Mostly empty words--what the discourse of "choice" in health care does

The illusion of treatment choice in abortion care: A qualitative study of comparative care experiences in England and Wales

Treatment choice is a key component of quality, person-centred care, but policies promoting choice often ignore how capacity to choose is unequally distributed and influenced by social structures. In abortion care, the choice of either medication or a procedure is limited in many countries, but the structuring of treatment choice from the perspective of people accessing abortion care is poorly understood. This qualitative study explored comparative experiences of abortion treatment choice in England and Wales, using in-depth interviews with 32 people who recently accessed abortion care and had one or more prior abortions. A codebook approach was used to analyse the data, informed by a multidisciplinary framework for understanding the relationship between choice and equity. Abortion treatment choice was structured by multiple intersecting mechanisms: limitations on the supply of abortion care, incomplete or unbalanced information from providers, and participants' socio-economic environments. Long waiting times or travel distances could reduce choice of both treatment options. In interactions with providers, participants described not being offered procedural abortions or receiving information that favoured medication abortion. Participants' socio-economic environments impacted the way they navigated decision-making and their ability to manage the experience of either treatment option. Individual preferences for care were shaped in part by the interplay between these structural barriers, creating an illusion of choice, as the health system bias towards medication abortion reinforced some participants' negative perceptions of procedural abortion. The erosion of choice, to the point it is rendered illusory, has unequal impacts on quality of care. People's needs for their abortion care are complex and diverse, and access to varied service models is required to meet these needs. Treatment choice could be expanded by integrating public and private non-profit sector provision, aligning time limits and workforce requirements for abortion care with international standards, addressing financial pressures on service delivery, and revising the language used to depict each treatment option.

Communicating National Disability Insurance Scheme - Exploring Interpreters' Perspective

This article reports of a study on 19 Australian community interpreters and their experience in facilitating mediated communication in the National Disability Insurance Scheme (NDIS), which was introduced in Australia in 2016. These interpreters were among those who attended a training workshop comprising of a pedagogical segment explaining this new scheme in detail, and a hands-on segment to translate a selection of NDIS terms into their target language to highlight possible linguistic and cultural challenges they may encounter. The training aimed to enable the interpreters to facilitate NDIS communication with clients from linguistically and culturally diverse backgrounds in ways that make sense to their culture and experience. The purpose of the current study is to understand the extent the participant interpreters applied their learning in NDIS communication, and their perspective about specific challenges in this new contextual area, where certain concepts and terms may be hard to translate, and the understanding of disability may be culturally bound. The aim of the study is to deepen the understanding of multicultural communication in disability services, and to inform similar future professional development during major changes to systems in the disability sector, and more broadly in health and welfare.

Health Promotion Practices and Michel Foucault: A Scoping Review

OBJECTIVE

To analyze Health Promotion (HP) practices in different settings worldwide, presented in studies that employed the Foucauldian framework.

DATA SOURCE

Scoping review performed on LILACS, MEDLINE, IBECS, BDENF, SciELO, CINAHL, Embase, Web of Science, and Scopus databases.

STUDY INCLUSION AND EXCLUSION CRITERIA

We included original articles, review articles, reflection articles, and case studies published in English, Portuguese, and Spanish, which addressed HP practices, analyzed using the Foucauldian framework.

DATA SYNTHESIS

In the numerical synthesis, the characteristics of the included studies were described: number of studies, types of method, year of publication, characteristics of the study population, origin countries, and the HP practices addressed in the articles. The thematic synthesis was organized according to the nature of the HP practices presented and the Foucauldian analysis matrix used.

RESULTS

The review covered 34 studies, published between 2006 and 2019, whose analysis resulted in 2 thematic synthesis: 1) HP as a biopolitical strategy in the neoliberal context; 2) HP as an expression of resistance and counter-conduct, presenting tensions, struggles, and power games.

CONCLUSION

The field of HP mostly consists of governmentality practices that reinforce the neoliberal health perspective. Some practices show resistance and counter-conduct in the face of governmentality practices, which explains the power relationships in the field of HP.

Enrolling citizens as informed consumers in quasi-markets

Purpose

Many countries today, especially in Europe, provide publicly funded public services in quasi-markets. As these markets commercialize, agencies of various types are providing technologies that support citizens’ choice of services. Citizens’ use of technologies for service provision is studied as e-government under labels of channel management, e-service uptake or adoption. In contrast, by using actor–network theory (ANT), the purpose of this paper is to focus on the marketing devices that are used to enroll citizens to choose technologies in a context with large penetration of quasi-market arrangements.

Design/methodology/approach

Based on a Swedish case study, this paper uses qualitative data from 11 occurrences of technologies to support citizens’ choice (“market devices”) in education, healthcare and public pension in an analysis of the means taken (“marketing devices”) to increase their use. The study formulates a tentative typology of these devices.

Findings

The marketing devices are intended to attract citizens’ attention to the possibility of choice (e.g. catalogs, postcards and commercials), invite interaction (e.g. various social media platforms), improve the technological support in line with user needs (e.g. user participation in development), increase visibility of technological support (e.g. search optimization) or directly connect citizens to technological support (e.g. via links).

