Mapping interventional components and behavior change techniques used to promote self-management in people with multimorbidity: a scoping review

Ageing populations and improved survival, have contributed to a rise in the number of people living with multimorbidity, raising issues related to polypharmacy, treatment burden, competing priorities and poor coordination of care. Self-management programs are increasingly included as an essential component of interventions to improve outcomes in this population. However, an overview of how interventions supporting self-management in patients with multimorbidity is missing. This scoping review focused on mapping the literature on patient-centered interventions for people living with multimorbidity. We searched several databases, clinical registries, and grey literature for RCTs published between 1990–2019 describing interventions that supported self-management in people with multimorbidity. We included 72 studies that were found to be very heterogeneous when it comes to the population, delivery modes and modalities, intervention elements and facilitators. The results pointed to an extensive use of cognitive behavioral therapy as a basis for interventions, as well as behavior change theories and disease management frameworks. The most coded behavior change techniques stemmed from the categories Social Support, Feedback and monitoring and Goals and Planning. To allow for implementation of effective interventions in clinical practice, improved reporting of intervention mechanisms in RCTs is warranted.

A broad consensus is that multimorbidity is best addressed by a patient-centered approach (Multiple Chronic Conditions: A Strategic Framework, 2010., (Farmer et al., 2016).While there is no single definition of patient-centered care (or person-centered care), Bauman and colleagues regard it as the partnership between health practitioner and patient, based on communication and a focus that goes beyond specific conditions to emphasize health promotion and healthy lifestyles (Bauman et al., 2003).McWilliam highlighted that empowering patients to self-manage is central to patient-centered approaches (McWilliam, 2009).Chronic condition self-management and patient-centeredness are closely linked through the emphasis on shared responsibility and decision-making to achieve better health and wellbeing as defined by the person and the acknowledgement of the social, psychological, biological, and spiritual aspects that impact on self-management ability, placed within a context that respects the beliefs and values of the person (Lawn & Pols, 2005).
Self-management programs are increasingly recognized as an essential component of patientcentered interventions to improve outcomes and considered high-quality care for patients living with multimorbidity (Smith et al., 2016), (Bayliss et al., 2003).Some core elements for this population include providing education about multiple chronic conditions, psychological strategies to support the adjustment to life with chronic conditions, strategies to support adherence to multiple treatments, support around activities of daily living and physical functioning and providing social support (Taylor et al., 2014).There is a strong consensus that multiple causes of mortality and morbidity are linked with the behavior of individuals (Conner & Norman, 1996).Previous studies have emphasized the importance of unhealthy behavior (e.g., smoking, diet, alcohol use, physical inactivity) in the development and progression of multimorbidity (Wikström et al., 2015), (Fortin et al., 2014), (Dhalwani et al., 2016).Given the fact that behavior is modifiable, considerable efforts have been devoted to research, campaigns and interventions targeting health behaviors (e.g., weight control, smoking cessation, and increased physical activity) to improve health and thereby deter the development of chronic conditions and multimorbidity (Suls & Green, 2019).Defined as 'overt behavioural patterns, actions and habits that relate to health maintenance, health restoration and health improvement' (Gochman, 1997), health behaviors have received considerable attention from researchers, who explored the factors influencing how and why people engage in these behaviors (Conner et al., 2002).Understanding how (patient-centered) interventions might support selfmanagement in patients with multimorbidity is pivotal in promoting health in this population (e.g., by preventing or reversing physical inactivity).However, an overview of the literature in this area is missing.
A scoping review is ideally suited to determine the scope or coverage of a body of literature on a given topic as well as an overview of its volume and focus.In addition, it can be a useful tool to develop a theoretical understanding of the likely process of change by drawing on existing evidence and theory.This scoping review was part of the process of informing the development of an exercise and self-management intervention designed for people living with multimorbidity (see https://www.mobilize-project.dk/).Conducting a scoping review of the literature is a very good strategy to get an overview of the field.Furthermore, despite the wide recognition of the biopsychosocial model and the connection between physical and psychological disorders, multimorbidity has not been a major focus in health psychology to date.This scoping review will be the first to contribute to a detailed understanding of the interventions evaluated in people with multiple chronic conditions by mapping the characteristics, types, duration, targets, delivery modes and modalities, impact, facilitators, behavior change techniques and frameworks/models used in the interventions.Classifying behavior change techniques used in interventions to promote self-management in people with multimorbidity will also be a first step in identifying potential mechanisms of change.

