Why Health and Social Care Support for People with Long-Term Conditions Should be Oriented Towards Enabling Them to Live Well

Telephone consulting for 'Personalised Care and Support Planning' with people with long-term conditions: a qualitative study of healthcare professionals' experiences during COVID-19 restrictions and beyond

BACKGROUND

Personalised Care and Support Planning (PCSP) replaces conventional annual reviews for people with long-term conditions. It is designed to help healthcare professionals (HCPs) and patients engage in conversations as equals and collaboratively plan actions oriented to each patient's priorities, alongside biomedical concerns. Little is known about how the shift to remote consulting initiated with COVID-19 restrictions has impacted PCSP.

AIM

To investigate HCPs' experiences of conducting PCSP conversations remotely and consider implications for the fulfilment of PCSP ambitions as remote consulting continues beyond COVID-19 restrictions.

METHODS

19 semi-structured interviews with HCPs in England and Scotland; interpretive analysis.

RESULTS

HCPs' accounts made clear that COVID-19 restrictions impacted multiple aspects of PCSP delivery, not just the mode of conversation. Broader disruption to general practice systems for gathering and sharing information ahead of PCSP conversations, and moves to 'wide window' appointment times, made it harder for patients to be prepared for PCSP conversations. This constrained scope to achieve PCSP ambitions even with the best professional communication skills. Most remote PCSP conversations were conducted by telephone. In the absence of visual communication with patients, it was sometimes harder to achieve the ambitions of PCSP conversations, including to balance patient and professional agendas, fulfil key planning activities, and foster a relational ethos of equal, collaborative partnership. The challenges were particularly severe when working with new patients and people with complex clinical and social problems. Although options for telephone appointments now offer valued flexibility, sustained experience of struggling to achieve PCSP ambitions via remote consulting led some HCPs to lower their standards for judging a "good" PCSP conversation, and to diminished professional satisfaction.

CONCLUSIONS

There are significant challenges to fulfilling the ambitions of PCSP via telephone, especially when preparatory support is limited. This study provides grounds for scepticism about how compatible telephone appointments can be with this person-centred model of working, especially for people who are socially disadvantaged and live with complex health conditions. These threats to the provision of person-centred support for people with long-term conditions warrant careful attention going forward if the PCSP model and its benefits are to be sustained.

Psychoeducational interventions for people living with chronic communicable disease: a systematic review

OBJECTIVE

Psychoeducation is increasingly recognised for its value in facilitating adaption to a chronic disease diagnosis. This study aimed to synthesise available literature on the psychoeducation interventions available to adults living with chronic communicable disease.

METHODS

PubMed, CINAHL, Embase, SocINDEX, PsycINFO and PsycArticles were systematically searched up to May 2023. Peer-reviewed studies, published in English, investigating the impact of psychoeducational interventions on adults living with chronic communicable disease were included, across a range of outcome measures. Narrative synthesis was performed. The Effective Public Health Practice Project tool and Critical Appraisal Skills Programme tool were used to assess risk of bias.

RESULTS

In total, 22 studies were included in the review. The majority (n=16) of study populations focused on people living with HIV, followed by hepatitis C (n=5) and genital herpes (n=1). Interventions were delivered online (n=2), via telephone (n=1) and in-person (n=19). The majority of interventions were delivered in group sessions (n=16) and studies emphasised the value of group cohesion for social support, encouraging participants to share their own knowledge in addition to standard didactic presentations. Four studies facilitated peer-led delivery of the psychoeducation. Studies aiming to improve psychological well-being were beneficial in reducing depressive symptoms and/or emotional distress or showed improvement in the participant group overall. There was some evidence to suggest psychoeducation can improve readiness to attend treatment and medication adherence.

CONCLUSION

The findings of this review highlight potential benefits of psychoeducation but indicate more robust clinical trials will be required to examine their effectiveness and elucidate the mechanisms by which they best operate. Future interventions incorporating a broader focus on resilience enhancement and coping skills specific to stigmatisation could more comprehensively serve the needs of adults living with chronic communicable disease, particularly with HIV. The role of peer support in group psychoeducation merits further exploration.

PROSPERO REGISTRATION NUMBER

CRD42021243058.

Tackling disrespect in health care: The relevance of socio-relational equality

Disrespect in health care often persists despite firm commitments to respectful service provision. This conceptual paper highlights how the ways in which respect and disrespect are characterised can have practical implications for how well disrespect can be tackled. We stress the need to focus explicitly on disrespect (not only respect) and propose that disrespect can usefully be understood as a failure to relate to people as equals. This characterisation is consonant with some accounts of respect but sometimes obscured by a focus on respecting people's autonomy and dignity. Emphasising equality is consistent with connections patients draw between being (dis)respected and (in)equality. It readily accommodates microaggressions as forms of disrespect, helping to understand how and why experiences of disrespect may be unintentional and to explain why even small instances of disrespect are wrong. Our view of disrespect with an emphasis on equality strengthens the demand that health systems take disrespect seriously as a problem of social injustice and tackle it at institutional, not just individual levels. It suggests several strategies for practical action. Emphasising relational equality is not an easy or short-term fix for disrespect, but it signals a direction of travel towards an important improvement ambition.

A lowered threshold to partnerships: a mixed methods process evaluation of participants' experiences of a person-centred eHealth intervention

BACKGROUND

In order to understand pathways of complex interventions, the Medical Research Council has suggested that process evaluations should be conducted alongside randomised controlled trials (RCTs). This paper presents a mixed methods process evaluation of a complex, person-centred eHealth intervention for persons on sick leave with common mental disorders.

AIM

The aim of the study was to explore participants' experiences of a person-centred eHealth intervention and illuminate meaningful activities and processes.

METHODS

Participants were recruited from the intervention arm of an RCT (n = 102). Questionnaires on perceived meaningfulness of the overall intervention and intervention activities were sent to participants on two occasions, after 3 and 6 months, and semi-structured interviews were conducted with a purposeful sample of 15 participants in the intervention group. Questionnaire data were analysed using descriptive statistics, and interview data were analysed using qualitative content analysis. The quantitative and qualitative data strands were integrated at interpretation.

RESULTS

At both follow-ups, a majority of participants reported that the intervention was fully or partly meaningful and that the most meaningful activity was the phone calls with health care professionals working in the intervention. In the qualitative analysis, three categories describing participants' experiences of the intervention were formed: Acknowledgment in a disconcerting situation, Finding ways forward and Unmet expectations. A synthesis of quantitative and qualitative findings resulted in the overarching theme of meaningfulness as constituted by a lowered threshold to partnerships: support within reach, when needed.

CONCLUSION

Experiences of meaningfulness of the intervention were constituted by a lowered threshold to forming care partnerships, in which support was within reach, when needed. If the content of the intervention was not in accordance with individuals' needs or expectations, access alone did not suffice to constitute meaningfulness.

TRIAL REGISTRATION

ClinicalTrials.gov; NCT03404583; 19/01/2018.

