Rethinking 'risk' and self-management for chronic illness

Understanding the disconnect between lifestyle advice and patient engagement: a discourse analysis of how expert knowledge is constructed by patients with CHD

OBJECTIVE

Adherence to healthy lifestyle advice is effective in prevention of non-communicable diseases like coronary heart disease (CHD). Yet patient disengagement is the norm. We take a novel discursive approach to explore patients' negotiation of lifestyle advice and behaviour change.

METHOD

A discourse analysis was performed on 35 longitudinal interviews with 22 heterosexual British people in a long-term relationship, where one had a diagnosis of CHD. The analysis examined the relationships between patients' constructions of expert knowledge and the implications of these accounts for patients' dis/engagement with lifestyle advice.

RESULTS

Expert knowledge was constructed in four ways: (1) Expert advice was valued, but adherence created new risks that undermined it; (2) expert knowledge was problematised as multiple, contradictory, and contested and therefore difficult to follow; (3) expert advice was problematised as too generalised to meet patients' specific needs; and (4) expert advice was understood as limited and only one form of valued knowledge.

CONCLUSION

Patients and partners simultaneously valued and problematised expert knowledge, drawing on elaborate lay epistemologies relating to their illness which produced complex patterns of (dis)engagement with expert lifestyle advice. Recognition of the multiple and fluid forms of knowledge mobilised by CHD patients could inform more effective interventions.

Digital Maturity as a Strategy for Advancing Patient Experience in US Hospitals

Patient experience is globally recognized as an important indicator of health system performance, linked to health system quality and improving patient outcomes. Post COVID-19, health systems have embraced digital health and advanced digital transformation efforts; however, the relationship between digital health and patient experience outcomes is not well-documented. Using HCAHPS hospital survey data to measure patient experience, and HIMSS EMRAM Maturity Model data to measure digital maturity, a cross-sectional design using multivariate analyses examined the impact of digital maturity on patient experience in US hospitals. Our analysis shows that advanced digital maturity in US hospitals is associated with stronger patient experience outcomes, particularly relative to communication with nurses, doctors, and communication about medicines and therapies. The findings suggest that there are significant differences in patient experience associated with teaching versus nonteaching hospitals, urban versus rural hospitals. As hospitals advance and progress digital transformation initiatives, evidence to inform how transformation efforts can engage and advance patient experience will contribute to health system performance well into the future.

Ethical issues experienced by persons with rheumatoid arthritis in a wearable-enabled physical activity intervention study

Introduction

Using wearables to self‐monitor physical activity is a promising approach to support arthritis self‐management. Little is known, however, about the context in which ethical issues may be experienced when using a wearable in self‐management. We used a relational ethics lens to better understand how persons with rheumatoid arthritis (RA) experience their use of a wearable as part of a physical activity counselling intervention study involving a physiotherapist (PT).

Methods

Constructivist grounded theory and a relational ethics lens guided the study design. This conceptual framework drew attention to benefits, downsides and tensions experienced in a context of relational settings (micro and macro) in which participants live. Fourteen initial and eleven follow‐up interviews took place with persons with RA in British Columbia, Canada, following participation in a wearable‐enabled intervention study.

Results

We created three main categories, exploring how experiences of benefits, downsides and tensions when using the intervention intertwined with shared moral values placed on self‐control, trustworthiness, independence and productivity: (1) For some, using a wearable helped to ‘do something right’ by taking more control over reaching physical activity goals. Some, however, felt ambivalent, believing both there was nothing more they could do and that they had not done enough to reach their goal; (2) Some participants described how sharing wearable data supported and challenged mutual trustworthiness in their relationship with the PT; (3) For some, using a wearable affirmed or challenged their sense of self‐respect as an independent and productive person.

Conclusion

Participants in this study reported that using a wearable could support and challenge their arthritis self‐management. Constructing moral identity, with qualities of self‐control, trustworthiness, independence and productivity, within the relational settings in which participants live, was integral to ethical issues encountered. This study is a key step to advance understanding of ethical issues of using a wearable as an adjunct for engaging in physical activity from a patient's perspective.

Patient or Public Contribution

Perspectives of persons with arthritis (mostly members of Arthritis Research Canada's Arthritis Patient Advisory Board) were sought to shape the research question and interpretations throughout data analysis.

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.

