treatment period from
each treatment condition). These people were con-
tacted at one year follow-up and asked to rate
changes in their headaches over the previous year on
four dimensions (overall, frequency, intensity and
duration), using a five-point rating scale. (Patients
who completed the study had also rated their im-
provement after one year on the same scales.) They
were also asked why they did not show or continue
to participate. Data was obtained from 19 no-shows
and 21 dropouts.
Analyses of variance of self-rated improvement for
headache on the four scales all showed significantly
greater improvement at one year for the self-care
condition than either no-shows or dropouts. On each
of the four headache dimensions rated, for both
no-shows and dropouts, mean-rated improvement
was slightly, but not significantly, higher than the
GP-control group. Telephone interviews with the
no-shows and dropouts indicated the major reasons
for non-participation in the self-care programme
were practical considerations, such as inability to give
the time required, inconvenient meeting times and
transportation difficulties.
Participating GPs attitudes towards self-care
All 31 GPs who referred patients to the project
were sent a questionnaire on completion of the
project (12-24 months after the first self-care groups).
Twenty-three (74%) of the GPs returned them. Of the
8 non-respondents, 3 had since died or left the state;
5 did not respond to follow-up requests. The ques-
tionnaire asked about the GPs’ attitudes towards,
and beliefs about, the self-care programme and asked
them to rate their patients’ improvement where it was
known to them. Three quarters (74%) of the respon-
dents were happy with their participation in the
project. While all saw the self-care groups as an
adjunct, not an alternative to conventional medical
care, only 3 indicated they would feel most confident
in referring their patients to a group led by another
GP. Seventy-four percent thought the self-care for-
mat would be useful for dealing with other health
problems (26% were not sure), e.g. particularly inter-
personal, behavioural or stress-related problems.
More positive views on the self-care format were
associated with greater rates of referral to the
programme (l-3 referrals, 6/10; 4-9 referrals 4/6;
10 + , 7/7). Forty-eight percent indicated that partic-
ipation in the project had led them to make increased
use of self-care techniques with their patients; this
also was associated with increased referral rates (l-3,
3/10; 4-9, 3/6; 10 +, 5/7).
The most frequently mentioned patient gains were
relaxation techniques (52%), improved ability to
cope (52%) and control of symptoms (48%). Table 2
presents the GPs’ ratings of improvement in 165
patients from the practices of the sample of GPs
surveyed. A high proportion of cases were rated by
their GPs as having unknown outcomes, probably
reflecting that the patients had not continued to
attend the GP or had not attended for headaches.
Table 2 indicates the GPs rated the self-care partici-
pants as being more improved at the end of the
project than GP controls or no-shows.
The GPs thought the major reasons people
dropout from self-care groups were practical ones,
particularly transport difficulties (55%) and time
constraints (55%). Psychological attributes of partici-
pants were believed to be important in increasing the
viability of self-care groups by 83% of the GPs. In
particular, these included patient motivation (36%),
insight (18%) and intelligence (27%).
DlSCUSSlON
The self-care groups added to the clinical effective-
ness of GP management of chronic headache.
Headache activity was reduced significantly more by
the self-care programme than in the GP-control
treatment condition. Treatment gains did not deterio-
rate but, if anything, increased over the 1Zmonth
follow-up period. Self-care participants felt more
confident in their ability to control headaches
through their own efforts, without the aid of drugs
and this confidence also was maintained over the
12-month follow-up period. Patients from the self-
care groups also perceived more improvement in their
headaches than did patients from the GP-control
condition, a view shared by their GPs.
Table 2. GP ratings of patient improvement on project completion
Patient No change
category or worse Improved Unknown Total
Self-care 6 I8 6 30
GP control IO 13 6 29
No-show or
dropout 22 31 53 106
Total 38 62 65 I65
x’ df4 = 16.87. P < 0.01.
 218 ROBIN WINKLER et al.
These results suggest that a self-care philosophy,
when put into practice through behavioural self-
management groups, is clinically effective for one
particular chronic problem commonly encountered in
primary care. This study gives a clearer and more
positive picture of psychology-based treatment pro-
cedures in primary care than had some previous
clinical trials. This is probably due to the specific
focus of the present study which employed one set of
procedures for one problem. The self-care pro-
gramme in this study was specifically tailored for
headaches, and was based on prior research which
indicated the specific procedures used in the pro-
gramme contribute to positive clinical outcomes.
Although important, non-specific processes, such as
meeting in a small group to discuss a common
problem, may have contributed to the observed
changes but not significantly so. Participants had the
opportunity to acquire specific, tested self-manage-
ment skills for use in the control of their headaches.
Patients in the GP-control condition also signifi-
cantly improved. Part of this improvement may be
attributed to the beneficial effects of self-recording.
Patients in both the self-management and the GP-
control conditions were free to consult their GP as
often as they wished. However, the study sample was
made up of chronic headache sufferers who had
stabilized in their patient careers, with the result that
they consulted their GP rarely for their headaches.