Implementing and evaluating care and support planning: a qualitative study of health professionals' experiences in public polyclinics in Singapore

BACKGROUND

Two polyclinics in Singapore modified systems and trained health professionals to provide person-centred Care and Support Planning (CSP) for people with diabetes within a clinical trial. We aimed to investigate health professionals' perspectives on CSP to inform future developments.

METHODS

Qualitative research including 23 semi-structured interviews with 13 health professionals and 3 co-ordinators. Interpretive analysis, including considerations of how different understandings, enactments, experiences and evaluative judgements of CSP clustered across health professionals, and potential causal links between them.

RESULTS

Both polyclinic teams introduced CSP and sustained it through COVID-19 disruptions. The first examples health professionals gave of CSP 'going well' all involved patients who came prepared, motivated and able to modify behaviours to improve their biomedical markers, but health professionals also said that they only occasionally saw such patients in practice. Health professionals' accounts of how they conducted CSP conversations varied: some interpretations and reported enactments were less clearly aligned with the developers' person-centred aspirations than others. Health professionals brought different communication skill repertoires to their encounters and responded variably to challenges to CSP that arose from: the linguistic and educational diversity of patients in this polyclinic context; the cultural shift that CSP involved; workload pressures; organisational factors that limited relational and informational continuity of care; and policies promoting biomedical measures as key indicators of healthcare quality. While all participants saw potential in CSP, they differed in the extent to which they recognised relational and experiential benefits of CSP (beyond biomedical benefits), and their recommendations for continuing its use beyond the clinical trial were contingent on several considerations. Our analysis shows how narrower and broader interpretive emphases and initial skill repertoires can interact with situational challenges and respectively constrain or extend health professionals' ability to refine their skills with experiential learning, reduce or enhance the potential benefits of CSP, and erode or strengthen motivation to use CSP.

CONCLUSION

Health professionals' interpretations of CSP, along with their communication skills, interact in complex ways with other features of healthcare systems and diverse patient-circumstance scenarios. They warrant careful attention in efforts to implement and evaluate person-centred support for people with long-term conditions.

Patient Safety and the Question of Dignitary Harms

Patient safety is a central aspect of healthcare quality, focusing on preventable, iatrogenic harm. Harm, in this context, is typically assumed to mean physical injury to patients, often caused by technical error. However, some contributions to the patient safety literature have argued that disrespectful behavior towards patients can cause harm, even when it does not lead to physical injury. This paper investigates the nature of such dignitary harms and explores whether they should be included within the scope of patient safety as a field of practice. We argue that dignitary harms in health care are-at least sometimes-preventable, iatrogenic harms. While we caution against including dignitary harms within the scope of patient safety just because they are relevantly similar to other iatrogenic harms, we suggest that thinking about dignitary harms can help to elucidate the value of patient safety, and to illuminate the evolving relationship between safety and quality.

Perception among NHIS-HMO Enrolees of the Attitudes of Medical Personnel during Outpatient Care in Lagos Hospitals

The quality of healthcare services depends on the interactions between administrators, customers, and healthcare providers. This study seeks to examine how National Health Insurance Scheme (NHIS)-Health Maintenance Organization (HMO) enrolees perceive the attitudes of medical personnel while receiving outpatient care in Lagos hospitals. Mixed methods were used, i.e., distributing questionnaires and in-depth interviews with participants. Quantitative data were analysed using Statistical Product and Service Solutions (SPSS) version 20, and approaches that involved frequency statistics, factor analysis, contingency chi-square and correlation analysis were applied. The results indicate that the variables "humane" and "empathetic" have a direct impact on enrolees' perception and an indirect impact on motivation to adhere to medical advice among enrolees. This research has practical implications, especially in light of new initiatives of NHIS collaboration with HMO to deliver quality healthcare services to enrolees.

How do peer support interventions for the self-management of chronic pain, support basic psychological needs? A systematic review and framework synthesis using self-determination theory

OBJECTIVE

To identify how peer support interventions, for self-management of chronic pain, support basic psychological needs from a self-determination theory (SDT) perspective, using a systematic review.

METHODS

Ten databases were searched for studies reporting qualitative research about peer interactions in pain management interventions. 'Best fit' framework synthesis methodology was applied to identify strategies that support the satisfaction of competence, autonomy and motivation. These were matched to definitions of strategies provided by standardised taxonomies.

RESULTS

18 studies were selected for inclusion. The synthesis resulted in a conceptual model, identifying 12 peer strategies that support psychological needs for self-management of chronic pain; 10 overlapped with existing taxonomies.

CONCLUSION

This was the first known attempt to synthesise evidence about peer support strategies for people living with pain, using SDT as an a priori framework. The model demonstrates commonality between the motivation-promoting processes of peer support and those of other behaviour change interventions and identifies additional unique strategies provided by peers. This systematic classification of peer support strategies provides a means for future study of the efficacy and comprehensiveness of peer interventions.

PRACTICE IMPLICATIONS

The model could assist healthcare professionals and support groups to optimise the potential of peer processes.

One size does not fit all: Participants' experiences of the selfBACK app to support self-management of low back pain-a qualitative interview study

BACKGROUND

Low back pain (LBP) is one of the most common reasons for disability globally. Digital interventions are a promising means of supporting people to self-manage LBP, but implementation of digital interventions has been suboptimal. An artificial intelligence-driven app, selfBACK, was developed to support self-management of LBP as an adjunct to usual care. To better understand the process of implementation from a participant perspective, we qualitatively explored factors influencing embedding, integrating, and sustaining engagement with the selfBACK app, and the self-perceived effects, acceptability, and satisfaction with the selfBACK app.

METHODS

Using a qualitative interview study and an analytic framework approach underpinned by Normalization Process Theory (NPT), we investigated the experiences of patients who participated in the selfBACK randomized controlled trial (RCT). Interviews focused on the motivation to participate in the RCT, experiences of using the selfBACK app, and views about future intended use and potential of using digital health interventions for self-management of LBP. Participants were purposively sampled to represent diversity in age, sex, and implementation reflected by a proxy measure of number of app-generated self-management plans during the first three months of RCT participation.

RESULTS

Twenty-six participants aged 21-78, eleven females and fifteen men, with two to fourteen self-management plans, were interviewed between August 2019 and April 2020. A broad range of factors influencing implementation of selfBACK within all constructs of NPT were identified. Key facilitating factors were preferences and beliefs favoring self-management, a friendly, motivational, and reassuring supporter, tailoring and personalization, convenience and ease of use, trustworthiness, perceiving benefits, and tracking achievements. Key impeding factors were preferences and beliefs not favoring self-management, functionality issues, suboptimal tailoring and personalization, insufficient time or conflicting life circumstances, not perceiving benefits, and insufficient involvement of health care practitioners. Self-perceived effects on pain and health, behavior/attitude, and gaining useful knowledge varied by participant.

CONCLUSIONS

The high prevalence of LBP globally coupled with the advantages of providing help through an app offers opportunities to help countless people. A range of factors should be considered to facilitate implementation of self-management of LBP or similar pain conditions using digital health tools.

