Advancing the Expert Patient?

Self-management education for hypertension, diabetes, and dyslipidemia as major risk factors for cardiovascular disease: Insights from stakeholders' experiences and expectations

BACKGROUND

Cardiovascular disease (CVD) is a leading cause of premature death, with hypertension, diabetes, and dyslipidemia as major risk factors. Effective self-management (SM) is crucial for controlling these conditions and improving quality of life. This study examines stakeholders' experiences and expectations of SM education to enhance program development.

METHODS

This study employed a qualitative grounded theory approach to explore the perspectives of three stakeholder groups: 19 patients with hypertension, type 2 diabetes, and dyslipidemia, 11 primary healthcare providers, and five provincial health policymakers and managers. Data were collected via semi-structured patient interviews and focus group discussions(FGDs) with health professionals. Coding and analysis were conducted separately using Corbin and Strauss principles with ATLAS. ti version 9.0 software.

RESULTS

Most patients were women (68%) aged 50-60 years (37%), with education levels from illiterate to master's degree; 32% had completed primary school. Most were housewives (52%), and 12 had multiple chronic diseases. Healthcare providers included six community health workers and five primary care physicians, with average experience of 12 and 19 years, respectively. Health policymakers and managers averaged 25 years of experience. Patient interviews and FGDs resulted in 12 and 13 subthemes, respectively, with five subthemes common to both sources. These subthemes were grouped into broader main themes, including "effective content design," "effective presentation and delivery," "characteristics and conditions of involved parties," and "educational needs," collectively reflect the central concept of "effective self-management education".

CONCLUSION

Although the core concept and its main themes were evident and consistent across stakeholder groups, significant variations in subthemes from each stakeholder emerged. This underscores the importance of considering diverse viewpoints and highlights that, while overarching concepts may seem uniform, exploring the details of stakeholder perspectives is crucial for understanding their nuanced opinions. Effective education should integrate these insights, focusing on tailored communication, interactivity, and active monitoring.

Examining the knowledge work of person-centred care: Towards epistemic reciprocity

OBJECTIVE

It is increasingly recognised that when healthcare staff fails to give adequate credence to patients' illness-related knowledge work, this epistemic injustice undermines person-centred care. Therefore, we set out to examine the experiences of people with long-term conditions with knowledge work in healthcare settings to identify changes needed to strengthen person-centred primary care.

METHODS

We designed a qualitative study and recruited people with long-term conditions in the UK. We conducted individual interviews (analysed using interpretive phenomenological analysis) and focus groups (analysed using thematic analysis), then integrated findings from both methods through an approach focused on their complementarity.

RESULTS

Participants described how successful person-centred consultations were characterised by a negotiation between patient and doctor and moments of broad exploration, reflexive listening, and reciprocal enquiry, which allowed for epistemic reciprocity.

CONCLUSIONS

Epistemic reciprocity is a core component of person-centred clinical consultations, fostering the co-creation of new knowledge of patient experience and need through the interactive knowledge work of patient and doctor.

PRACTICE IMPLICATIONS

Medical education could benefit from initiatives that develop knowledge use and integration skills across primary care professionals. Accommodating for patient's and doctor's knowledge work during clinical practice requires redesigning the consultation process, including timing, headspace, pre-consultation, and post-consultation work.

Framing Kin Resistance to Opioid Overdose in Philadelphia

Interviews with close kin of those who died from opioid overdose in Philadelphia in 2017 reveal myriad strategies that families employ to minimize overdose risk, secure treatment options, and mitigate everyday precarity that can result from heroin addiction. Their efforts to keep kin alive - at times contradictory, conflicted, desperate and, in the end, ineffectual - reveal deeply situated structural vulnerabilities. When understood as "resistance" to death, however, kin strategies return us to a vital tenet of harm reduction - the imperative to develop programs in collaboration with those most impacted, in this case families at risk of overdose fatality.