Objectives
This scoping review focused on mapping the literature on patient-centered interventions for people living with multimorbidity that support self-management.In accordance with the definition of selfmanagement by Lorig and Holman (2003) (i.e., medical, or

Materials and methods
This scoping review conformed to the framework for conducting scoping reviews developed by the Joanna Briggs Institute (Peters et al., 2015).The reporting followed the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) (Tricco et al., 2018).The protocol for the scoping review was made public a priori and is available on the Open Science Framework (https://osf.io/eszb7).

Eligibility criteria
The following eligibility criteria were formulated to identify relevant studies.The studies were randomized controlled trials published between January 2000 and November 2019 as multimorbidity is a newer term (Tugwell & Knottnerus, 2019).The participants were adults (18 + years old) living with multimorbidity, defined for this review, as having at least two of the following conditions: osteoarthritis (OA), ischemic heart disease or heart failure, hypertension, type 2 diabetes mellitus (T2DM), chronic obstructive pulmonary disease (COPD) and depression. 1 Studies that targeted multimorbidity (two or more chronic conditions) where at least two of the conditions of interest for this scoping review were present were also included.Further, the interventions had to incorporate self-management elements directed at individuals.We focused on self-management elements that included patient education, support for decision-making, self-monitoring, and psychological and social support.We excluded interventions focusing solely on medical service usage (e.g., physician visits, hospital stays etc.) or merely evaluating professional and organizational interventions.In addition, one or more behavior change techniques (BCTs) had to be present for the study to be included.Studies focusing solely on medical service usage (e.g., physician visits, hospital stays etc.) or merely evaluating professional and organizational interventions were excluded.We did not apply any restriction to the type of comparator groups, outcome domains, country of origin or the language of the papers.

Information sources
The search strategy (see Supplementary file 1) was adapted from two previous reviews (Bricca et al., 2020), (Willett et al., 2019).The final search strategy was tailored for use in the different databases.
The following electronic databases were searched: Cochrane Database of Systematic Reviews, Joanna Briggs Library, MEDLINE via PubMed, EMBASE via Ovid, CINAHL 1 The reason why we focus on six specific conditions is that these conditions share a common risk factor (physical inactivity) and pathogenesis (systemic inflammation).Previous research has shown that interventions targeting specific related conditions, e.g., via risk factors, or with a shared focus on improving function, may be more beneficial than interventions targeting multimorbidity in general (Smith et al., 2016).In addition, these six conditions have been selected as the focus of our overall project (Mobilize-see https://www.mobilize-project.dk/).

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Europe PMC Funders Author Manuscripts via Ovid, Scopus, and Psychinfo via Ovid.In addition, a search for grey literature was performed to identify unpublished trials.The search was done in the following databases: World Health Organization International Clinical Trials Registry Platform, Agency for Healthcare Research and Quality, ClinicalTrials.gov,Open-Grey.eu,and WorldCat.org.Citation tracking was be performed using Web of Science (WoS).Finally, the reference lists of reviews and trials found through the searches were hand-searched for additional references to ensure that relevant articles were not missed.

Selecting the studies
The identified citations were uploaded to EndNote X9, and duplicates were removed.Due to the search size, four reviewers participated in the screening (MS, GZ, AB & MD).The identified studies were divided into two, and the two teams (AB & MD and MS & GZ) screened titles and abstracts independently and applied the eligibility criteria accordingly.Eligibility uncertainties were resolved by screening the full-text article and discuss until a consensus was reached.The qualified studies were then read in full text and evaluated against the eligibility criteria for the final decision by two reviewers (MS & GZ).Any disagreement was discussed until consensus.If information was missing (e.g., distribution of included conditions), the corresponding author was contacted via email.They were given two weeks to reply and sent a second email if they did not respond to the first one.

Data charting process
Key variables were extracted using an a priori developed extraction template compiled in Microsoft Excel (2019) in duplicates by two reviewers (MJ & GZ).Study information on identifiers of the target population, purpose, context, intervention details, outcome(s), theoretical framework or theory, and the target behavior(s)/outcomes was extracted.The two reviewers checked the data and uncertainties were resolved by revisiting the full-text, supplementary materials or requesting additional information from the authors.