Time to Revisit Heart Failure Self-Care: A Concept Analysis

Self-care is a central concept in heart failure management and nursing practice. Yet, the uptake of heart failure self-care has been uncritical and detached from broader contexts. Therefore, heart failure self-care was explored using Rodger's evolutionary concept analysis approach to identify antecedents, attributes, and consequences with attention to context, time, application, and meaning. The analysis suggests that heart failure self-care tends to focus on individual behaviors to the detriment of social and structural determinants of health. It also shifts responsibility away from the health care system and onto the individual. Moving forward, a more robust conceptualization of heart failure self-care is needed or possibly, the development of a new concept that focuses beyond the self .

Developing a global practice-based framework of person-centred care from primary data: a cross-national qualitative study with patients, caregivers and healthcare professionals

INTRODUCTION

Person-centred care (PCC) is internationally recognised as a critical component of high-quality healthcare. However, PCC evolved in a few high-income countries and there are limited data exploring this concept across the vast majority of countries which are low- and middle-income. This study aimed to appraise and adapt a PCC model across three serious physical conditions in three middle-income countries and generate an evidence-based framework and recommendations for globally relevant PCC.

METHODS

Cross-national, cross-sectional qualitative study. In depth, semistructured interviews conducted with: advanced cancer patients in Jordan (n=50), their caregivers (n=20) and healthcare professionals (HCPs) (n=20); chronic obstructive pulmonary disease patients in South Africa (n=22), their caregivers (n=19) and HCPs (n=22); heart failure patients in Thailand (n=14), their caregivers (n=10) and HCPs (n=12). Data were analysed using framework analysis. Santana et al's PCC model (2018) and Giusti et al's systematic review (2020) were used to construct an a priori coding frame for deductive analysis, with additional inductive coding for coding that did not fit the frame.

RESULTS

The findings both reveal specific practical actions that contribute towards delivering PCC and highlight new cross-national domains of person-centredness: interdependency and collectivism; bringing care into the home and community; equity and non-discrimination; addressing health and illness within the context of limited resources; and workforce well-being.

CONCLUSION

The data suggest that PCC requires particular structural features of the healthcare system to be in place, such as professional education in PCC values and partnerships with community-based workers. These structures may better enable PCC processes, including tailored information sharing and providing genuine opportunities for patients to do the things that matter to them, such as making informed care decisions and sustaining social relationships. PCC must also accommodate a collectivist perspective and support the well-being of the workforce.

Vagueness and variety in person-centred care

Person-centred care is a cornerstone of contemporary health policy, research and practice. However, many researchers and practitioners worry that it lacks a ‘clear definition and method of measurement,’ and that this creates problems for the implementation of person-centred care and limits understanding of its benefits. In this paper we urge caution about this concern and resist calls for a clear, settled definition and measurement approach. We develop a philosophical and conceptual analysis which is grounded in the body of literature concerning the theory and practice of person-centred care. We consider a range of influential definitional frameworks of person-centred care, highlighting their differences and showing that they do not correspond to a clearly circumscribed and consistent underlying concept. We argue that a degree of indeterminacy and vagueness should not be seen as a problem with the concept of person-centred care; these are features of a rich and contested concept which exists prior to and outside of practical and technical operational definitions and applications. We defend the value of operating with multiple accounts of person-centred care, arguing that what counts as being person-centred can vary across different care contexts, in relation to different patient groups, and as a reflection of different, defensible ethical perspectives. Although the idea of a single, agreed definition is attractive and may seem to be a practical or even necessary step towards meaningful and coordinated action, we argue that this is only the case in a qualified sense. Comprehensive attempts to narrow down the concept in this way should be resisted, as they risk undermining what it is that makes person-centredness a valuable concept in healthcare.

How do nurses support chronically ill clients' participation and self-management in primary care? A cross-country qualitative study

BACKGROUND

In the context of the advancement of person-centered care models, the promotion of the participation of patients with chronic illness and complex care needs in the management of their care (self-management) is increasingly seen as a responsibility of primary care nurses. It is emphasized that nurses should consider the psychosocial dimensions of chronic illness and the client's lifeworld. Little is known about how nurses shape this task in practice.

METHODS

The aim of this analysis is to examine how primary care nurses understand and shape the participation of patients with chronic illness and complex care needs regarding the promotion of self-management. Guided interviews were conducted with nurses practicing in primary care and key informants in Germany, Spain, and Brazil with a subsequent cross-case evaluation. Interpretive and practice patterns were identified based on Grounded Theory.

RESULTS

Two interpretive and practice patterns were identified: (1) Giving clients orientation in dealing with chronic diseases and (2) supporting the integration of illness in clients' everyday lives. Nurses in the first pattern consider it their most important task to provide guidance toward health-promoting behavior and disease-related decision-making by giving patients comprehensive information. Interview partners emphasize client autonomy, but rarely consider the limitations chronic disease imposes on patients' everyday lives. Alternatively, nurses in the second pattern regard clients as cooperation partners. They seek to familiarize themselves with their clients' social environments and habits to give recommendations for dealing with the disease that are as close to the client's lifeworld as possible. Nurses' recommendations seek to enable patients and their families to lead a largely 'normal life' despite chronic illness. While interview partners in Brazil or Spain point predominantly to clients' socio-economic disadvantages as a challenge to promoting client participation in primary health care, interview partners in Germany maintain that clients' high disease burden represents the chief barrier to self-management.

CONCLUSIONS

Nurses in practice should be sensitive to client's lifeworlds, as well as to challenges that arise as they attempt to strengthen clients' participation in care and self-management. Regular communication between clients, nurses, and further professionals should constitute a fundamental feature of person-centered primary care models.

Social relationship influence on self-care and health among older people living with long term conditions: A mixed-methods study

BACKGROUND

Social relationships influence health, yet less is known on how social relationships influence self-care among older people living with multiple long-term conditions.

OBJECTIVES

The purpose of this study was to determine how social networks influence therapeutic self-care behaviours and health among community dwelling older people living with multiple long-term conditions.

DESIGN

Explanatory sequential mixed-methods.

SETTING/SAMPLE

Community dwelling older people living in the Northeast United States.

METHODS

A cross-sectional sample of eighty-nine people aged sixty-five and older participated in telephone surveys. A nested sample of twelve participants completed a follow-up open-ended interview. Descriptive statistics, bivariate correlations and regression statistics were used to examine the associations between social network features and functions with the dependent variables of therapeutic self-care behaviours and health. Qualities that emphasised the contexts of the relationships were integrated in the data analysis.

RESULTS

The strength of the social network and level of social support influenced the outcomes of therapeutic self-care and mental health. Thematic analysis expanded this explanation of self-care in relation to social network size, psycho-social support, activation of support, interaction frequency and type.

CONCLUSION

In supporting older people living with multiple long-term conditions, this nursing research offers new ways to understand close social relationships influence on self-care in developing systems of care at the community level.

IMPLICATIONS FOR PRACTICE

Designing care systems that include small trusted formal and informal caregivers that integrate social network members could improve health outcomes and improve access to supportive resources.

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OBJECTIVE

The aim of this study was to identify the health education needs of people suffering from several pathologies including HIV and/or hepatitis, living in vulnerable conditions in Therapeutic Coordination Apartments (known in French as Appartements de Coordination Thérapeutique under the acronym ACT).

