Systematic literature review (SLR) is a comprehensive and structured approach to identifying, evaluating, and synthesizing relevant research studies to answer specific research questions. In the context of enhancing primary healthcare, an SLR can be used to examine the attributes like patient trust, health literacy, cultural competence, engagement, advocacy, acuity, age, gender, medical history, lifestyle factors, socioeconomic status, ethnicity and culture, self-care, self-efficacy , resilience.
PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) is a frequently employed guideline for conducting and reporting systematic literature reviews and meta-analyses.
The PRISMA guideline has become the standard for reporting systematic reviews and meta-analyses and is acknowledged by a large number of journals and funding agencies. By adhering to the PRISMA guidelines, researchers can guarantee that their literature reviews are transparent, exhaustive, and reproducible, thereby enhancing the credibility and utility of their findings(Grimshaw et al., 2021).
The figure (1.1) represents the PRISMA guidelines in which the method of extraction of the reliable and relevant papers are processed. Initially, based on the inclusion criteria in determining the patient attributes, the study identified 400 papers from Google scholar, PubMed and Science direct database. Due to the duplication issues and automatic exclusion , 160 articles were excluded during screening of the extracted files. Among those 240 articles met the eligibility criteria such as inclusion of patient attributes . Further filtering of the articles based on the precise content extraction i.e., relevance of attributes followed by concepts leads to a total of 20 articles then another new set of 20 recent articles added in this SLR. Total 40 articles are studied.
2.2 Patient attributes:
The characteristics or traits of a person who is getting medical care or attention are called "patient attributes." Some of the different patient attributes include:
Age: The age of a patient can affect the diagnosis, treatment, and management of medical conditions. For example, the treatment plan for a child with a particular illness may differ from that of an adult with the same condition(Jack Jr, C.R., Bennett, D.A., Blennow, K., Carrillo, M.C., Dunn, B., Haeberlein, S.B., Holtzman, D.M., Jagust, W., Jessen, F., Karlawish, J. and Liu, 2018).
Gender: Gender can influence the presentation of certain medical conditions, as well as the diagnosis and management of these conditions. For example, prostate cancer affects only men, and the treatment options for breast cancer may differ for men and women(Liu et al., 2018).
Medical history: A patient's medical history includes information about previous illnesses, surgeries, and medical procedures. This information can help healthcare providers make a diagnosis, determine the best treatment options, and avoid potential complications(Schoen et al., 2011).
Lifestyle factors: Lifestyle factors such as diet, exercise, and smoking can affect a patient's health and influence the development of certain medical conditions(Buttar et al., 2005).
Family history: A patient's family history can provide important information about the risk of developing certain medical conditions. For example, if a patient has a family history of heart disease, they may be at a higher risk of developing this condition(Rich et al., 2004).
Socioeconomic status: Socioeconomic status can affect access to healthcare, the quality of care received, and the overall health outcomes of a patient(Fitzpatrick et al., 2015).
Ethnicity and culture: Ethnicity and culture can influence the way in which a patient experiences and responds to medical care. For example, some cultural beliefs may affect a patient's willingness to seek medical care or comply with treat(Narayan, 2010).
Patient Health Literacy: Patient Health Literacy refers to an individual's capacity to comprehend and use health-related information in order to make informed choices about their health. A Research on this subject may examine how healthcare practitioners may increase patient health literacy via effective communication tactics, health education initiatives, and patient-centered treatment(Ishikawa & Yano, 2008).
Cultural competence: Cultural competence refers to the capacity of healthcare personnel to offer treatment that is sensitive to and respectful of the cultural and language demands of varied patient groups. In a Dissertation on this subject, the influence of cultural competency training on the knowledge, attitudes, and behaviours of healthcare personnel in providing culturally competent treatment may be examined(Sharifi et al., 2019).
Engagement: Engagement is the active participation of patients and their families in the healthcare decision-making process. An SLR on this issue may examine the advantages of patient participation, such as enhanced health outcomes, decreased health care expenditures, and higher patient happiness(Higgins et al., 2017).
Advocacy: Advocacy is the process of supporting or advancing the interests of patients and their families within the healthcare system. An SLR on this subject may examine the role of healthcare practitioners in advocating for patients' rights and fostering health fairness(Wong-Rieger, 2017).