BCT coding process
Each intervention was coded for BCTs using Michie et al.V1 behavior change taxonomy (Michie et al., 2013).BCTs have been conceptualized as replicable components of an intervention designed to alter or redirect causal processes that regulate behavior (e.g., Social support, Providing feedback, Goal setting, Information about health consequences).
All the intervention elements (stated either in the manuscript, protocol, or supplementary material) that contained a specific BCT were coded.Two researchers (MJ & GZ) performed the coding independently after being trained in using the taxonomy.After coding the interventions, the two researchers discussed coding related issues and consulted a third researcher (ZS) for advice on these issues.Coding related disagreements were resolved through discussion.The final agreed coding was summarized in a grid presenting each study and the coded BCTs.The interventions were clustered by type, target behavior(s)/outcomes and combinations of chronic conditions they address.These elements were reported in the original studies or deduced from the content of the interventions

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Europe PMC Funders Author Manuscripts calculated.A breakdown of the frequency and specific combinations of BCTs utilized in the interventions was compiled.The results were presented visually (using tables, charts, and diagrams) and in a descriptive format (narrative synthesis).

Synthesis of results
The results are presented both in a visual form (e.g., using tables, and charts, as appropriate) and in a descriptive format (narrative synthesis) and include frequencies and proportions according to the intervention characteristics (type, duration, targets, delivery modes and modalities, impact, facilitators, behavior change techniques and frameworks/ models utilized).

Results
The initial search yielded a total of 12,879 studies and 23 additional studies from other sources.After checking for full-text availability, removing duplicates and screening articles against the inclusion and exclusion criteria, a total of 72 RCT studies were identified for inclusion and data extraction (Figure 1).Table 1 presents the participants, intervention characteristics and target of interventions of the included RCT studies.

Intervention characteristics
The 72 studies included a total of 13,866 participants.Age was giving in 65 of the 72 included studies, and the participants had a combined mean age of 61.1 years (SD 5.8).In seven studies, age was reported as a median or percentage, with a median age of 60.6 years.In the 70 studies that reported gender, 51% of the participants were females.In the 37 studies where ethnicity was stated, the majority was given as white (30%), other (10%), or African American (6%).The 72 studies were conducted in 20 different countries, with the USA being the most represented (44%), followed by Australia (10%), the United Kingdom (7%) and the Netherlands (7%).Depression was the most prevalent condition (56 studies), while osteoarthritis was the least occurring (4 studies).Regarding clusters of conditions, the most frequent combinations were heart disease and depression and Type 2 Diabetes and depression (both were present in 18 studies) (see Figure 3).Although not an inclusion criteri anxiety was present in 11 studies, either as an inclusion criterion for the single studies or as a comorbidity co-occurring with depression (see Figure 2).

Intervention type and comparator
The 72 studies reported a diversity of interventions with different combinations of elements (see Figure 3).

Primary outcomes and impact of interventions on outcomes
The most frequently encountered primary outcome in the included studies was Depression (see Figure 4).Other commonly reported primary outcomes were blood pressure (17 studies), and quality of life (15 studies).Regarding intervention effectiveness (on primary outcomes), a large percentage of studies reported significant differences favoring the intervention group(s) (54 studies).
Sixteen studies reported that there was no significant difference in outcomes between the intervention and the control group, while two studies were reported as being underpowered.

Professionals facilitating the interventions
Various professionals (i.e., diverse backgrounds and training) delivered the interventions either alone on their own or in a team.28 interventions were delivered by nurses, followed by psychotherapists and psychologists (ten and eight, respectively).Other facilitators were physicians (n = 6), social workers (n = 3), occupational therapist (n = 1), pharmacists (n = 3), or physiotherapist (n = 1).Volunteers and research coordinators were also involved in the delivery of interventions.

BCTs identified in the interventions
A total of 582 different BCTs were coded 2 (see Supplementary file 2).The highest number of BCTs used in a single study was 16, while the lowest was two.The most frequently identified BCTs were Social support (unspecified) (coded 62 times), Instruction on how to perform a behaviour (n = 48), Problem-solving (n = 31) and Goal setting (outcome) (n = 30) (see Figure 5).In line with this, the clusters with the most coded BCTs were Social support (n = 108), Feedback and monitoring (n = 99) and Goals and planning (n = 96).The least coded BCTs were Vicarious consequences, Self-talk, Rewarding completion, Valued self-identity and Incompatible beliefs all coded one time.These BCTs correspond to the 2 BCTs range from 1.1 to 16.3 (See Behaviour change taxonomy V1), ✓ means the specific BCT is present clusters: Associations, Scheduled consequences, Self-belief, Covert learning and Reward and threat.
Challenges arose when faced with coding BCTs present in interventions delivered to the comparator groups due to the lack of information describing their content.This was also because the most frequently encountered comparator was usual care or enhanced usual care, without providing details about usual care.