METHOD

This article is based on a qualitative and collaborative study involving in research team people living in ACT, professionals of ACT and academics. Interview guides based on the literature were developed. Nine ACTs participated: there were interviews with 36 people with chronic conditions, 9 focus groups with staff members and 9 additional interviews with ACT managers.

RESULTS

Health education needs were identified. These involved: managing one's multiple conditions, managing certain diseases in particular, daily life with multiple chronic conditions, the connections and origins of the diseases. Factors influencing how they deal with one disease rather than another were expressed. The educational needs of people with HIV and/or hepatitis have been highlighted.

CONCLUSION

Health education needs still exist despite the care that people living in ACTs receive. The study makes it possible to put forward proposals for improving support and, more specifically, health education interventions implemented in ACTs: asking additional questions to identify health education needs more precisely, providing polypathology therapeutic patient education (TPE) training to the teams, involving the affected populations, taking into account health literacy levels.

Are We Transitioning Toward Person-centered Practice on Self-management Support? An Explorative Case Study Among Rheumatology Outpatient Clinic Nurses in Norway

Introduction

There are only a few studies investigating nurses’ views on self-management in the care of patients with rheumatic diseases.

Objective

The aim of this study is to explore how Norwegian rheumatology outpatient nurses describe their ways of supporting patients’ self-management focusing on the core dimensions of person-centered self-management support.

Methods

Ten individual semistructured interviews with rheumatology outpatient nurses were conducted in Norway from March to September 2017. The interviews were audiorecorded and transcribed verbatim. NVIVO was used to support a systematic analysis of themes and patterns.

Results

Nurses’ views on self-management support fell into three approaches; (1) narrowly biomedically orientated, (2) biomedically and holistic, and (3) person-centered. The nurse's views of self-management support varied and did not fully align with the core dimensions of person-centered practice.

Conclusion

The findings indicate that the biomedical paradigm continues to influence Norwegian rheumatology outpatient clinic nurses’ approach to self-management support. If person-centered principles of self-management support are to be translated into standard nursing practice, including identifying and supporting patient-defined self-management goals and processes, there is a need to challenge established structures in health care systems.

A co-design study to develop supportive interventions to improve psychological and social adaptation among adults with new-onset type 1 diabetes in Denmark and the UK

OBJECTIVE

To develop supportive interventions for adults with new-onset type 1 diabetes (T1D) to facilitate positive adaptive strategies during their transition into a life with diabetes.

DESIGN

The study used a co-design approach informed by Design Thinking to stimulate participants' reflections on their experiences of current care and generate ideas for new supportive interventions. Visual illustrations were used to depict support needs and challenges. Initial discussions of these needs and challenges were facilitated by researchers and people with diabetes in workshops. Data comprising transcribed audio recordings of the workshop discussions and materials generated during the workshops were analysed thematically.

SETTINGS

Specialised diabetes centres in Denmark and the United Kingdom.

PARTICIPANTS

Adults with new-onset T1D (n=24) and healthcare professionals (HCPs) (n=56) participated in six parallel workshops followed by four joint workshops with adults (n=29) and HCPs (n=24) together.

RESULTS

The common solution prioritised by both adults with new-onset T1D and HCP participants was the development of an integrated model of care addressing the psychological and social elements of the diagnosis, alongside information on diabetes self-management. Participants also indicated a need to develop the organisation, provision and content of care, along with the skills HCPs need to optimally deliver that care. The co-designed interventions included three visual conversation tools that could be used flexibly in the care of adults with new-onset T1D to support physical, psychological and social adaptation to T1D.

CONCLUSION

This co-design study has identified the care priorities for adults who develop T1D, along with some practical conversational tools that may help guide HCPs in attending to the disruptive experience of the diagnosis and support adults in adjusting into a life with diabetes.

Participants' experiences of and perceived value regarding different support types for long-term condition self-management programmes

OBJECTIVES

Health professional-led group programmes are a common form of long-term condition self-management support. Much research has focused on clinical outcomes of group participation, yet there is limited research on how group participants perceive and experience the support they receive. We aim to identify the different types of support that participants receive from both facilitators and other participants, and how they value this support.

METHODS

Semi-structured interviews were conducted with 20 participants taking part in a self-management group programme for a long-term condition (obesity, type 2 diabetes or chronic obstructive pulmonary disease). Data pertaining to support types were deductively identified through a social support framework prior to interpretive thematic analysis.

RESULTS

Participants identified information and emotional support from both facilitators and other participants as complementary yet distinct. Facilitators' support came from professional training and other participants' support reflected the contextual, lived experience. Professional interactions were prioritised, constraining opportunities for participant-participant support to be received and exchanged.

DISCUSSION

We identified a key gap in how self-management support is enacted in groups. Engaging participants to share experiential knowledge will make group support more relevant and mutually beneficial to participants living with a long-term condition.

Mental-physical multimorbidity treatment adherence challenges in Brazilian primary care: A qualitative study with patients and their healthcare providers

Improved understanding of multimorbidity (MM) treatment adherence in primary health care (PHC) in Brazil is needed to achieve better healthcare and service outcomes. This study explored experiences of healthcare providers (HCP) and primary care patients (PCP) with mental-physical MM treatment adherence. Adults PCP with mental-physical MM and their primary care and community mental health care providers were recruited through maximum variation sampling from nine cities in São Paulo State, Southeast of Brazil. Experiences across quality domains of the Primary Care Assessment Tool-Brazil were explored through semi-structured in-depth interviews with 19 PCP and 62 HCP, conducted between April 2016 and April 2017. Through thematic conent analysis ten meta-themes concerning treatment adherence were developed: 1) variability and accessibility of treatment options available through PHC; 2) importance of coming to terms with a disease for treatment initation; 3) importance of person-centred communication for treatment initiation and maintenance; 4) information sources about received medication; 5) monitoring medication adherence; 6) taking medication unsafely; 7) perceived reasons for medication non-adherence; 8) most challenging health behavior change goals; 9) main motives for initiation or maintenance of treatment; 10) methods deployed to improve treatment adherence. Our analysis has advanced the understanding of complexity inherent to treatment adherence in mental-physical MM and revealed opportunities for improvement and specific solutions to effect adherence in Brazil. Our findings can inform research efforts to transform MM care through optimization.

The preferences of people with asthma or chronic obstructive pulmonary disease for self-management support: A qualitative descriptive study

AIMS AND OBJECTIVES

The aim of this study was to explore and describe the self-management support (SMS) preferences of adults with asthma and/or chronic obstructive pulmonary disease (COPD).

BACKGROUND

Self-management support interventions have had beneficial outcomes for people with asthma and people with COPD, though challenges remain in their implementation. Increased understanding of the support preferences of people with asthma/COPD can help inform the development of future interventions to address patients' preferences.

DESIGN

A qualitative descriptive design was used.

METHODS

Semi-structured focus group and individual interviews were conducted with 20 adult participants who had asthma and/or COPD in Ireland. Qualitative content analysis was used to analyse interviews. The SRQR reporting guideline was used.