Acuity: Acuity refers to the intensity or complication of a patient's health condition. An SLR on this subject may examine how healthcare practitioners can successfully manage patients with high acuity demands in the primary care context via care coordination, team-based care, and patient-centered medical homes(Brennan et al., 2019).
An Examination of these ideas may give useful insights into how primary healthcare might be enhanced to better meet the different needs of patients and families. By finding successful techniques and actions, healthcare professionals may strive to offer high-quality, patient-centered care.
Patient involvement may be characterised as a practise and a behaviour that shapes the interaction between the patient, the healthcare provider, and the setting in which services are provided.
The bulk of previous research looked at the adage cited above from the perspective of high-quality healthcare or the healthcare system.
2.3 In-Depth Analysis of Patient Attributes regarded as Concepts:
2.3.1 Patient Engagement with treatment
According to some, if patient engagement were a drug, it would be the "blockbuster drug of the century"(Krist et al., 2020) because individuals who are more actively involved in their own treatment have better health outcomes and more satisfying interactions with healthcare providers.
In order to improve their health results, people actively participate in their own healthcare,
which is known as patient engagement.. It can be seen as an attribute of both patients and healthcare providers. As an attribute of patients, patient engagement refers to their willingness and ability to take an active role in their own care. This may include things like asking questions, seeking out information, adhering to treatment plans, and making healthy lifestyle choices. As an attribute of healthcare providers, patient engagement refers to their ability to involve patients in decision-making processes, listen to patient concerns, provide clear and concise information, and support patients in taking an active role in their own care. Overall, patient engagement is an important aspect of healthcare that can lead to improved health outcomes, increased patient satisfaction, and more efficient use of healthcare resources.
Patient Engagement is a well-studied Concept in healthcare literature. It is generally defined as the active involvement of patients in their own healthcare, with the goal of improving health outcomes. Below are some examples of how patient engagement is discussed in healthcare literature:
The concept of personalization is discussed, as well as admission, loyalty, and the restorative agreement in "Unravelling the Meaning of Patient Participation" (Higgins, 2017). Patient involvement is the ability and willingness of the patient to choose or take part in the care-giving process for which he or she is best qualified. Other decision-makers, such institutions or healthcare experts, are actively engaged to ensure that the patient receives the best care possible.
A review published in the Journal of Social Science & Medicine(Mead & Bower, 2000) found that patient engagement can lead to improved health outcomes, increased patient satisfaction, and more efficient use of healthcare resources. The review also found that patient engagement can be improved through interventions such as shared decision-making, patient education, and patient activation.
A study published in the Wolters Kluwer Health found that patient engagement can be improved through effective communication between patients and healthcare providers(Coulter, 2012). The study found that patients who reported high levels of engagement had more positive perceptions of their healthcare experiences and were more likely to adhere to treatment plans.
A review published in the BMC Health Services Research found that patient engagement can be improved through the use of technology(Roberts et al., 2017). The review found that technology can be used to engage patients in their own care by providing access to health information, facilitating communication with healthcare providers, and tracking health outcomes.
Improving health outcomes, patient satisfaction with treatment, cost savings, and even physician experience may all be benefited by effectively including patients in their care.
2.3.2 Patient Trust:
In "A Concept Analysis of Nurse-Patient Trust" (Bell & Duffy, 2009), Rodger's concept analysis is used to define the word "Trust." (Rodgers' evolutionary concept analysis is suggested as an effective method for studying nursing science.) The technique for gathering and evaluating data may enhance comprehension of Rodgers' evolutionary concept analysis. By providing examples and consequences, these methods facilitate comprehension of the concept and its associated terminology. Particular focus is put on understanding the concept of trust, which is seen as fundamental to the nurse-patient relationship. The fundamental difficulty with the concept of the nurse-patient relationship is that, owing to its uncertain true meaning, it is employed carelessly in everyday discourses. This shows that because patient trust in the nursing profession is a fundamental aspect of nursing care, it cannot be ignored.
Patient trust is a concept that refers to the degree to which a patient has confidence in their healthcare provider and the healthcare system as a whole. It is an important part of the patient-provider relationship because it has a big impact on how happy the patient is, how well they stick to their treatment, and how well their health turns out.