Patients' and healthcare professionals' perceptions of self-management support interactions: Systematic review and qualitative synthesis

Objective To review studies examining the experience of self-management support in patient-provider interactions and the shaping of goals through interactions. Methods We undertook a systematic review and thematic synthesis of the qualitative literature. We searched six databases (2004-2015) for published studies on the provision of self-management support in one-to-one, face-to-face, patient-provider interactions for obesity, type 2 diabetes mellitus and chronic obstructive pulmonary disease, with 14 articles meeting inclusion criteria. Results Themes identified from studies were (1) dominance of a traditional model of care, encompassing the provision of generic information, exclusion of the psychosocial and temporal nature of interactions and (2) a context of individual responsibility and accountability, encompassing self-management as patients' responsibility and adherence, accountability and the attribution of blame. Interactions were constrained by consultation times, patient self-blame and guilt, desire for autonomy and beliefs about what constitutes 'effective' self-management. Discussion Encounters were oriented towards a traditional model of care delivery and this limited opportunity for collaboration. These findings suggest that healthcare professionals remain in a position of authority, limiting opportunities for control to be shared with patients and shared understandings of social context to be developed.

Self-care support for children and adolescents with long-term conditions: the REfOCUS evidence synthesis

Background

Self-care support (e.g. education, training, peer/professional support) is intended to enhance the self-care capacities of children and young people, while simultaneously reducing the financial burden facing health-care systems.

Objectives

To determine which models of self-care support for long-term conditions (LTCs) are associated with significant reductions in health utilisation and costs without compromising outcomes for children and young people.

Design

Systematic review with meta-analysis.

Population

Children and young people aged 0–18 years with a long-term physical or mental health condition (e.g. asthma, depression).

Intervention

Self-care support in health, social care, educational or community settings.

Comparator

Usual care.

Outcomes

Generic/health-related quality of life (QoL)/subjective health symptoms and health service utilisation/costs.

Design

Randomised/non-randomised trials, controlled before-and-after studies, and interrupted time series designs.

Data sources

MEDLINE, EMBASE, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, ISI Web of Science, NHS Economic Evaluation Database, The Cochrane Library, Health Technology Assessment database, Paediatric Economic Database Evaluation, IDEAS, reference scanning, targeted author searches and forward citation searching. All databases were searched from inception to March 2015.

Methods

We conducted meta-analyses, simultaneously plotting QoL and health utilisation effects. We conducted subgroup analyses for evidence quality, age, LTC and intervention (setting, target, delivery format, intensity).

Results

Ninety-seven studies reporting 114 interventions were included. Thirty-seven studies reported adequate allocation concealment. Fourteen were UK studies. The vast majority of included studies recruited children and young people with asthma (n = 66, 68%). Four per cent of studies evaluated ‘pure’ self-care support (delivered through health technology without additional contact), 23% evaluated facilitated self-care support (≤ 2 hours’/four sessions’ contact), 65% were intensively facilitated (≥ 2 hours’/four sessions’ contact) and 8% were case management (≥ 2 hours’ support with multidisciplinary input). Self-care support was associated with statistically significant, minimal benefits for QoL [effect size (ES) –0.17, 95% confidence interval (CI) –0.23 to –0.11], but lacked clear benefit for hospital admissions (ES –0.05, 95% CI –0.12 to 0.03). This finding endured across intervention intensities and LTCs. Statistically significant, minimal reductions in emergency use were observed (ES –0.11, 95% CI –0.17 to –0.04). The total cost analysis was limited by the small number of data. Subgroup analyses revealed statistically significant, minimal reductions in emergency use for children aged ≤ 13 years (ES –0.10, 95% CI –0.17 to –0.04), children and young people with asthma (ES –0.12, 95% CI –0.18 to –0.06) and children and young people receiving ≥ 2 hours per four sessions of support (ES –0.10, 95% CI –0.17 to –0.03). Preliminary evidence suggested that interventions that include the child or young person, and deliver some content individually, may optimise QoL effects. Face-to-face delivery may help to maximise emergency department effects. Caution is required in interpreting these findings.

Limitations

Identification of optimal models of self-care support is challenged by the size and nature of evidence available. The emphasis on meta-analysis meant that a minority of studies with incomplete but potentially relevant data were excluded.