RESULTS

Three themes were identified. Support accessibility included having access to routine and unscheduled support from healthcare professionals with specialist knowledge. Consultation content described the need for comprehensive and person-centred support. The person-provider relationship described the value of healthcare professionals acknowledging patient concerns, noted as a challenge for people with asthma, and continuity in relationships over time.

CONCLUSIONS

Routine support for people with asthma/COPD needs to be comprehensive in addressing the individual patient's challenges. Access to timely advice during exacerbations was a priority for people with asthma/COPD, suggesting that flexible access to services as well as routine review may be optimal for supporting self-management of asthma/COPD. Feeling listened to regarding symptoms experienced may be of intrinsic value to people with asthma/COPD.

RELEVANCE TO CLINICAL PRACTICE

The study emphasises the importance of continued training in communications skills for healthcare professionals supporting people with asthma/COPD, particularly acknowledging the patient's concerns in the context of symptom changes/flare-up. A respiratory nurse specialist was valued as being a care coordinator who could support routine management as well as managing exacerbations, having specialist knowledge and knowing the patient over time.

Telehealth-delivered, Cardioprotective Diet and Exercise Program for Liver Transplant Recipients: A Randomized Feasibility Study

Supplemental Digital Content is available in the text.

Rapid excess weight gain and metabolic complications contribute to poor outcomes following liver transplant care. Providing specialist lifestyle intervention with equitable access is a challenge for posttransplant service delivery.

The pain self-management paradox: why do we focus on the individual when life context plays such a major role?

Although there has been a drive toward pain self-management, self-management has not yet in my opinion been successfully defined or evaluated and neither has it been consistently translated from idea to practice. In this perspective article, I identify gaps in our approach to pain management and argue that even though we know life context plays a huge role in influencing our health, by and large we fail to take this into account. I argue for a shift in focus away from the 'self' and explore how we might be able to do this within the constraints of our tired and over-stretched health system.

Quality of Life and Value Assessment in Health Care

Proposals for health care cost containment emphasize high-value care as a way to control spending without compromising quality. When used in this context, 'value' refers to outcomes in relation to cost. To determine where health spending yields the most value, it is necessary to compare the benefits provided by different treatments. While many studies focus narrowly on health gains in assessing value, the notion of benefit is sometimes broadened to include overall quality of life. This paper explores the implications of using subjective quality of life measures for value assessment. This approach is claimed to be more respectful of patients and better capture the perspectival nature of quality of life. Even if this is correct, though, subjective measurement also raises challenging issues of interpersonal comparability when used to study health outcomes. Because such measures do not readily distinguish benefits due to medical interventions from benefits due to personal or other factors, they are not easily applied to the assessment of treatment value. I argue that when the outcome of interest in value assessment is broadened to include quality of life, the cost side of these measures should also be broadened. I show how one philosophical theory of well-being, Jason Raibley's "agential flourishing" theory, can be adapted for use in quality of life research to better fit the needs and aims of value assessment in health care. Finally, I briefly note some implications of this argument for debates about fairness in health care allocations.

A qualitative investigation of lived experiences of long-term health condition management with people who are food insecure

Background

As more people are living with one or more chronic health conditions, supporting patients to become activated, self-managers of their conditions has become a key health policy focus both in the UK and internationally. There is also growing evidence in the UK that those with long term health conditions have an increased risk of being food insecure. While international evidence indicates that food insecurity adversely affects individual’s health condition management capability, little is known about how those so affected manage their condition(s) in this context. An investigation of lived experience of health condition management was undertaken with food insecure people living in north east Scotland. The study aimed to explore the challenges facing food insecure people in terms of, i. their self-care condition management practices, and ii. disclosing and discussing the experience of managing their condition with a health care professional, and iii. Notions of the support they might wish to receive from them.

Methods

Twenty in-depth interviews were conducted with individuals attending a food bank and food pantry in north east Scotland. Interview audio recordings were fully transcribed and thematically analysed.

Results

Individuals reporting multiple physical and mental health conditions, took part in the study. Four main themes were identified i.e.: 1. food practices, trade-offs and compromises, that relate to economic constraints and lack of choice; 2. illness experiences and food as they relate to physical and mental ill-health; 3. (in) visibility of participants’ economic vulnerability within health care consultations; and 4. perceptions and expectations of the health care system.

Conclusions

This study, the first of its kind in the UK, indicated that participants’ health condition management aspirations were undermined by the experience of food insecurity, and that their health care consultations in were, on the whole, devoid of discussions of those challenges. As such, the study indicated practical and ethical implications for health care policy, practice and research associated with the risk of intervention-generated health inequalities that were suggested by this study. Better understanding is needed about the impact of household food insecurity on existing ill health, wellbeing and health care use across the UK.

'It is like learning how to live all over again' A systematic review of people's experiences of living with a chronic illness from a self-determination theory perspective

Objective: To conduct a systematic review and synthesis of qualitative evidence exploring the views and experiences of people living with a chronic illness that utilised self-determination theory. Methods: We searched MEDLINE via OvidSP, PsycINFO via OvidSP, PubMed, CINAHL, EMBASE, Google Scholar, the journals Qualitative Health Research and Qualitative Research. Studies were included if they used qualitative methods, explored the subjective experiences of people living with a chronic illness and underpinned the analysis with self-determination theory. Results: From 4605 articles, six met the inclusion criteria. The synthesis culminated in a line of argument that patients endeavoured to be 'free from disease'. People's desire to live a life free from disease required nurturing their: (1) need to feel empowered (autonomy), (2) perceived ability to self-care (competence) and, (3) their need to feel a sense of belonging (relatedness). Conclusion: This review has highlighted that the majority of studies included in this review focused on the clinical aspects of managing a chronic condition and changing patient health behaviours. This suggests that there is a need for deep reflection on the current practice of caring for patients with a chronic illness. Exploring the lived experience has the potential to unravel the psychological and emotional needs of those living with a chronic illness.

Mediating engagement in a social network intervention for people living with a long-term condition: A qualitative study of the role of facilitation

Background

Successful facilitation of patient‐centred interventions for self‐management support has traditionally focussed on individual behaviour change. A social network approach to self‐management support implicates the need for facilitation that includes an orientation to connecting to and mobilizing support and resources from other people and the local environment.

Objective

To identify the facilitation processes through which engagement with a social network approach to self‐management is achieved.

Method

Thematic analysis was used to analyse data from a longitudinal study design using quasi‐ethnographic methods comprising non‐participant observation, video and qualitative interviews involving 30 participants living with a long‐term condition recruited from a marginalized community.

Results

Findings centred on three themes about the social network approach facilitation processes: reversing the focus on the self by bringing others into view; visualization and reflection as a mediator of positive disruption and linking to new connections; personalized matching of valued activities as a means of realizing preference elicitation.

Discussion and conclusions

Engagement processes with a social network approach illuminated the relevance of cognizance of an individual's immediate social context and forefronting social participation with others as the bases of self‐management support of a long‐term condition. This differs from traditional guided facilitation of health behaviour interventions that frame health as a matter of personal choice and individual responsibility.