In medicine the yearning by consumers to be seen as individuals is particularly poignant because the relationship between doctor and patient is in many ways so intimate— and, too often, so distant. — Anna Quindlen
Patient trust is an essential attribute in healthcare and refers to the belief or confidence a patient has in their healthcare provider or the healthcare system as a whole. Patient trust is built on many things, such as the quality of care, communication, empathy, and respect from healthcare providers, and the openness of the healthcare system.
When people trust their doctors, they are more likely to do what they say, share personal information, and stick to their treatment plans. Trust can also lead to better health outcomes, more satisfied patients, and better relationships between patients and providers.
However, a bad experience, a lack of communication, or perceived incompetence can easily destroy patient trust. So, healthcare providers and systems need to work to build and keep patients' trust through open communication, good care, and honesty.
The positive effects of trusting affiliation with patients on the source of health amenities were highlighted directly by health care workers in seven studies for performance motivation(Wolka et al., 2018) . The article contains a report on a cross-sectional analysis of private and public sector nurses and medics. Cross-sectional surveys of 1916 public and private sector health workers in two Indian states(Andhra Pradesh, Uttar Pradesh) found out that gaining trust from patients on the basis of health amenities was ranked first as a motivator for health care workers (Peters et al., 2010).
In contrast, health worker motivation can potentially affect the provision of health services. Low morale among the workforce can undermine the quality of service provision and drive workers away from the profession. "The quality of the health services, their efficacy, efficiency, accessibility, and viability depend on the performance of those who deliver them”(Mbilinyi et al., 2011).
- (Hall et al., 2002) conducted a study to explore the relationship between patient trust and patient satisfaction with their healthcare provider. Due to the pressures generated by managed care, the quality of patient-provider interactions has gained enormous importance in the realm of medical policy. Historically, these connections were measured largely based on satisfaction and communication. Although these characteristics are definitely significant and connected to trust, trust itself may show to be the most basic relationship characteristic, one that pervasively influences actions, outcomes, and attitudes. Trust is essential in the interactions between patients and doctors and other health care professionals, and it may affect crucially important behaviours and results.
- (Quindlen, 1997) investigated the relationship between patient trust and adherence to medical recommendations. They found that patients who had higher levels of trust in their healthcare provider were more likely to follow the provider's recommendations.
- (Etc & Das C, Lucia MS, 2019) Shared decision-making (SDM) is an approach in which clinicians and patients share the best available evidence when faced with the task of making decisions. It has been advocated and researched for decades on the idea that it enhances patient-centered treatment, promotes patient autonomy, and may increase resource utilisation. SDM has also been advocated as a way to reduce over-testing, as research shows that when patients fully comprehend risks and benefits, they are less likely to pick invasive or aggressive treatment alternatives. SDM may minimise defensive medicine, which is projected to cost $46 billion yearly in the US.
- (Stokes et al., 2005) investigated the relationship between patient trust and healthcare utilisation. They found that patients who had higher levels of trust in their healthcare provider were more likely to seek care when needed and were less likely to use unnecessary healthcare services.
Overall, the concept of patient trust is well-known in the healthcare field, and it is thought to be a key part of healthcare delivery
Table 1.1: The characteristics related trust and a few existing methods associated with the trust of patients:
Author
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The objective of the study
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Methodology
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Conclusion on patient trust
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(Piippo & Aaltonen, 2008)
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Trust-making factors to be identified with the perspective of public mental health potential. The whole concerned method considered a question of patient's trust.
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The 22 psychiatric patients were interviewed individually; they were social service users. This analysis mainly focused on the patients' experience in terms of the caring system and whether the trust was created or not.
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Found the trust-creating categories. Recognition of the patient's life situation, frankness, and joint conversation is essential. Power and autonomy are closely allied in trust: As independence increases, the patients can feel the addition of faith and power is not possessed by any individual.
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(Brown et al., 2011)
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Existing research disregards the 'embodied-ness' of the relationships on which trust is founded, despite the fact that trust is crucial for achieving high-quality healthcare results..
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This report induced a semi-structured interview with qualitative data of patients affected by cervical cancer.
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As a primary theme, undermining trust is emerged in significant bodywork like occasions or winning. Trust bridges consist in the present with a future, and this shows the formation of emotion-work connected to the bodywork of the concerned role and touch as a craft-work of bodywork.