Originality/value

The paper contributes to e-government research through a typology of means taken to increase citizens’ technology use based on selected concepts from ANT, and to a discussion of technologies and humans.

What choice? Risk and responsibilisation in cardiovascular health policy

Employing a policy-as-discourse approach, we explore how the language of choice, risk and responsibilisation influences cardiovascular disease policy. We analyse four key pieces of public health literature produced in the UK between 1999 and 2013 that consider the prevention and treatment of coronary heart disease: Saving Lives: Our Healthier Nation; National Service Framework for Coronary Heart Disease; Mending Hearts and Brains and Cardiovascular Disease Outcomes Strategy. This critical discourse analysis problematises how neoliberal discourses of responsibilisation, risk and choice operate to govern health practices. Textual analysis reveals there are multiple dimensions evident in the way that responsibility for health is framed. Organisations are considered responsible 'for' illness prevention strategies and service provision, while individuals are conceptualised as responsible 'to' maintain healthy lifestyles. Conceptualising individuals as responsible health-conscious consumers enables a backward-looking narrative that holds individuals to account. Furthermore analysis reveals assumptions and messages that demonstrate the operation of moral discourses around patient behaviour. We suggest moral dimensions to public health strategies obscure the structural disparities that influence healthy life chances, imposing a system of limitations and exclusions that lead to allocation of liability and attributing blame for illness.

From one-sized to over-individualized? Service logic's value creation

Purpose There is a current trend in healthcare management away from produced and standardized one-size-fits-all processes toward co-created and individualized services. The purpose of this paper is to increase understanding of the value concept in healthcare organization and management by recognizing different levels of value (private, group and public) and the interconnectedness among these levels. Design/methodology/approach The paper uses social constructionism as a lens to problematize the individualization of service logic's value concept. Theories from consumer culture theory/transformative service research and public management add group and public levels of value to the private level. Findings An intersubjective (rather than subjective) approach to value creation entails the construction and sharing of value perceptions among groups of people. Such an approach also implies that group members may face similar barriers in their value creation efforts. Practical implications Healthcare management should be aware of the inherent individualism of service logic and, consequently, the need to balance private value with group and public levels of value. Social implications Identifying and addressing disadvantaged groups and the reasons for their disadvantaged positions is important in order to enhance the individual's value creation prerequisites as well as to address public and societal values, such as equal/equitable health(care). Originality/value It is important to complement service logic's value creation with group and public levels in order to understand the complexity and interconnectedness of value and the creation thereof.

Managing Matajoosh: determinants of first Nations' cancer care decisions

BACKGROUND

Accessing cancer treatment requires First Nation peoples living in rural and remote communities to either commute to care, or to relocate to an urban centre for the length or part of the treatment. While Canadians living in rural and remote communities must often make difficult decisions following a cancer diagnosis, such decisions are further complicated by the unique policy and socio-historical contexts affecting many First Nation peoples in Canada. These contexts often intersect with negative healthcare experiences which can be related to jurisdictional confusion encountered when seeking care. Given the rising incidence of cancer within First Nation populations, there is a growing potential for negative health outcomes.

METHODS

The analysis presented in this paper focuses on the experience of First Nation peoples' access to cancer care in the province of Manitoba. We analyzed policy documents and government websites; interviewed individuals who have experienced relocation (N = 5), family members (N = 8), healthcare providers and administrators (N = 15).

RESULTS

Although the healthcare providers (social workers, physicians, nurses, patient navigators, and administrators) we interviewed wanted to assist patients and their families, the focus of care remained informed by patients' clinical reality, without recognition of the context which impacts and constrains access to cancer care services. Contrasting and converging narratives identify barriers to early diagnosis, poor coordination of care across jurisdictions and logistic complexities that result in fatigue and undermine adherence. Providers and decision-makers who were aware of this broader context were not empowered to address system's limitations.

CONCLUSIONS

We argue that a whole system's approach is required in order to address these limitations.

Judith Butler's theories: reflections for nursing research and practice

Judith Butler is one of the most influential late 20th and early 21st century philosophers in regard to left wing politics, as well as an active campaigner for social justice within the United States and worldwide. Her academic work has been foundational to the academic discipline of queer theory and has been extensively critiqued and applied across a hugely wide range of disciplines. In addition, Butler's work itself is extensive covering topics such as gender, sexuality, race, literary theory, and warfare. This article can only serve as a taster for the potential application of her work in relation to nursing, which is in its infancy. This introduction covers three of the potentially most productive themes in Butler's work, namely power, performativity, and ethics. Each of these themes are critically explored in turn, sometimes in relation to their actual application in nursing literature, but also in relation to their potential for producing novel critiques of nursing practice. Suggestions are made about how Butler's work can develop nursing research and practice. The article concludes with a short summary of Butler's key works as well as suggested reading for people interested in examining how her theories have been applied across different academic settings.