Grounding the right to live in the community (CRPD Article 19) in the capabilities approach to social justice

For advocates of the rights of persons with disabilities, particularly persons with mental disabilities, the human right to live in the community as an equal member is seen to be central and, often, even as the basis for all other human rights. Yet, despite its articulation in human rights law in the Convention on the Rights of People with Disabilities (CRPD), foundational issues about the right remain undertheorized and unclear. This paper brings to bear the capabilities approach, a normative framework about human well-being, social development and social justice, to this central concern in disability rights, mental health ethics, and international human rights law: protecting and respecting a person's right to live in a community as an equal. We argue that this human and moral right is best conceptualized as a capability to live in the community as an equal member. The capabilities approach provides this capability with a strong ethical framework and conceptual resources to guide reasoning and its practical realization.

Health professionals' experiences and perspectives on food insecurity and long-term conditions: A qualitative investigation

Estimates suggest that over 10% of the UK population are affected by food insecurity. International evidence indicates that food insecurity is a risk factor for many long-term health conditions, and can adversely affect people's ability to manage existing conditions. Food insecurity is thus not only a serious social concern but also a healthcare issue requiring the attention of UK health professionals. An exploratory qualitative study was undertaken to investigate the experiences and views of health professionals in north east Scotland, with a particular focus on support for people with long-term conditions whom they believed were affected by food insecurity. Two focus groups and nine semi-structured interviews were undertaken with a total of 20 health professionals between March and July 2016. Thematic analysis generated three main themes. The health professionals had (a) diverse levels of understanding and experience of food insecurity, but between them identified a range of (b) negative impacts of food insecurity on condition-management, especially for diet dependent conditions or medication regimes, and for mental health. Even for those health professionals more familiar with food insecurity, there were various (c) practical and ethical uncertainties about identifying and working with food insecure patients (it could be difficult to judge, for example, whether and how to raise the issue with people, to tailor dietary advice to reflect food insecurity, and to engage with other agencies working to address food insecurity). This study indicates that health professionals working with food insecure patients have learning and support needs that warrant further investigation. Debates about health professionals' responsibilities, and interventions to guide and support health professionals, including tools that might be used to screen for food insecurity, must also reflect the diverse lived needs and values of people who experience food insecurity.

The work and relatedness of ties mediated online in supporting long-term condition self-management

The 'care transition' is characterised by reduced state involvement in chronic illness management in response to socio-political movements aimed at meeting the challenges presented by an increased prevalence of chronic illness. Amongst these changes has been online communities' rising importance in everyday interactions and attention is being increasingly paid towards the ways online contacts might contribute to self-management. Whilst research has illuminated the relevance of personal networks in long-term condition management, it is relevant to extend this work to consider the place of ties mediated online in this bricolage of support, including better understanding the work drawn from them and the strategies involved in eliciting it. This study examined the work and relatedness of 30 participants, who used online communities. Participants were asked about the role of on and offline ties and ego network mapping was used to frame conversations about the nature of this support. The context of engagement followed three main themes. Participants drew from online communities in response to deficits in offline support, they used online ties to leverage support or action from offline ties and they used online ties to substitute offline support, with less intimate online ties.

Between knowing and doing person-centredness: A qualitative examination of health professionals’ perceptions of roles in self-management support

Self-management is a contemporary model of chronic condition care that places expectations on, and roles for, both patients and health professionals. Health professionals are expected to form partnerships with their patients, and patients are expected to be active participants in their own care. In these new roles, control and responsibility for self-management are shared between people with chronic conditions and their health professionals. We still have limited knowledge about how these new roles are enacted in self-management support. In this article, we examine how health professionals perceive the roles of patients and professionals in chronic condition self-management, drawing on Bourdieu’s concepts of field, doxa and capital. In this qualitative study, 32 in-depth interviews were conducted with 11 health professionals in Sydney, Australia. Data were analysed thematically. Three themes were derived. First, there was incongruence between how participants characterised and enacted their roles. Second, participants compartmentalised clinical and non-clinical aspects of self-management support. Finally, the roles of health professionals entwined with emotions and judgements of patienthood revealed that the provision of self-management support was linked to a fit between individuals’ cultural health capital and the expectations governing the field. We argue that ‘taken for granted’ assumptions about self-management and self-management support must be challenged to mitigate negative social representations and unrealistic expectations placed on patients and health professionals, particularly those patients with less capital, who are more marginalised within clinical interactions.

The Year of Care approach: developing a model and delivery programme for care and support planning in long term conditions within general practice

BACKGROUND

People with long term conditions (LTCs) make most of the daily decisions and carry out the activities which affect their health and quality of life. Only a fraction of each contact with a health care professional (HCP) is spent supporting this. This paper describes how care and support planning (CSP) and an implementation framework to redesign services, were developed to address this in UK general practice. Focussed on what is important to each individual, CSP brings together traditional clinical issues and the person's lived experience in a solution focussed, forward looking conversation with an emphasis on 'people not diseases'.

METHODS

The components of CSP were developed in three health communities using diabetes as an exemplar. This model was extended and refined for other single conditions and multimorbidity across 40 sites and two nations, over 15 years. Working with local teams and communities the authors used theoretical models of care, implementation and spread, developing and tailoring training, support and resources to embed CSP as usual care, sharing learning across a community of practice.

RESULTS

The purpose, content, process, developmental hurdles and impact of this CSP model are described, alongside an implementation strategy. There is now a robust, reproducible five step model; preparation, conversation, recording, actions and review. Uniquely, preparation, involving information sharing with time for reflection, enables an uncluttered conversation with a professional focussed on what is important to each person. The components of the Year of Care House act as a checklist for implementation, a metaphor for their interdependence and a flexible framework. Spreading CSP involved developing exemplar practices and building capacity across local health communities. These reported improved patient experience, practitioner job satisfaction, health behaviours and outcomes, teamwork, practice organisation, resource use, and links with wider community activities.

CONCLUSIONS

Tested in multiple settings, CSP is a reproducible and practical model of planned care applicable to all LTCs, with the capacity to be transformative for people with LTCs and health care professionals. It recaptures relational dimensions of care with transactional elements in the background. Options for applying this model and implementation framework at scale now need to be explored.

Responsibility in healthcare across time and agents

It is unclear whether someone's responsibility for developing a disease or maintaining his or her health should affect what healthcare he or she receives. While this dispute continues, we suggest that, if responsibility is to play a role in healthcare, the concept must be rethought in order to reflect the sense in which many health-related behaviours occur repeatedly over time and are the product of more than one agent. Most philosophical accounts of responsibility are synchronic and individualistic; we indicate here what paying more attention to the diachronic and dyadic aspects of responsibility might involve and what implications this could have for assessments of responsibility for health-related behaviour.

Health assessment and the capability approach

Health has an important role in the achievement of a good quality of life. Many public policies intended to enhance individual and population health. Amartya Sen’s Capability Approach (CA) offers a framework to assess well-being, as well as interventions seeking to increase it. There are, however, important practical challenges that must be faced before applying CA to concrete situations, such as health. One of these challenges is defining whether it is functioning or a capability that is the feature to be assessed. Moreover, some aspects of freedom that are relevant for CA are frequently neglected, such as agency. These aspects must be considered when performing a health assessment using the CA as a framework. A health assessment using the CA as a framework should include indicators based on the achieved dimension (health functioning), resources and conversion factors (health capability), and freedom to achieve (agency).