Results of a similar study among others earlier in
their patient careers (e.g. within the first year after
diagnosis by the GP) might be different.
It is important to note that improvements appeared
substantial and significant in a clinical as well as in
a statistical sense. Mean headache scores for the
experimental group were 180, compared with 330 for
the control group, indicating a reduction in headache
frequency, intensity and duration of 45%. Of the
seven self-care groups, on average six improved
significantly more than the control groups attending
a GP only.
The low rate of health-care utilization in the
patients studied may explain why visit costs, calcu-
lated from patients’ own daily records for five, one-
month periods, did not differentially change in the
two conditions. This, plus the wide variation in
service utilization, made it difficult to determine
whether differential cost reductions had, in fact,
occurred. The wide variation in drug consumption,
and the unexpected higher consumption at baseline
and throughout for the GP-control group, also made
it difficult to assess any differential effect on drug
costs. The higher drug costs at baseline for the
GP-control group may have been due to the fact that
self-care participants, having been told about the
self-care philosophy at their organizational meeting,
had cut back on drug use prior to their first group
meeting. A clear picture did not therefore emerge of
the ability of this self-care programme to reduce
health costs. However, the data is nor consistent with
a strong claim that a self-care programme, such as the
one used in the study, substantially reduces health-
care costs, at least in the case of chronic headaches
in general practice.
Wallston et al. [13] have found the two attitudes,
‘I create my own health’ and ‘My health is created
by good professional care are largely independent.
We ‘.dve found the same in a preliminary analysis
of sample who referred themselves for self-care
programmes for headaches, insomnia and weight
reduction. Given such findings, it does not necessarily
follow that an increase in patients’ confidence and
ability to control their problem without drugs will be
accompanied by a reduction in reliance upon drugs
and professional expertise. At the 6-month follow-up,
increased patient confidence in their ability to control
their headaches without drugs was related to lower
drug use. However, this was not so at 12 months.
The acceptance of self-care philosophies by patients
in primary care cannot be fully gauged from this
study since the GPs did not recommend self-care
groups but simply referred patients to a university
study. However, the high non-acceptance among
those referred suggests that the widespread pro-
mulgation of self-care approaches in primary care
may meet with some patient resistance. Interviews
with no-shows and dropouts indicated that the time
required for the self-care programme (10 evening
sessions) was the biggest single barrier. While no
formal data were obtained on income and socio-
economic status, variation in these attributes did not
appear to greatly affect attrition rates, since the rates
were similar from areas which differed widely in terms
of the socio-economic status of their populations.
Since dropout rates were very low after the first
self-care group session, the major problem in delivery
of this kind of self-care seems to be in getting patients
to participate in the programme.
The self-rated improvement of no-shows and drop-
outs a year after their invitation to participate in the
study was significantly lower than the corresponding
improvement data for self-care participants. This
suggests that the beneficial effect of the self-care
groups was not likely to have been an artifact of
dropout rates (which were very similar in toro at
one-year follow-up). The failure of self-rated im-
provement in the GP-control group to exceed self-
rated improvement in the dropout group raises
the possibility that the GP-control group may have
improved simply due to participation in the project
and the passage of time.
It is often asserted that GPs will not be open to the
use of self-care groups in their practices because of
their adherence to a traditional medical model and
because of perceived threats to income in fee-for-
service settings. However, the GPs in this study
supported behavioural self-management groups as a
form of self-care, saw them as useful for a range of
health-related problems and were happy to have them
facilitated by staff other than GPs; indeed, they
preferred this option. They concurred with the no-
show and dropout patients that practical constraints
were the major limitation to patient participation.
However, it is not clear whether the GPs were positive
from the outset, or became so. While more positive
attitudes related to greater involvement in the project,
and half the GPs said they more often used self-care
philosophies as a result of participation, in the ab-
sence of pre-post comparison, any interpretation of
this data must be made with caution.
In summary, a self-care programme, based on be-
havioural self-management groups using specifically
 A self-care approach to chronic headaches in general practice
tailored self-care procedures, added to the clinical
effectiveness of GP management of chronic headache.
There was no evidence that the self-care programme
reduced costs or health-care service utilization but
this may have reflected prior established low attend-
ance and drug usage. There was significant patient
resistance to entering a self-care programme but little
once exposed to it. Participating GPs accepted the
self-care programme well. Patient resistance to enter-
ing the self-care programme was likely to have been
inflated by the fact that the GPs simply referred
patients to the project as a whole rather than pre-
pared them explicitly for the self-care groups. Patient
acceptance is likely to be increased where GPs pre-
pare patients prior to referral by emphasizing the
time commitment that effective self-care requires.
Acknowledgements-This project was, in large measure, a
result of Robin Winkler’s ideas and work and we wish to
acknowledge his substantial contribution and mourn his
loss. The authors also wish to record their gratitude to the
Commonwealth Department of Health which supported this
research with a generous grant, and the 30 Perth general
practitioners who referred patients for the study.
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