Conclusions

Self-care support is associated with positive but minimal effects on children and young people’s QoL, and minimal, but potentially important, reductions in emergency use. On current evidence, we cannot reliably conclude that self-care support significantly reduces health-care costs.

Future work

Research is needed to explore the short- and longer-term effects of self-care support across a wider range of LTCs.

Study registration

This study is registered as PROSPERO CRD42014015452.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Introducing the chronic disease self-management program in Switzerland and other German-speaking countries: findings of a cross-border adaptation using a multiple-methods approach

BACKGROUND

Stanford's Chronic Disease Self-Management Program (CDSMP) stands out as having a large evidence-base and being broadly disseminated across various countries. To date, neither evidence nor practice exists of its systematic adaptation into a German-speaking context. The objective of this paper is to describe the systematic German adaptation and implementation process of the CDSMP (2010-2014), report the language-specific adaptation of Franco-Canadian CDSMP for the French-speaking part of Switzerland and report findings from the initial evaluation process.

METHODS

Multiple research methods were integrated to explore the perspective of workshop attendees, combining a longitudinal quantitative survey with self-report questionnaires, qualitative focus groups, and interviews. The evaluation process was conducted in for both the German and French adapted versions to gain insights into participants' experiences in the program and to evaluate its impact. Perceived self-efficacy was measured using the German version of the Self-Efficacy for Managing Chronic Disease 6-Item Scale (SES6G).

RESULTS

Two hundred seventy eight people attending 35 workshops in Switzerland and Austria participated in the study. The study participants were receptive to the program content, peer-led approach and found principal methods useful, yet the structured approach did not address all their needs or expectations. Both short and long-term impact on self-efficacy were observed following the workshop participation (albeit with a minor decrease at 6-months). Participants reported positive impacts on aspects of coping and self-care, but limited effects on healthcare service utilization.

CONCLUSIONS

Our findings suggest that the process for cross-border adaptation was effective, and that the CDSMP can successfully be implemented in diverse healthcare and community settings. The adapted CDSMP can be considered an asset for supporting self-management in both German-and French-speaking central European countries. It could have meaningful, wide-ranging implications for chronic illness care and primary prevention and potentially tertiary prevention of chronic disease. Further investigations are needed to tailor the program for better access to vulnerable and disadvantaged groups who might benefit the most, in terms of facilitating their health literacy in chronic illness.

Temporally divergent significant meanings, biographical disruption and self-management for chronic joint pain

Self-management is recommended by policy and clinical guidelines as a way to contend with the growing incidence of osteoarthritis-related joint pain in an ageing population. Sociologists assert that self-management is as much about lay strategies for dealing with the biographically disruptive qualities of chronic illness as opposed to solely complying with medical regimens. The original concept of biographical disruption coined by Bury is not uncontested. Chronic joint pain has been characterised as featuring 'co-existing meanings' of significance and consequence. The former conferring no biographical disruption due to osteoarthritis being associated with 'normal ageing' and the latter causing biographical disruption due to the corporeal limitations joint pain imparts, which, in turn, can influence whether, why and how self-management is undertaken. This article reports findings from repeat interviews and a diary study completed by 22 participants with chronic knee pain. We explore the co-existing but temporally divergent 'meanings as significance' associated with knee pain. Participants describe the onset and current experience of the pain in terms of biographical normality (retrospective or contemporaneous meanings). Future meanings as significance are mediated by cultural beliefs about ageing and current physical consequences of the condition, and also have a distinct character of their own. Knee pain is associated with the possibility of disability and harbours a distinct risk; potential disruption to everyday social relationships, notably relating to care and dependency. In turn, future meanings of significance influence the preventative self-management strategies that people utilise. We argue for a more cogent theoretical understanding of temporal dimensions of biographical disruption, biographical work and subsequent self-management by utilising and extending the thought of Bury, and Corbin and Strauss. Doing so helps to understand patient self-management strategies and facilitates self-management support in clinical settings for osteoarthritis and potentially other chronic conditions.