'A confident parent breeds a confident child': Understanding the experience and needs of parents whose children will transition from paediatric to adult care

Transitional care for young people with long-term conditions emphasizes the importance of supporting parents, particularly in relation to promoting adolescent healthcare autonomy. Yet, little practical guidance is provided, and transitional care remains suboptimal for many families. This study aimed to examine how parents understand and experience their caregiving role during their child's transition to adult services, to identify parents' needs, and to inform service improvements. Focus groups were undertaken with parents of young people with brittle asthma, osteogenesis imperfecta, or epilepsy. Data were analysed using interpretative phenomenological analysis. Participants (n = 13) described how their parenting roles extended beyond what they consider usual in adolescence. These roles were presented as time consuming, stressful, and unrelenting but necessary to protect children from harm in the face of multiple risks and uncertainties. Such protective strategies were also perceived to hinder adolescent development, family functioning, and their own development as midlife adults. Finding a balance between protecting immediate health and long-term well-being was a major theme. Participants called for improved support, including improved service organization. Recommendations are provided for working with parents and young people to manage the risks and uncertainties associated with their condition, as part of routine transitional care.

Care Professionals Manage the Future, Frail Older Persons the Past. Explaining Why Frailty Management in Primary Care Doesn't Always Work

Frailty management focuses on optimizing the physical and psychological functioning of older people with frail health through early risk identification and intervention in primary care. Such care programs demand a joint effort by primary care professionals and older persons, one in which professionals are expected to promote or facilitate self-management practices and older persons are expected to adhere to the professional advice. It is known that patients and professionals hold different perspectives on frailty, but we know little about how this may affect their cooperation in frailty management. In this article, we therefore study how different perspectives of older persons and their primary care professionals play a role frailty management in practice. Nine cases of frailty management were reconstructed through semi-structured interviews with older persons, their family doctor and practice nurse. Drawing from literature on managing complex problems, we analyzed how "factual" and "normative" orientations played a role in their perspectives. We observe that the perspectives of care professionals and older persons on frailty management were substantially different. Both actors "manage" frailty, but they focus on different aspects of frailty and interestingly, care professionals' rationale is future-oriented whereas older person's rationale past-oriented. Primary care professionals employed practices to manage the medical and social factors of frailty in order to prevent future loss. Older persons employed practices to deal with the psychological, emotional and social aspects of the different types of loss they already experienced, in order to reconcile with loss from the past in the present. These findings raise fundamental questions regarding the different perceptions of and priorities around not only care for frail older people in general, but also implied professional-patient relations and the value of a risk-management approach to care for older people with frail health. The distinction between these perspectives could help care professionals to better respond to older patients' preferences and it could empower older persons to voice preferences and priorities that might not fit within the proposed care program.

Lifestylisation of the social: The government of diabetes care in Denmark

Since the 1970s, the public authorities of many OECD countries have emphasised the need for preventing lifestyle diseases and promoting the vigour of their populations. Based on the Foucauldian analytics of dispositive, we critically address some of the normative implications of the preventive interventions in the area of type 2 diabetes care. Through an analysis of public health documents from 1981 to 2016, it is shown that the government of lifestyle was extended and institutionalised by a reform of the Danish public sector in 2007. Following the reform, rationalities of public health policies sought to prevent unhealthy lifestyles not only through individual behaviour but also through the social surroundings of citizens. In contrast to the claim that we are seeing a retraction of state responsibility and interventions in the area of public health, it is suggested that we are witnessing an expansion in state ambitions expressed through a lifestyle dispositive. These ambitions are less about transferring the responsibility to the individual and more about governing and mobilising the social relations and environments of type 2 diabetes patients and citizens in general to make the everyday choice of a healthy lifestyle easier.

Challenges to concordance: theories that explain variations in patient responses

To meet the challenges of an increasingly ageing and multimorbid population, patients must be fully engaged to work in partnership with their health professional (HP) in the management of their condition(s). The NHS Long Term Plan (2019) outlines goals to manage the increasing demands on the health service-hospital admission avoidance, shorter length of hospital stays through enhanced recovery pathways, increased management of patients within primary care and ensuring a person-centred approach to care provision. Meeting these goals is predicated on HPs being equipped to activate patients using the skills of motivational interviewing, person-centred care and a willingness to share decision making. This article presents a range of psychological theories that could explain the everyday challenges faced in care delivery. Awareness of these theories may help HPs target their approach to care delivery more effectively, to understand patient responses and, therefore, optimise the provision of person-centred care.