Frameworks/models used in interventions
All 72 studies included either a framework, model, or theory to inform the development of the intervention (based on information from the articles and supplementary materials).Specific information about how the theory/model was used was in most cases deemed insufficient or lacking.

Discussion
To our knowledge, this is the first study to compile a comprehensive map of the interventional components and behavior change techniques used in patient-centered interventions that target self-management in people living with multimorbidity.We included 72 studies that reported interventions that were heterogeneous in terms of targeted populations, delivery modes and modalities, intervention elements, and facilitators (see Table 1 & Figure 5).The results pointed to extensive use of CBT as a basis for interventions, as well as behavior change theories and chronic disease management frameworks.In addition, the most coded BCTs stemmed from the categories of Social Support, Feedback and monitoring, and Goals and planning.
Very few studies have explored behavior change strategies utilized in patient-centered interventions for people living with chronic conditions.Findings from a previous review identifying BCTs and intervention features of dietary and physical activity interventions for patients with type 2 diabetes revealed that four BCTs were associated with a > 0.3% reduction in HbA1c: Instruction on how to perform a behaviour, Behavioural practice/ rehearsal, Demonstration of the behaviour and Action planning (Cradock et al., 2017).
However, contrary to our results that showed extensive use of theoretical models and frameworks as a basis for the interventions, this previous review by (Cradock et al., 2017) found that only three out of the thirteen RCTs included used a theory or model.Another similar systematic review focusing on the effects of BCTs for physical activity and healthy eating in overweight and obese adults found support for the use of goal setting and selfmonitoring of behavior (Samdal et al., 2017).The authors of this review highlighted the importance of using a person-centered approach in maintaining healthy eating and physical activity long-term.The findings of our review are in line with previous literature focusing on the essential role of social support in improving outcomes for people with multimorbidity.Olaya and colleagues (Olaya et al., 2017) conducted a longitudinal survey including 2113 participants aged 60 + and confirmed the hypothesis that having two chronic physical conditions increased the risk of mortality over a 3-year follow-up period among people with low social support, compared with participants with no chronic illnesses.The authors emphasized that designing interventions that aim to increase social support can help improve the health status and survival of people who suffer from multimorbidity.Similarly, Vogel et al. explored the impact of perceived social support on health-related quality of life in people living with multimorbidity and found that higher perceived social support was associated with higher health-related quality of life scores (Vogel et al., 2012).Given the important role that social support (both emotional and practical) plays in the adaptation to chronic conditions (Eriksson & Rosenqvist, 1993), (King et al., 2018) future interventions designed for people experiencing multimorbidity should consider.
incorporating elements of social support (e.g., emotional support from family or friends, practical support from healthcare professionals).This may potentially act as a buffer to the limitations that multimorbidity imposes on people's social lives (Sells et al., 2009).Finally, the findings of this review are in line with a Cochrane systematic review looking at interventions for improving outcomes in patients with multimorbidity in the primary care (Smith et al., 2021) in those interventions designed for this population are complex and multifaceted, reflecting the different needs of the individuals.

Limitations
One limitation is related to the poor reporting and vague description of interventions, which contributed to difficulties in coding the BCTs utilized in the studies.Furthermore, we cannot judge the quality of the trials included due to the absence of a quality assessment, which was beyond the scope of this review, that aimed to map the literature on interventions in this specific area.Another important limitation is the short duration of interventions, most of which (60%) were short (1-3 months).At best, the studies provide an indication of the characteristics of short-term interventions supporting self-management, lacking a focus on the maintenance of behavior change which is fundamental in self-management long-term.
While we included studies published until 2019 we believe that given the large number of studies included (k = 72) and the level of details of our analyses, including the BCT assessment, our results provide an unbiased and comprehensive overview of the topic.
Finally, defining multimorbidity as living with two or more of six specific chronic conditions as well as the period searched (2000-2019) may have limited the volume of literature selected for this review.