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(Cain et al., 2012)
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To create a highly detailed patient-centered view of patients and the need of caregivers in the hospital for the home changeover.
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Participant observation, ethnographic approach, semi-structured video-recorded interviews, in-depth. In the range of chronic and acute conditions, 24 inpatients were hospitalized. They were characterized by illness severity, diagnoses, age, and ability to self-manage and unplanned or planned hospitalization.
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"Trust providers and feeling connected to" are one of the experiences where the caregivers and patients are expressed during the transition from hospital to home. Reducing readmission and broadening understandings are helped by this support.
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(Nygårdh et al., 2012)
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To discover the patient-staff encounter empowerment based on the out-patients experience those with chronic kidney disease.
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Twenty patients with chronic kidney disease were interviewed. Latent content analysis was subjected to the interview.
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Empowerments are signified by the analysis from the five of the seven sub-themes evolving: confirming encounters, accessibility according to the appointment, participation in decision making, trust in the competence of healthcare staff, and the learning improves the self-management. Non-empowerment: lack of influence and dialogue, meeting with nonchalance .one comprehensive refrain was generated from the seven sub-themes, through encounters, created trust and learning.
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(S. Rogers, 2012)
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Toward describing the barriers and uncovering the enablers to employing NICE's(National Institute for Health and Care Excellence) endorsements to the obesity management in adults using a hands-on qualitative approach.
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A qualitative examination was done in a semi-structured interview, with seven nurses who were in practice, seven general practitioners, and nine patients with obesity or overweight, analyzing their opinion and point of view on the implementation of the NICE guidelines on obesity with the help of health service researchers the interview was investigated by the health professional. Verbatim were transcribed and recorded by them and also analyzed. The methodology of the thematic framework.
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Examined the barriers and enablers of NICE implements in the guidance on obesity. One of the various enablers to such implementation was the trust between patients and practitioners.
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2.3.3 Patient Advocacy
Patient advocacy is an attribute that refers to the promotion and defence of patients' rights and interests. Assisting patients in navigating complicated healthcare systems and advocating on their behalf to ensure they get the best care and treatment available.
Patient advocacy often requires perseverance and tenacity, since advocates may be required to battle for patients' rights and interests in the face of bureaucracy and other obstacles. to be a vital component of quality healthcare delivery.
Patient advocacy is a concept that has been mentioned in literature across various fields, including healthcare, nursing, and social work. It involves supporting and empowering patients in making informed decisions about their healthcare and ensuring that their rights are protected. Here are a few examples of how patient advocacy has been discussed in literature:
- On patient advocacy in nursing (Abbasinia et al., 2020), covers the idea of valuing, which involves exercising restraint, letting patients make choices, supporting humanity, and safeguarding patient privacy. It has been shown that patient-related behaviours and characteristics are largely thought of as ideas.
- Understanding and respecting the patient's beliefs, preferences, and requirements, and fighting for their best interests within the healthcare system constitute patient-centered care Patient-centered care has risen to the forefront of quality debates. As a result of the "quality chasm" study by the Institute of Medicine, health care institutions, health planners, legislative representatives, and hospital public relations departments increasingly include the word into their vocabularies. Increasingly, insurance payments are tied to the provision of patient-centered care. In many discussions on patient-centered care, the revolutionary and vital idea of what it means to be patient-centered is lost. The originators of client-centered and patient-centered health care were acutely aware of the ethical implications of their work, which was predicated on a profound regard for patients as distinct living beings and the need to provide treatment on their terms. Thus, patients are recognised as individuals within the context of their own social worlds; they are listened to, educated, respected, and participated in their treatment; and their desires are honoured (but not blindly carried out) throughout the course of their health care journey (Epstein & Street, 2011).
- Throughout nursing literature, the role of nurses as patient advocates has been stressed. Since they spend more time with patients than any other healthcare practitioner, nurses are in a unique position to advocate for their patients. Nurses can assist patients in navigating the healthcare system, expressing their needs and preferences, and making educated choices (International Council of Nurses, 2010).
- Patient advocacy has been considered in the context of healthcare access and equality in social work literature. Social workers may advocate on behalf of patients who experience challenges to healthcare, such as lack of insurance, language problems, and prejudice. Also, they may collaborate with healthcare practitioners to address systemic factors that lead to health inequalities (Reisch and Andrews, 2016).