The problem with self-management: Problematising self-management and power using a Foucauldian lens in the context of stroke care and rehabilitation

Self-management is a concept which is now firmly established in Western healthcare policy and practice. However, the term remains somewhat ambiguous, multi-faceted and contentious. This is evident in stroke care and rehabilitation, in which a self-management approach is increasingly adopted and advocated, yet interpreted in different ways, resulting in contradictions and tensions around control, responsibility, power and discipline. This paper aims to further our understanding of tensions and contradictions in stroke self-management, by critically examining contemporary self-management practices. We use a Foucauldian theoretical lens to explore the various power dynamics in the operationalisation of self-management, in addition to the complexity of the term self-management itself. Conducting a secondary analysis of interview and focus group data from the Self-Management VOICED study, supplemented with analysis of relevant documentary evidence from policy and practice, we describe the multiple aspects of power in operation. These include rhetorical, hierarchical, personal and mutual forms of power, representing interweaving dynamics evident in the data. These aspects of power demonstrate underlying agendas and tacit and explicit understandings of self-management which exist in clinical practice. These aspects of power also give insight into the multiple identities of ‘self-management’, acting as a simultaneous repressor and liberator, directly in keeping with Foucauldian thinking. The findings are also consistent with Foucault’s notions of bodily docility, discussions around governance and biopower, and contemporary discipline. Our analysis positions self-management as a highly nuanced and complex concept, which can fluctuate in its conceptualisation depending on the structures, routines, and the individual. We encourage healthcare professionals, policymakers and commissioners in the field of self-management to reflect on these complexities, to make transparent their assumptions and to explicitly position their own practice accordingly.

The complexities of contagion: The experience of social isolation among children and youth living with cystic fibrosis in Canada

While cross-respiratory infection guidelines reduce the risk of infection, this may have deleterious impacts on the socialization skills of young people living with cystic fibrosis (CF). The purpose of this study was to explore the experience of social isolation among young Canadians with CF, as well as how they navigate these complex contamination restrictions. The thematic analytic qualitative research tradition was adopted and social theories of risk provided theoretical grounding. The youth described a pressing sense of social isolation in their everyday lives. Although most of the youth 'obeyed' the cross-contamination guidelines, some demonstrated a more carefree attitude. Social media was employed across the group as a tool to reduce isolation. In accordance with the sociology of risk, youth with CF demonstrate sophisticated decision-making abilities, navigating exceedingly difficult choices to preserve an always-precarious future. While necessary, cross-contamination guidelines might further marginalize an already isolated group of children and youth.

Chronic venous leg ulcer care: Putting the patient at the heart of leg ulcer care Part 2: Development and evaluation of the consultation template

Part 2 in this article series summarises the final two phases of a study which explored the experiences of patients with leg ulcers and the impact of this condition on their quality of life. Early phases of the study revealed a mismatch between issues that affected a patient's quality of life and what they discussed during subsequent health care consultations. In light of this, a nominal group technique was employed to facilitate the development of a new leg ulcer consultation template with patient partners. The aim of this was to include many of the issues raised in phases 1. The new template was evaluated in terms of its utility, significance and clinical potential. The application of this template during routine consultations appears to encourage the patient to disclose issues that are important to them and may have otherwise been overlooked.

The articulation of neoliberalism: narratives of experience of chronic illness management in Bulgaria and the UK

The shift from social democratic to a neoliberal consensus in modern welfare capitalist states is characterised by an emphasis on individual responsibility, consumer choice, market rationality and growing social inequalities. There has been little exploration of how neoliberalism has shaped the environment within which chronic illness is experienced and managed. This article explores the different articulations of neoliberalism manifest in the arena of personal illness management in Bulgaria and the UK. People with type 2 diabetes discussed their experiences in terms of struggling with diet, diabetes as a personal failure, integrating illness management and valued activities, and the trustworthiness of the healthcare system. The UK narratives were framed within an individual responsibility discourse while in Bulgaria lack of resources dominated discussions, which were framed as structurally generated and unrelated to individual capabilities and choices. Respondents faced personal management challenges related to consumer and healthcare market failures in both countries. Differences in market regulation and emerging stakeholder and interest coalitions influenced users' expectations and their navigation and adaption to market failures in managing their everyday illnesses. The UK and Bulgarian articulations of neoliberalism can be described differently: the first as a logic of managed choice and the second as a logic of unmanaged consumerism.