Maintenance and Development of Social Connection by People with Long-term Conditions: A Qualitative Study

Social connection is important for people’s health and well-being. Social isolation arising from a lack of meaningful connection with others can result in deterioration of well-being with negative consequences for health. For people living with multiple long-term conditions, the building and maintaining of social connection may be challenging. The aim of this study was to explore with people with long-term conditions how they perceive they maintain and develop social connections. We undertook semi-structured interviews with seventeen adults, and analyzed the data for themes. Themes were “Meaningful connection”, “Wherewithal for social connection” and “Impact of a major change in life course”. The findings suggest that social connection is valued, and facilitates meaningful ways to reciprocate support with others, thus enabling access to knowledge and resources for better health and well-being. However, people with long-term conditions can experience challenges to developing and maintaining social connectedness after a major change in life course. We suggest that healthcare providers are well placed to facilitate ways for people with long-term conditions to socially connect with others in their neighbourhood and community, and that this in particular be attended to after a major life change.

Goals for living with a chronic condition: The relevance of temporalities, dispositions, and resources

INTRODUCTION

Premised on the idea that setting goals motivates action and allocation of resources toward a desired future state, goal-setting has become a key component of self-management support. The notions that underpin goal-setting situate self-management firmly within the control and responsibility of individuals. Yet, we argue that goals are not solely individual pursuits to be achieved if individuals have the right knowledge and enough motivation; rather, they are social products, influenced by individual and collective subjectivities, which are structured over time.

OBJECTIVE

Drawing primarily on Bourdieu's concept of habitus, along with capital and field, we examine how goals are constructed in self-management support encounters.

METHOD

Seventeen patient-professional dyads comprising 15 patients and 11 health professionals were interviewed on up to three occasions. In total 64 semi-structured interviews were conducted between 2015 and 2017 in Sydney, Australia.

RESULTS

Goals were manifested through patient participants' expressions of goal agency (as self-owned wants and opportunities; responsibilities to self and others; or necessities); goal-oriented dispositions (determined; responsible; or powerless); temporal orientations (past, present or future); and access to resources to support self-management. These characteristics were grouped into three typologies: 'Goals as opportunities'; 'From goals to responsibilities'; and 'Necessities when living precariously'.

CONCLUSIONS

The way goals were constructed was structured over time by present experiences superimposed on past experiences and access to resources. These findings help broaden understandings of the tensions between patient and professionals' goals for living well with chronic conditions and draw attention to the need for structural change to support people to live well with their chronic conditions.

Supporting self-management after traumatic brain injury: Codesign and evaluation of a new intervention across a trauma pathway

Background

Supported self‐management (SSM) is a recognized approach for people with long‐term conditions but, despite the prevalence of unmet needs, little is known about its role for people with traumatic brain injury (TBI).

Objectives

To codesign an SSM intervention with people with TBI and evaluate feasibility of implementation through multidisciplinary staff across a trauma pathway.

Setting and participants

People who had previously been admitted to a Major Trauma Centre following TBI and family members participated in a series of codesign activities. Staff attended SSM workshops and used the intervention with patients in acute and rehabilitation settings.

Methods

We used Normalization Process Theory constructs to guide and interpret implementation. Knowledge, beliefs and confidence of staff in SSM were assessed through pre‐ and post‐training questionnaires, and staff, patients' and families' experiences were explored through semi‐structured interviews. Qualitative data were analysed thematically, and clinical measures were mapped against a matched sample.

Results

Codesigned resources were created and used within an SSM approach for which 110 staff participated in training. Evaluation demonstrated significant differences in staff SSM confidence and skills, following training. Qualitative evaluation revealed adoption by staff, and patients' and families' experiences of using the resources. Challenges included reaching staff across complex pathways to achieve collective implementation.

Conclusion

This is the first project to demonstrate feasibility of SSM for people after TBI starting in an acute trauma setting. Through an open approach to codesign with a marginalized group, the SSM resources were valued by them and held meaning and relevance for staff.

'It's a powerful message': a qualitative study of Australian healthcare professionals' perceptions of asthma through the medium of drawings

OBJECTIVES

This study aimed to explore healthcare professionals' (HCPs') perspectives of asthma through their drawings, and their responses when viewing patients' drawings of their experiences of asthma.

DESIGN

A qualitative exploratory study with a purposive, convenience sample of participants. Participants were asked to first express their perspectives of asthma in a drawing, which was followed by a review of drawings made by patients with asthma.

SETTING

Primary and tertiary HCPs from Sydney, Australia.

PARTICIPANTS

Twenty-three HCPs from a range of health professions.

RESULTS

The HCPs illustrated their perspective of asthma through drawings which were largely biomedically framed, depicting physiological and clinical aspects of asthma. In contrast, their discussion around the patients' drawings centred on the person more than the condition. The patients' drawings triggered the HCPs to revisit their personal expectations of their patients' illness experience; prompted differing degrees of acknowledgement and empathy regarding the patient experience; and encouraged clinical reflexivity.

CONCLUSIONS

Our findings provide support for the educational application of patients' drawings in bringing HCPs closer to the patient lived experience. The drawings fostered deeper insight into patient perspectives of asthma and stimulated critical reflection on current healthcare practices.

Identifying the processes of change and engagement from using a social network intervention for people with long-term conditions. A qualitative study

Background

Personal and community networks are recognized as influencing and shaping self‐management activities and practices. An acceptable intervention which facilitates self‐management by mobilizing network support and improves network engagement has a positive impact on health and quality of life. This study aims to identify the processes through which such changes and engagement take place.

Methods

The study was conducted in the south of England in 2016‐2017 and adopted a longitudinal case study of networks design. Purposive sample of respondents with long‐term conditions (n = 15) was recruited from local groups. Barriers and facilitators to implementation were explored in interviews with key stakeholders (5).

Results

Intervention engagement leads to a deepening of relationships within networks, adding new links and achieving personal objectives relevant for improving the health and well‐being of users and network members. Such changes are supported through two pathways: the mobilization of network capabilities and by acting as a nudge. The first is a gradual process where potentially relevant changes are further contemplated by forefronting immediate concerns and negotiating acceptable means for achieving change, prioritizing objective over subjective valuations of support provided by network members and rehearsing justifications for keeping the status quo or adopting change. The second pathway changes are enacted through the availability of a potential fit between individual, network and environmental conditions of readiness.

Conclusions

The two pathways of network mobilization identified in this study illuminate the individual, network and environmental level processes involved in moving from cognitive engagement with the intervention to adopting changes in existing practice.

"The more you know, the more you realise it is really challenging to do": Tensions and uncertainties in person-centred support for people with long-term conditions

OBJECTIVE

To identify and examine tensions and uncertainties in person-centred approaches to self-management support - approaches that take patients seriously as moral agents and orient support to enable them to live (and die) well on their own terms.