Overall, patient advocacy is a concept that emphasizes the importance of empowering patients and advocating for their best interests within the healthcare system. It is an essential component of patient-centered care and can improve patient outcomes and satisfaction.
Table 1.2: Defining attributes of patient advocacy
Defining attributes
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Description
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Mediating (S. Telke, 2022)
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Health care professionals and families, being patients' voice, liaison between patients, cultural values to members of the health care system, and patient preferences communication.
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Safeguarding (Nyholm & Koskinen, 2017)
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Protecting patients from incompetency or trail medical errors or miss conduct co-workers and other health care team members.
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Apprising (S. L. Rose, 2017)
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Information about the patient's Prognosis, treatment, and diagnosis, providing details about the discharge program and suggesting alternatives to health care.
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Championing social justice in the provision of Healthcare (D. Wong-Rieger, 2017)
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Rules in the health care system antagonize untimely policies, simplifying access to community health services and health resources, and correcting and recognizing disparities in health service deliveries.
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Valuing (Civantos et al., 2021)
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Allowing patients to make results freely maintain self-control, maintain humanity and individualization, act in patients' culture, values, preference, and beliefs, and preserve patients' privacy.
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2.3.4 Patient Acuity :
Patient acuity is a concept often discussed in the medical literature. It refers to the care and attention a patient needs depending on their medical condition and the severity of their disease or injury. Acuity may be used to assess the degree of personnel, resources, and actions required to provide a patient with safe and effective care.
Several criteria, including the patient's medical history, present symptoms, vital signs, and functional state, are often used to determine the patient's acuity. With standardized tools and scales, nurses and other healthcare professionals may assess the severity of a patient's condition and establish the right degree of treatment.
In addition to staffing and resource allocation, the severity of a patient's condition might affect patient outcomes. Patients with a higher acuity may be at a higher risk for adverse events or consequences, necessitating more rigorous monitoring and intervention to avoid or manage these outcomes.
In the article "Patient Acuity: A Concept Analysis"( Brennan & Daly, 2009), the health sciences literature, the phrase "stated patient perception" is often used. It is, nevertheless, widely used without understanding what it implies. It enhances the requirement for idea clarification so that the importance of patient acuity may be established. It requires focusing on the traits of patient acuity, which include endurance, focus, and the marriage of acuity dimensions with supplemental conception. Following "Holzemer's Outcomes Model for Health Care Research," patient acuity attributes may be classified as patient-, provider-, or system-oriented. Focusing on subcategories found by physical analysis, psychosomatic, nursing care requirements, workload, challenging work pressure, case mix, patient classification systems, exigency/triage scales, and other methods is part of it.
Historically, nurse staffing decisions have been based on census, hours per patient day, and/or nurse to patient ratios, which provide key information for executives to determine the number of employees to hire but are insufficient for nurse assignment decisions because they do not account for variation in specific patients' nursing care needs from day to day and shift to shift. In a setting where patients are enrolled in research protocols or clinical trials, hiring and assignment choices must be based not only on the clinical requirements of patients, but also on their care needs as dictated by the research protocol(Brennan et al., 2019).
Overall, patient acuity is essential in healthcare because it helps ensure that patients get the proper degree of care and assistance depending on their specific requirements and circumstances.
Apart from the Trust, Engagement , Advocacy and Acuity there are many patient attributes regarded as concepts which are important for healthcare providers to consider when caring for patients. Here are a few examples:
2.3.5 Health literacy:
This refers to a patient's ability to understand and act upon health information. Patients with low health literacy may have difficulty understanding medical terminology or following treatment plans. In light of increased user-generated online health information, the changing role of the patient, and the trend towards patient-driven treatment, it is essential to review the idea of health literacy by recognising the patient's dual position as information seeker and information producer. We argue that rather than confining the patient's position to that of a passive information receiver, more emphasis should be placed on the patient's role as an active information source, especially in peer-to-peer communication. Individuals should thus not only be assisted in strengthening their abilities to seek, assess, and utilise health information, but also in sharing pertinent health information(Rubinelli et al., 2014).