Towards a genealogy of pharmacological practice

Following Foucault's work on disciplinary power and biopolitics, this article maps an initial cartography of the research areas to be traced by a genealogy of pharmacological practice. Pharmacology, as a practical activity, refers to the creation, production and sale of drugs/medication. This work identifies five lines of research that, although often disconnected from each other, may be observed in the specialized literature: (1) pharmaceuticalization; (2) regulation of the pharmaceutical industry; (3) the political-economic structure of the pharmaceutical industry; (4) consumption/consumerism of medications; (5) and bio-knowledge. The article suggests that a systematic analysis of these areas leads one to consider pharmacological practice a sui generis apparatus of power, which reaches beyond the purely disciplinary and biopolitical levels to encompass molecular configurations, thereby giving rise not only to new types of government over life, but also to new struggles for life, extending from molecular to population-wide levels.

Context and complexity: the meaning of self-management for older adults with heart disease

Self-management policies have presented opportunities for patients with long-term conditions to take control and actively improve their health. However, the work of self-management appears to be packaged in the form of essential and desirable skills and attributes required for success. This article presents the findings of a qualitative study, employing longitudinal diary interviews with 21 patients aged between 60 and 85 years diagnosed with coronary heart disease from three contrasting general practice areas. Drawing on concepts of the care of the self and the reflexive self, this article presents the diversity of self-management practices by older patients in the context of their lifeworld. Illustrated through individual case studies, it clearly identifies where patients are engaged self-managers with the agency, knowledge and self-discipline to modify their behaviour for an improved health outcome. This study highlights their life and illness perspectives as well as those of patients who are burdened with emotional insecurity, comorbidities and caring responsibilities. It shows the spectrum of relationships with health professionals that influence engaged self-management. We suggest that policy initiatives that favour behavioural change neglect social context and the individualised practices that are a necessary response to structural and psychosocial constraints.

Risk and self-managing chronic joint pain: looking beyond individual lifestyles and behaviour

Self-managing chronic musculoskeletal pain is predominantly framed within a discourse of modifying behaviour, or lifestyle risk factors such as diet, weight loss and exercise by policymakers, researcher and clinicians. Little research has been conducted which explores how 'risk' is understood or encountered by those with joint pain and how it may relate to self-management. Drawing from serial interviews and a diary study with 22 participants, the findings demonstrate that people with chronic pain engage in a process of assessing and adapting to hazardous or pain conferring situations in relation to daily activities. 'Risks' are embedded within a dialectic between corporeal experience and the design features of everyday social environments. Self-management, in this context, is not necessarily solely related to following clinical advice, rather it includes dealing with 'risks' of pain, hazards relating to bodily limitations and the environment, and ensuring the ability to continue with valued activities. Findings contribute to sociological understandings of self-management and risk while demonstrating the limits of viewing self-management as an individualised endeavour of changing behaviour.

UK policy on social networking sites and online health: From informed patient to informed consumer?

Background

Social networking sites offer new opportunities for communication between and amongst health care professionals, patients and members of the public. In doing so, they have the potential to facilitate public access to health care information, peer-support networks, health policy fora and online consultations. Government policies and guidance from professional organisations have begun to address the potential of these technologies in the domain of health care and the responsibilities they entail for their users.

Objective

Adapting a discourse analytic framework for the analysis of policy documents, this review paper critically examines discussions of social networking sites in recent government and professional policy documents. It focuses particularly on who these organisations claim should use social media, for what purposes, and what the anticipated outcomes of use will be for patients and the organisations themselves.

Conclusion

Recent policy documents have configured social media as a new means with which to harvest patient feedback on health care encounters and communicate health care service information with which patients and the general public can be ‘empowered’ to make responsible decisions. In orienting to social media as a vehicle for enabling consumer choice, these policies encourage the marketization of health information through a greater role for non-profit and commercial organisations in the eHealth domain. At the same time, current policy largely overlooks the role of social media in mediating ongoing support and self-management for patients with long-term conditions.

A new quality of life consultation template for patients with venous leg ulceration

OBJECTIVE

Chronic venous leg ulcers (CVLUs) are common and recurrent, however, care for patients predominantly has a focus which overlooks the impact of the condition on quality of life. The aim of this study was to develop a simple, evidence-based consultation template, with patients and practitioners, which focuses consultations on quality of life themes.

METHOD

A nominal group was undertaken to develop a new consultation template for patients with CVLUs based on the findings of earlier qualitative study phases.

RESULTS

A user-friendly two-sided A4 template was designed to focus nurse-patient consultations on the quality of life challenges posed by CVLUs.