Perceptions of recovery and prognosis from long-term conditions: The relevance of hope and imagined futures

OBJECTIVE

Analyses of the experiences of chronic conditions demonstrate the importance of moral worth and social meaning linked to undertaking self-management practices. Rather less attention has been paid to the contemplation and significance of adopting, embedding and continuing with established practices overtime. This study explored perceptions about recovery and prognosis from the point of view of people with long-term physical health conditions and compared these findings with the mental health literature.

METHODS

A longitudinal qualitative study was conducted incorporating semi-structured interviews and thematic analysis. Thirty-two participants identified as having a chronic long-term physical health condition such as heart disease and diabetes were included in the study.

RESULTS

In line with the notions of recovery in the mental health field, respondents viewed recovery as a complex journey related to the ability to undertake things of value in everyday life. However, there were differences in relation to reflections on trajectories and imagined futures centred on physical health.

DISCUSSION

These findings are discussed in the context of literature from the mental and physical health fields and recent health policies for those with long-term conditions. The study adds to existing literature by examining the similarities and differences in the experience of chronic physical and mental health conditions.

Dynamics and nature of support in the personal networks of people with type 2 diabetes living in Europe: qualitative analysis of network properties

BACKGROUND

Living with and self-managing a long-term condition implicates a diversity of networked relationships. This qualitative study examines the personal communities of support of people with type 2 diabetes.

METHODS

We conducted 170 biographical interviews in six European countries (Bulgaria, Greece, the Netherlands, Norway, Spain and UK) to explore social support and networks. Analysis was framed with reference to three predetermined social support mechanisms: the negotiation of support enabling engagement with healthy practices, navigation to sources of support and collective efficacy. Each interview was summarized to describe navigation and negotiation of participants' networks and the degree of collective efficacy.

RESULTS

Analysis highlighted the similarities and differences between countries and provided insights into capacities of networks to support self-management. The network support mechanisms were identified in all interviews, and losses and gains in networks impacted on diabetes management. There were contextual differences between countries, most notably the impact of financial austerity on network dynamics. Four types of network are suggested: generative, diverse and beneficial to individuals; proxy, network members undertook diabetes management work; avoidant, support not engaged with; and struggling, diabetes management a struggle or not prioritized.

CONCLUSIONS

It is possible to differentiate types of network input to living with and managing diabetes. Recognizing the nature of active, generative aspects of networks support is likely to have relevance for self-management support interventions either through encouraging continuing development and maintenance of these contacts or intervening to address struggling networks through introducing the means to connect people to additional sources of support.

Implementation of a self-management support approach (WISE) across a health system: a process evaluation explaining what did and did not work for organisations, clinicians and patients

BACKGROUND

Implementation of long-term condition management interventions rests on the notion of whole systems re-design, where incorporating wider elements of health care systems are integral to embedding effective and integrated solutions. However, most self-management support (SMS) evaluations still focus on particular elements or outcomes of a sub-system. A randomised controlled trial of a SMS intervention (WISE-Whole System Informing Self-management Engagement) implemented in primary care showed no effect on patient-level outcomes. This paper reports on a parallel process evaluation to ascertain influences affecting WISE implementation at patient, clinical and organisational levels. Normalisation Process Theory (NPT) provided a sensitising background and analytical framework.

METHODS

A multi-method approach using surveys and interviews with organisational stakeholders, practice staff and trial participants about impact of training and use of tools developed for WISE. Analysis was sensitised by NPT (coherence, cognitive participation, collective action and reflective monitoring). The aim was to identify what worked and what did not work for who and in what context.

RESULTS

Interviews with organisation stakeholders emphasised top-down initiation of WISE by managers who supported innovation in self-management. Staff from 31 practices indicated engagement with training but patchy adoption of WISE tools; SMS was neither prioritised by practices nor fitted with a biomedically focussed ethos, so little effort was invested in WISE techniques. Interviews with 24 patients indicated no awareness of any changes following the training of practice staff; furthermore, they did not view primary care as an appropriate place for SMS.