2.3.6 Cultural competence:
This refers to a healthcare provider's ability to understand and respect the cultural beliefs, values, and practices of their patients. Patients who feel understood and respected by their providers may be more likely to adhere to treatment plans and engage in their care. The findings suggested that cultural competency is the capacity to deliver effective, safe, and high-quality treatment to patients of diverse cultures while taking into account the many cultural features of those patients. This skill is obtained via a slow, continual process. Cultural awareness, cultural knowledge, cultural sensitivity, cultural skill, cultural proficiency, and dynamic-ness are the distinguishing characteristics of the idea of cultural competency. These characteristics demonstrate that nurse researchers have mostly concentrated on the sub-concept of competence(Sharifi et al., 2019).
2.3.7 Self-efficacy:
This refers to a patient's belief in their ability to manage their health and well-being. Patients with high self-efficacy may be more likely to follow through with recommended treatments and make healthy lifestyle choices.
The concept of self-efficacy was derived by Albert Bandura from his psychological research . Based on Bandura's self-efficacy theory , which was subsequently renamed social cognitive theory, self-efficacy was defined as the individual's perception of one's ability to perform specific behaviours through four processes including cognitive, motivational, affective, and selection processes(Dlttmer, 1977). The stronger an individual's cognitive perception of self-efficacy, the more ambitious their objectives and commitment to achieving them . Through cognitive comparisons of one's own standard and knowledge of one's performance level, individuals will select the challenges they must face and the amount of effort required to undertake or surmount those challenges(Zulkosky, 2009). Goal-based motivation leads to perseverance in achieving one's objectives. Their level of motivation is determined by their perception of self-efficacy . Affective processes influence how individuals control and manage threats such as tension and depression, and are therefore a powerful source of incentive motivation(Haugan & Eriksson, 2021).
2.3.8 Self-care:
Is the application of the concept of self-efficacy to the setting of self-care. Until 1996, the word self-care was Self-efficacy was not mentioned in the research. Based on self-efficacy theory, the strategies used by Patients to Improve Health scale, a measure of self-care behaviour confidence, was created for publication(Eller et al., 2018).
2.3.9 Resilience:
This refers to a patient's ability to adapt and cope with difficult or stressful situations, such as illness or injury. Patients with high resilience may be better able to manage the emotional and physical challenges of their condition.
Understanding the resilience of the healthcare system is crucial. One might expect a resilient healthcare system to consistently provide high-quality care, to withstand disruptive events, and to continuously adapt, learn, and improve. Nevertheless, there are numerous theories, models, and definitions of resilience, and the vast majority are contested and debated in the literature. For both theoretical and practical considerations of any phenomenon, precise conceptual definitions are essential; resilience is no exception(Wiig et al., 2020).
Additionally, resilience has become a central concept in safety research. Over the past ten to fifteen years,'resilience engineering' has become an accepted field within safety science and has attracted considerable interest by advocating for new methods to comprehend work processes in complex adaptive sociotechnical systems(Wiig & Fahlbruch, 2022).
2.3.10 Social support :
This refers to the resources and assistance available to a patient from family, friends, or other community members. Patients with strong social support networks may be better able to manage the demands of their illness and maintain their quality of life.
In the last three decades, there has been a great deal of research on social support, particularly in the context of health. Prior research has shown that those with high quality or quantity of social networks have a lower risk of mortality than those with low quality or quantity of social relationships, even when controlling for baseline health status1. In fact, social isolation has been identified as a significant independent risk factor for death from all causes. Current research in this field has focused on expanding knowledge in a number of subfields. These include (1) the effects of social support on morbidity, mortality, and quality of life in chronic disease populations, (2) an understanding of the mechanisms underlying such associations, and (3) the application of such findings to the design of appropriate interventions(Reblin & Uchino, 2008).
2.3.11 Self- management:
In health service contexts, there is a growing interest in the function of self-management' interventions to support the management of chronic conditions. Self-management may involve patient education, decision-making support, self-monitoring, as well as psychological and social support. Self-management support has the potential to improve the efficiency of health services by reducing other forms of utilisation (such as primary care or hospital use), but a shift to self-management may result in negative outcomes, such as patients who feel more anxious about their health, are less able to cope, or receive poorer quality of care, all of which may have an impact on their health and quality of life. We intended to determine which self-management support models are associated with significant reductions in health services utilisation among patients with long-term conditions without compromising outcomes(Panagioti et al., 2014).