Life on a slippery slope: perceptions of health in adults with cystic fibrosis

Meaning of critical traumatic injury for a patient's body and self

BACKGROUND

Patients with a traumatic injury often require intensive care for life-saving treatments. Physical suffering and emotional stress during critical care can be alleviated by ethical caring provided by nurses. The relationship between body and self are fundamentally inseparable. Nurses need to understand the impacts of traumatic injury on a patient's body and self.

AIM

To understand the meaning of traumatic injury for body and self for patients receiving intensive care.

RESEARCH DESIGN

A qualitative descriptive study using Giorgi's phenomenological approach.

PARTICIPANTS AND RESEARCH CONTEXT

Patients receiving intensive care for physical trauma were selected by purposive sampling (N = 15) from a medical center in Taiwan. Individual in-depth, face-to-face audiotaped interviews, guided by semi-structured questions, were used to collect data. Each interview lasted 30-60 min. Audiotaped interviews were transcribed and analyzed.

ETHICAL CONSIDERATIONS

This study was approved by the Institutional Review Board of the medical center.

FINDINGS

The impact of the experience of traumatic injury on participants' body and self was described by three main themes: (1) Searching for the meaning of the injured body, (2) Feeling trapped in the bed, and (3) The carer and the cared-for.

DISCUSSION AND CONCLUSION

The implications of the three themes described in the findings are as follows: Trauma as a source of meaning; Body and self are mutually limiting or mutually enabling; and Ethical relationships. The experience of needing intensive care following a traumatic injury on the body and self was dynamic and mutual. The experience of the injury changed the relationship between body and self, and gave new meaning to life. Nurses play a crucial role in continuity of care by understanding the meaning of a traumatic injury for patient's body and self that facilitates ethical care and recovery from injury.

Pharmacist-led cardiovascular risk prevention in Western Canada: a qualitative study

OBJECTIVES

Preventing cardiovascular diseases (CVD) is a public health and policy priority, including for employers. A novel CVD risk management programme that included medication management was delivered by pharmacists to employees of a Canadian university. This qualitative study describes the experiences and perceptions of participants who received individual health consultations in this programme.

METHODS

A qualitative study design using free-text responses was adopted. Data (5658 words) came from evaluation surveys completed by 119 programme participants were iteratively coded and thematically analysed.

KEY FINDINGS

We identified four themes characterising participant experiences of pharmacist-led CVD prevention. Theme one was labelled self-efficacy because personalised health information and advice on CVD risk factor management empowered participants to make improvements for their health. Participants expressed a range of positive responses about the longer consultations, supportive communication and safe setting of their pharmacist-led encounters; hence, Theme two is labelled pharmacists' interpersonal skills. The wider context of the programme included a number of enabling factors (Theme three) that either supported or limited participant engagement in the programme. A number of changes to behaviour and health measures were identified and participant suggestions to expand and continue the programme further contributed to perceptions of positive programme impact (Theme four).

CONCLUSIONS

This study raises questions about how external resources and broader determinants might enable, or hinder, future programme success and sustainability. It also highlights the need for greater understanding and communication of the importance of primary prevention and the role of pharmacists in CVD risk reduction and workplace health promotion.

Caring through distancing: Spatial boundaries and proximities in the cystic fibrosis clinic

This paper re-examines relations between proximity, distance and care, focusing on practices of 'distancing' in the cystic fibrosis (CF) clinic. While care is often thought of in terms of proximity, literature on 'landscapes of care' highlights the potential for 'care at a distance'. We extend this literature to examine practices of social distancing, specifically the act of maintaining a 'space between' bodies in communal areas - a practice currently brought to the fore by the COVID-19 pandemic. Using the CF clinic as a case study, we examine how distancing can be understood as an emplaced practice of care, shaped by - and shaping - architectures and materialities in particular contexts. We explore these issues drawing on data from Pathways, practices and architectures: containing antimicrobial resistance in the cystic fibrosis clinic, a UK AHRC funded study (AH/R002037/1) examining practices in three cystic fibrosis clinics using visual and ethnographic methods. Clinical staff practices of maintaining distancing were often regarded by patients as 'care-ful', part of personalised 'care in place', embroiling a wider care assemblage including ancillary staff, materialities and architectures. Patients also actively participate in distancing as an 'ethic of care', using strategies of 'holding back' and 'looking out' in confined spaces. Yet our findings also highlight tensions between care, proximity and distance in circulation spaces and communal areas, including transient spaces where the assemblage of care breaks down. The article concludes by considering wider implications for healthcare design and for the COVID-19 pandemic.

The lived experience of adults with cystic fibrosis: what they would tell their younger selves about the gut

Background

Little is known about adults’ experience of living with cystic fibrosis (CF) specifically in relation to the gut. However, their unique perspectives may be meaningful to children with CF and inform the understanding and practice of dietitians. The present study aimed to explore adults’ lived experience of the CF gut and how they learnt to manage the gut as they were growing up.