CONCLUSION

CVLUs impact negatively on the quality of life of the patient but this receives inadequate attention during current consultations. This new template will help to ensure that key concerns are effectively raised, explored and addressed during each consultation.

DECLARATION OF INTEREST

The NHS West Midlands Strategic Health Authority funded this study. The authors have no conflicts of interest to declare.

The commodification of patient opinion: the digital patient experience economy in the age of big data

As part of the digital health phenomenon, a plethora of interactive digital media platforms have been established in recent years to elicit lay people's experiences of illness and health care. The overt function of these platforms is to provide forums where patients and caregivers can share their experiences with others, benefit from the support and knowledge of other users and contribute to large aggregated data archives as part of developing better medical treatments and services and conducting medical research. However, what may not always be readily apparent to the users of these platforms are the growing commercial uses by many of the platforms' owners of the data they contribute. This article examines this phenomenon of what I term 'the digital patient experience economy'. Such aspects of this economy as prosumption (the combination of content consumption and production that is characteristic of the use of Web 2.0 technologies), the valorising of big data, the discourse and ethic of sharing and the commercialisation of affective labour are discussed. It is argued that via these online platforms patients' opinions and experiences may be expressed in more diverse and accessible forums than ever before, but simultaneously they have become exploited in novel ways.

Self-management of buprenorphine/naloxone among online discussion board users

BACKGROUND

Buprenorphine/naloxone is an effective medication used to treat opioid dependence. Patients in treatment and those using it illegally without prescriptions have discussed using buprenorphine/naloxone anonymously on Internet discussion boards. Their beliefs about self-treatment and efforts to self-treat are not well known.

OBJECTIVES

To identify facilitators of self-treatment by online buprenorphine/naloxone users.

METHODS

A qualitative, retrospective study of discussion board postings from September 2010 to November 2012 analyzed 121 threads from 13 discussion boards using grounded theory.

RESULTS

Facilitators of self-management themes that emerged included: (1) a ready supply of buprenorphine/naloxone from a variety of sources; (2) distrust of buprenorphine prescribers and pharmaceutical companies; (3) the declaration that buprenorphine/naloxone is a "bad-tasting" medicine; (4) the desire to adopt a different delivery method other than sublingually; and (5) a desire to become completely "substance-free." The sublingual film formulation appears to be an important facilitator in self-treatment because it can more easily be apportioned to extend the medication because of limited supply, cost, or to taper. CONCLUSIONS/IMPORTANCE: The findings indicate a range of self-management activities ranging from altering the amount taken to modifying the physical medication composition or changing the administration route; some of these behaviors constitute problematic extra-medical use. Contributors to discussion boards seem to trust each other more than they trust pharmacists and prescribing physicians. The shared knowledge and behaviors of this understudied online community are important to healthcare providers because of the previously unknown precautions and risks taken to self-treat.

Exploring patient priorities among long-term conditions in multimorbidity: A qualitative secondary analysis

OBJECTIVE

A lack of agreement between health-care providers and patient priorities can impact the health-care provider-patient relationship, treatment concordance and potentially health outcomes. Evidence suggests that people living with multiple morbidities do prioritise among their long-term conditions. However, the evidence revealing the underlying reasons behind this prioritisation remains limited. Given the potential implications for day-to-day self-management activity and ultimately patient outcomes, this study aims to explore how and why people with multimorbidity prioritise some long-term conditions over others and what the potential implications may be for self-management activity, and in turn, suggest how such information may help clinicians negotiate the management of multimorbidity patients.

METHODS

A secondary analysis of qualitative data was conducted utilising four existing data sets collated from the three research centres involved. Purposive sampling provided a sample of 41 participants who had multimorbidity. The research team collectively coded and analysed the data thematically.

RESULTS

All participants, except two, identified one 'main' priority long-term condition. Current priorities were arrived at by participants making comparisons between their long-term conditions, specifically by trading off the various attributes, impacts and perceived consequences of their individual long-term conditions. Two main themes emerged as to why participants identified a particular main long-term condition: (a) proximate issues surrounding barriers to functional health and (b) prioritisation of long-term conditions perceived to have a particular future risk.

CONCLUSIONS

The recent focus on multimorbidity within the medical literature reflects its prevalence. It is therefore important to understand the complexities of the multimorbidity illness experience. We have added to the limited literature on condition prioritisation by revealing some novel understandings of the process of condition prioritisation which can feed into patient-provider consultations in order to allow better communication and treatment planning as well as, ultimately, optimise patient outcomes.