CONCLUSION

The results contribute to understanding why SMS is not routinely adopted and implemented in primary care. WISE was not embedded because of the perceived lack of relevance and fit to the ethos and existing work. Enacting SMS within primary care practice was not viewed as a legitimate activity or a professional priority. There was failure to, in principle, engage with and identify patients' support needs. Policy presumptions concerning SMS appear to be misplaced. Implementation of SMS within the health service does not currently account for patient circumstances. Primary care priorities and support for SMS could be enhanced if they link to patients' broader systems of implementation networks and resources.

Using focused ethnography in paediatric settings to explore professionals' and parents' attitudes towards expertise in managing chronic kidney disease stage 3-5

Background

Interactions between parents and healthcare professionals are essential when parents of children with chronic conditions are learning to share expertise about clinical care, but limited evidence exists on how they actually interact. This paper discusses the use of focused ethnography in paediatric settings as an effective means of exploring attitudes towards expertise.

Methods

The paper draws on repeated observations, interviews and field-notes involving the parents of six children with chronic kidney disease, and 28 healthcare professionals at two, tertiary, children’s hospital-based units. Data were analysed using the Framework approach and the concepts of expertise and self-management.

Results

Our study highlighted rewards and challenges associated with focused ethnography in this context. Rewards included the ability to gain a richer understanding of the complex phenomena of mutual acknowledgement of expertise that occurs during parent/ healthcare professional interactions. Challenges related to gaining informed consent and ensuring potential participants had an adequate understanding of the purpose of the study. Two dimensions of parental expertise around their child (personal and clinical) were evident in our data. Parents’ and professionals’ expertise about the child and their condition was acknowledged and exchanged as parents learnt to share clinical-care with the multi-disciplinary team. Healthcare professionals acknowledged parents’ need to understand aspects of each of the eight disciplinary knowledge bases relating to their child’s management and recognised parents’ expert knowledge of their child, found ways to mobilise this knowledge, and wove parents’ expertise into the management plan. Parents spoke of the degree to which their own expert knowledge of their child complemented healthcare professionals’ clinical knowledge. However, ambivalence around expertise was evident as both parents and healthcare professionals questioned what the expertise was, and who the expert was. Our discussion focuses on the ways healthcare professionals and parents share expertise around the child’s condition as parents take on responsibility for home-based clinical care.

Conclusions

Our findings point to focused ethnography being an effective way of capturing new insights into parent and professional interactions in a paediatric setting and mutual acknowledgement of expertise; these insights may help redress the reported limitations of previous, retrospective studies.

Behaviour change and social blinkers? The role of sociology in trials of self-management behaviour in chronic conditions

Individual-focused self-management interventions are one response to both an ageing society and the purported increase in chronic conditions. They tend to draw on psychological theories in self-management interventions, but over-reliance on these theories can reinforce a narrow focus on specified attitudinal and behavioural processes, omitting aspects of living with a chronic condition. While advances have been made in health behaviour change theory and practice, scant attention has been paid to the social, with the question of social context remaining under-theorised and under-explored empirically. This is particularly noticeable in trials of behaviour change interventions for self-management. The common sociological critique is that these ignore context and thus no explanation can be given as to why, for whom and under what circumstances a treatment works. Conversely, sociologists are criticised for offering no positive suggestions as to how context can be taken into account and for over-emphasising context with the risk of inhibiting innovation. This article provides an overview of these issues and provides examples of how context can be incorporated into the rigid method of trials of self-management for chronic conditions. We discuss modifications to both trial interventions and design that make constructive use of the concept of context.

Participating in research: exploring participation and engagement in a study of self-management for people with chronic obstructive pulmonary disease

With growing emphasis on the importance of scientific evidence through clinical trials, qualitative studies have been used to deepen our understanding of research from participants' perspectives. For people with a chronic illness, research participation could represent an additional impost on lives already overwhelmed with medical and care issues, and little is known about participants' motivations when the research requires them to think differently about their illness and participate over an extended period. We interviewed participants with chronic obstructive pulmonary disease participating in a trial of a chronic disease self-management (CDSM) program. Our finding that people participate in research for altruistic reasons has similarities with other studies. We then extend our understanding of why people participate to explore how they participate. We argue that motivation based on dominant voluntaristic or altruistic values can be problematic for researchers attempting to demonstrate the benefits of CDSM strategies.