The 'empty choice': A sociological examination of choosing medical research participation in resource-limited Sub-Saharan Africa

This article explores the views of frontline research staff in different Sub-Saharan African contexts on the notion of choice in biomedical research. It argues that the current emphasis on individual choice, in the conduct of biomedical research, ignores significant structural and contextual factors in resource-limited settings. These factors severely constrain individual options and often make biomedical research enrolment the most amenable route to healthcare for the world's poorest. From the position of frontline research staff, local contextual factors and structural issues narrowly frame the parameters within which many prospective participants are asked to choose, to such an extent that individuals are effectively presented with an 'empty choice'. The article draws on ethnographic and interview data and insights gained through graphic elucidation techniques. It demonstrates that for frontline research staff, macro-level structural factors and their bearing on everyday realities shape what choice in biomedical research participation means in practice.

Promoting competition in Swedish primary care

PURPOSE

The purpose of this paper is to examine the role of accreditation documents (ADs) in the competition based on provider quality in a quasi-market for primary healthcare.

DESIGN/METHODOLOGY/APPROACH

The paper uses a mixed-method research methodology to analyse two primary healthcare ADs in two Swedish regions. In total, 19 interviews were conducted with actors involved in the creation and use of such documents.

FINDINGS

This paper points to the crucial role of ADs in the identification of quality differences that influence the competition in primary healthcare. This finding contrasts with the commonly held laissez-faire idea that competition causes providers to develop their own service concepts and where the invisible hand creates quality differences. The paper adds to the discussion with its detailed description of how ADs create competition among primary healthcare providers through selection processes, quality differentiation, and ranking.

RESEARCH LIMITATIONS/IMPLICATIONS

The paper does not explore quality differences in the medical treatment of patients in primary healthcare centres.

PRACTICAL IMPLICATIONS

The paper provides insights for politicians on how to use ADs to control competition and regulate choice.

ORIGINALITY/VALUE

The paper takes an innovative approach to the examination of how ADs increase the competition in primary healthcare choice.

Implementing change in physiotherapy: professions, contexts and interventions

Purpose

– The purpose of this paper is to report findings from qualitative interviews with physiotherapists to demonstrate why even minor changes to clinical work resulting from the introduction of new interventions, are often difficult to implement. The paper seeks to illustrate how some of the obstacles to implementing change were managed by physiotherapists.

Design/methodology/approach

– A total of 32 qualitative interviews with participating physiotherapists were conducted, 12 interviews prior to the introduction of the new system, and 20 afterwards. The interviews were coded and analysed thematically.

Findings

– The findings reveal a number of perceived limitations of current management of low back pain and identify key themes around convergence with the new approach, such as willingness by physiotherapists to adopt the new approach, the perception of benefits to adopting the new approach, as well as some difficulty in adjusting to it. The authors refer to the positive and negative elements as “soft” and “hard” disruption. The adoption of the new approach is explored with reference to the “situated” dimensions of physiotherapy practice and normalisation process theory.

Research limitations/implications

– The study raises the need to conduct future observational research to support the interview findings.

Originality/value

– The study describes the “situated” components of physiotherapy work, which have received limited research attention. The value of the study lies less in its ability to explain specifically why physiotherapists adopted or rejected the new system, but in describing the conditions and consequences of change that might be translated to other professions, contexts and interventions.

Cultural dilemmas of choice: Deconstructing consumer choice in health communication between maternity-care providers and ethnic Chinese mothers in New Zealand

This article critically analyses the discourse of consumer choice embedded in health communication interactions between maternity-care providers and migrant ethnic Chinese mothers in New Zealand. Findings indicate that Chinese mothers, as the customers of the New Zealand maternity and health care services, are encouraged to "fit in" with the Western discourse of choice. However, the mothers' cultural predispositions for childbirth and communication have a significant impact on the ways in which they respond to and resist this discourse. Drawing on theoretical insights from postcolonialism and Third World feminism, this article contributes to the study of intercultural health communication by examining cultural dilemmas in the discourse of choice that is often taken for granted in Western health contexts. In doing so, it builds a platform for an inclusive maternity care and health environment in multicultural societies.

Healthcare matching: conditions for developing a new service system

Purpose

The purpose of this paper is to outline the conditions for a new service system in healthcare, which will be able to match the available capacity in and between healthcare units, in order to match the need of care for the patients.

Design/methodology/approach

By drawing on statements from patients, experiences from similar services (a literature review), empirical research into the effects of the reforms on free choice and the care guarantee and a theoretically informed discussion drawing on value‐creation and service productivity, it is claimed that a matching system is needed to be developed.

Findings

As healthcare lacks incentives and structures of matching capacity between various care providers, and for coordinating episodes of care for the patient, the result is management of capacity that is difficult and uncertain for patients. Continuity and coordination during all the healthcare process are seen as important values by patients. It is valuable for patients to be matched in the coordination of contacts with providers and specialists.

Practical implications

Healthcare matching generates the supportive data for innovative service research. For management, it could be applicable in different organisational areas, for patients in their choices of provider and for the providers, when matching the needs for patients. In further research, it would be of value to discuss the barriers of matching.

Originality/value

Outlining the conditions for a service system, healthcare matching, has not been done before.