METHODS

Interviews with 26 UK clinicians about working with people with diabetes or Parkinson's disease, conducted within a broader interdisciplinary project on self-management support. The analysis reported here was informed by philosophical reasoning and discussions with stakeholders.

RESULTS

Person-centred approaches require clinicians to balance tensions between the many things that can matter in life, and their own and each patient's perspectives on these. Clinicians must ensure that their supportive efforts do not inadvertently disempower people. When attending to someone's particular circumstances and perspectives, they sometimes face intractable uncertainties, including about what is most important to the person and what, realistically, the person can or could do and achieve. The kinds of professional judgement that person-centred working necessitates are not always acknowledged and supported.

CONCLUSION

Practical and ethical tensions are inherent in person-centred support and need to be better understood and addressed.

PRACTICE IMPLICATIONS

Professional development and service improvement initiatives should recognise these tensions and uncertainties and support clinicians to navigate them well.

Patient empowerment in young persons with chronic conditions: Psychometric properties of the Gothenburg Young Persons Empowerment Scale (GYPES)

PURPOSE

Empowerment in patients can lead to a higher participation in care and self-management skills. However, there are a limited number of high-quality instruments to assess empowerment and its various dimensions in young persons. The aim was to develop and assess the psychometric properties of the Gothenburg Young Persons Empowerment Scale (GYPES).

METHODS

The GYPES is a 15-item questionnaire designed to measure patient empowerment in young persons with chronic conditions. Three studies were conducted to evaluate the psychometric properties of the scale. Studies I and II assessed face, content and factorial validity, as well as responsiveness and reliability in young persons with congenital heart disease and diabetes. After these studies problematic items were identified and reworded and the final version of the GYPES was tested in young persons with diabetes in study III.

RESULTS

The content and face validity of the scale was confirmed in study I. Confirmatory factor analyses (CFA) in study II supported the five-factor structure of the GYPES. However, one item had a low factor loading. The scale was revised and evaluated in study III. CFA of this version supported adequate model fit with factor loadings ranging from 0.385-0.941. A second-order model had an adequate fit to the data. Cronbach's alpha for the overall scale was 0.858 and for each subscale, alphas range from 0.609-0.858.

CONCLUSIONS

GYPES was developed to measure patient empowerment in young persons with chronic conditions. Preliminary evidence supports that the GYPES may be a valid and reliable tool for assessing young persons' empowerment.

Improvement Science Meets Improvement Scholarship: Reframing Research for Better Healthcare

In this editorial essay I explore the possibilities of 'improvement scholarship' in order to set the scene for the theme of, and the other papers in, this issue. I contrast a narrow conception of quality improvement (QI) research with a much broader and more inclusive conception, arguing that we should greatly extend the existing dialogue between 'problem-solving' and 'critical' currents in improvement research. I have in mind the potential for building a much larger conversation between those people in 'improvement science' who are expressly concerned with tackling the problems facing healthcare and the wider group of colleagues who are engaged in health-related scholarship but who do not see themselves as particularly interested in quality improvement, indeed who may be critical of the language or concerns of QI. As one contribution to that conversation I suggest that that the increasing emphasis on theory and rigour in improvement research should include more focus on normative theory and rigour. The remaining papers in the issue are introduced including the various ways in which they handle the 'implicit normativity' of QI research and practice, and the linked theme of combining relatively 'tidy' and potentially 'unruly' forms of knowledge.

Long-Term Conditions Questionnaire (LTCQ): initial validation survey among primary care patients and social care recipients in England

OBJECTIVE

The aim of this study was to validate a new generic patient-reported outcome measure, the Long-Term Conditions Questionnaire (LTCQ), among a diverse sample of health and social care users in England.

DESIGN

Cross-sectional validation survey. Data were collected through postal surveys (February 2016-January 2017). The sample included a healthcare cohort of patients recruited through primary care practices, and a social care cohort recruited through local government bodies that provide social care services.

PARTICIPANTS

1211 participants (24% confirmed social care recipients) took part in the study. Healthcare participants were recruited on the basis of having one of 11 specified long-term conditions (LTCs), and social care participants were recruited on the basis of receiving social care support for at least one LTC. The sample exhibited high multimorbidity, with 93% reporting two or more LTCs and 43% reporting a mental health condition.

OUTCOME MEASURES

The LTCQ's construct validity was tested with reference to the EQ-5D (5-level version), the Self-Efficacy for Managing Chronic Disease scale, an Activities of Daily Living scale and the Bayliss burden of morbidity scale.

RESULTS

Low levels of missing data for each item indicate acceptability of the LTCQ across the sample. The LTCQ exhibits high internal consistency (Cronbach's α=0.95) across the scale's 20 items and excellent test-retest reliability (intraclass correlation coefficient=0.94, 95% CI 0.93 to 0.95). Associations between the LTCQ and all reference measures were moderate to strong and in the expected directions, indicating convergent construct validity.

CONCLUSIONS

This study provides evidence for the reliability and validity of the LTCQ, which has potential for use in both health and social care settings. The LTCQ could meet a need for holistic outcome measurement that goes beyond symptoms and physical function, complementing existing measures to capture fully what it means to live well with LTCs.

"Was that a success or not a success?": a qualitative study of health professionals' perspectives on support for people with long-term conditions

Background

Support for self-management (SSM) is a prominent strand of health policy internationally, particularly for primary care. It is often discussed and evaluated in terms of patients’ knowledge, skills and confidence, health-related behaviours, disease control or risk reduction, and service use and costs. However, these goals are limited, both as guides to professional practice and as indicators of its quality. In order to better understand what it means to support self-management well, we examined health professionals’ views of success in their work with people with long-term conditions. This study formed part of a broader project to develop a conceptual account of SSM that can reflect and promote good practice.

Methods

Semi-structured individual interviews (n = 26) and subsequent group discussions (n = 5 groups, 30 participants) with diverse health professionals working with people with diabetes and/or Parkinson’s disease in NHS services in London, northern England or Scotland. The interviews explored examples of more and less successful work, ways of defining success, and ideas about what facilitates success in practice. Subsequent group discussions considered the practical implications of different accounts of SSM. Interviews and group discussions were audio-recorded, transcribed and analysed thematically.

Results

Participants identified a wide range of interlinked aspects or elements of success relating to: health, wellbeing and quality of life; how well people (can) manage; and professional-patient relationships. They also mentioned a number of considerations that have important implications for assessing the quality of their own performance. These considerations in part reflect variations in what matters and what is realistically achievable for particular people, in particular situations and at particular times, as well as the complexity of questions of attribution.

Conclusions

A nuanced assessment of the quality of support for self-management requires attention to the responsiveness of professional practice to a wide, complex range of personal and situational states, as well as actions and interactions over time. A narrow focus on particular indicators can lead to insensitive or even perverse judgements and perhaps counterproductive effects. More open, critical discussions about both success and the assessment of quality are needed to facilitate good professional practice and service improvement initiatives.

Electronic supplementary material

The online version of this article (doi:10.1186/s12875-017-0611-7) contains supplementary material, which is available to authorized users.