Implications
The findings presented here provide a starting point for further investigation of patientcentered interventions that include self-management designed for people living with multiple chronic conditions.Within the context of multimorbidity, there are some populations or clusters that could benefit from more focus.For example, while a vast volume of research has concentrated on people living with diabetes and depression or heart disease and depression, only a restricted number of trials were designed for people living with multimorbidity involving COPD or osteoarthritis.
There is a need for a better understanding of the emergence and persistence of multiple chronic conditions as well as an awareness of the relationship between psychological, Europe PMC Funders Author Manuscripts Europe PMC Funders Author Manuscripts behavioral, social, and environmental factors and multiple chronic conditions.Despite that the focus of health psychology is studying the connection between physical and psychological disorders, including the psychological determinants of health behavior, multimorbidity has not been a primary concern (Suls & Green, 2019).Nevertheless, health psychology has demonstrated the adoption of a biopsychosocial approach concerning the co-occurrence of psychological and medical conditions.Interventions are needed to promote health behavior adherence among people with chronic conditions that also address the challenges of living with multimorbidity.Recent developments in the design of health behavior interventions have highlighted the importance of theory and classifying intervention components (BCTs) (Michie et al., 2013) and mapping these intervention components onto mechanisms of change.Clear and accurate reporting of interventions is needed (Michie et al., 2009).Both CONSORT and TIDieR guidelines are useful in providing recommendations for reporting specific characteristics such as intervention content and delivery (Moher et al., 2001), (Hoffmann et al., 2014).To further develop effective programs for people with multiple chronic conditions, researchers should adhere to MRC guidelines by incorporating behavior change theory into interventions (Craig et al., 2008) and adequately report the relevant active components or BCTs (Painter et al., 2008).This will contribute to increased transparency and improved reporting as well as provide clinicians with sufficient information to implement effective interventions, also facilitating the understanding of potential intervention mechanisms.
We suggest that future research should focus on enriching the existing evidence base regarding the effectiveness of interventions for people living with multimorbidity.This aligns well with Smith et al. (2021) who highlighted that there are remaining gaps in our knowledge about the effectiveness of interventions for people with multimorbidity despite the increased number of RCTs in this area.One of the challenges is that the interventions tested so far for people with multimorbidity were not developed and tailored to this population (but for people with single chronic conditions).This might have contributed to the small effects observed in systematic reviews (Smith et al., 2021).Moreover, in addition to effectiveness, it is also important to consider the potential for implementation of interventions and the contextual factors relevant in their implementation (MRC Framework, 2021).
Finally, intervention designers should consider a full range of different components when developing patient-centered programs for people living with multimorbidity, using previous research evidence and recommendations, and based on a good understanding of patients' needs and preferences, preferably also involving these when designing interventions.Not only will this enhance the acceptability of the interventions, but it will potentially lead to higher effectiveness.

Conclusions
This review highlighted the complexity and diversity of patient-centered interventions designed for people living with multiple chronic conditions.Even though all the interventions included in this review were informed either by a chronic disease management framework, psychotherapeutic approach, behavior change model, or theory, reporting needs          Characteristics of included studies.
behavioral management of the disease, role management, and emotional management), we included a broad range of interventions focusing on health behavior change and/or providing psychological or social support or other approaches.These interventions were classified according to the underlying theory and behavior change techniques (BCTs) and strategies utilized.
Most of the interventions (37) had a psychotherapeutic component (e.g., cognitive behavioral therapy (CBT) or internet-based CBT, Cognitive Therapy, Counseling, Mindfulness Therapy, Motivational Interviewing, Telepsychology) consistent with the fact that depression was the most prevalent single condition.Patient education, psychoeducation, self-management, and self-care were also frequently included (n = 31) in addition.Other elements less frequently encountered were music therapy, biofeedback, stress management and exercise therapy.We included studies utilizing different types of comparators, from usual care to active interventions.The most common comparators were usual care (n = 38) and enhanced usual care (n = 23).Delivery modes and modalities Most of the interventions were delivered either face-to-face (n = 36) or both face-to-face and via telephone (n = 25).Only eight interventions had a web-based element, while two were delivered exclusively via telephone and one employed audiotape.Most of the interventions (n = 40) included were delivered one-to-one.Seventeen interventions were delivered in a group, ten were mixed, and five were self-guided.

Figure 1 .
Figure 1.Prisma diagram illustrating the flow of information through the different phases.

Figure 2 .
Figure 2. Presence of single conditions in the 72 studies.

Figure 3 .
Figure 3. Types of interventions according to the most common clusters of conditions.
. SPSS 26 (IBM SPSS Statistics for Windows [Internet], 2019) and Microsoft Excel (2019) were used to categorize and summarize the data.A table presenting the BCTs used in each study was developed.The total number of BCTs (individually and hierarchal groups) used across trials was Health Psychol Rev. Author manuscript; available in PMC 2024 February 28.