Methods

Semi‐structured interviews were conducted with adult inpatients (n = 10). Interviews were audio‐recorded, transcribed verbatim and accounts analysed using interpretative phenomenological analysis.

Results

Three super‐ordinate themes were identified: taking Creon, the learning process and this much I (now) know. Participants accounts of how CF affects the gut predominantly focused on taking Creon (pancreatin, Mylan). Various strategies were employed for coping with peer responses to taking Creon at school. Several participants reached adulthood before they understood and/or accepted that taking Creon consistently needed to be normal for them. Knowledge and understanding developed over time, with ‘CF experience’ and was shaped by family, CF care teams and other children with CF. All had unmet information needs when growing up. Having key explanations earlier, to make connections between eating, taking Creon, gaining weight and growth, did or would have helped most participants. Participants urged children to be assertive, ask questions and not only be involved in managing their diet and gut, but also begin to take control of this aspect of their CF.

Conclusions

Supporting development of knowledge, skills and confidence to manage diet and the gut needs to be integral to care throughout childhood.

The agentic Self and uncontrollable body: Young people's management of chronic illness at university

Young people's experiences of living with a long-term health condition have been largely investigated from the perspective of developing autonomy and optimal self-management of treatment regimens. Little existing research explores how young people adjust to the experience of chronic illness within everyday social contexts. Drawing on sociocultural theories of healthism, in this article, we examine the everyday strategies students employed to manage their health condition at university. Data were drawn from a qualitative study with 16 undergraduate students in Australia. Findings from interviews highlight how participants took up discourses of the (hard-working, diligent) Self to discursively position themselves as 'health conscious' and 'in control'. This positioning was maintained through separating the controlled Self from the (uncontrollable) body. The unpredictability of the body posed a threat to young people's abilities to maintain control and denied them opportunities to exercise personal agency. Yet, participants also described a number of subversive strategies in order to take back control and resist the experience of ill health. These potential agentic practices often held unintended consequences, including loss of optimal medical control or (self) exclusion from university life - offering new insights into the differing ways young people concomitantly take-up, rework and resist the pursuit of healthism to 'successfully' manage their health conditions.

An observational study of Donor Ex Vivo Lung Perfusion in UK lung transplantation: DEVELOP-UK

BACKGROUND

Many patients awaiting lung transplantation die before a donor organ becomes available. Ex vivo lung perfusion (EVLP) allows initially unusable donor lungs to be assessed and reconditioned for clinical use.

OBJECTIVE

The objective of the Donor Ex Vivo Lung Perfusion in UK lung transplantation study was to evaluate the clinical effectiveness and cost-effectiveness of EVLP in increasing UK lung transplant activity.

DESIGN

A multicentre, unblinded, non-randomised, non-inferiority observational study to compare transplant outcomes between EVLP-assessed and standard donor lungs.

SETTING

Multicentre study involving all five UK officially designated NHS adult lung transplant centres.

PARTICIPANTS

Patients aged ≥ 18 years with advanced lung disease accepted onto the lung transplant waiting list.

INTERVENTION

The study intervention was EVLP assessment of donor lungs before determining suitability for transplantation.

MAIN OUTCOME MEASURES

The primary outcome measure was survival during the first 12 months following lung transplantation. Secondary outcome measures were patient-centred outcomes that are influenced by the effectiveness of lung transplantation and that contribute to the health-care costs.

RESULTS

Lungs from 53 donors unsuitable for standard transplant were assessed with EVLP, of which 18 (34%) were subsequently transplanted. A total of 184 participants received standard donor lungs. Owing to the early closure of the study, a non-inferiority analysis was not conducted. The Kaplan-Meier estimate of survival at 12 months was 0.67 [95% confidence interval (CI) 0.40 to 0.83] for the EVLP arm and 0.80 (95% CI 0.74 to 0.85) for the standard arm. The hazard ratio for overall 12-month survival in the EVLP arm relative to the standard arm was 1.96 (95% CI 0.83 to 4.67). Patients in the EVLP arm required ventilation for a longer period and stayed longer in an intensive therapy unit (ITU) than patients in the standard arm, but duration of overall hospital stay was similar in both groups. There was a higher rate of very early grade 3 primary graft dysfunction (PGD) in the EVLP arm, but rates of PGD did not differ between groups after 72 hours. The requirement for extracorporeal membrane oxygenation (ECMO) support was higher in the EVLP arm (7/18, 38.8%) than in the standard arm (6/184, 3.2%). There were no major differences in rates of chest radiograph abnormalities, infection, lung function or rejection by 12 months. The cost of EVLP transplants is approximately £35,000 higher than the cost of standard transplants, as a result of the cost of the EVLP procedure, and the increased ECMO use and ITU stay. Predictors of cost were quality of life on joining the waiting list, type of transplant and number of lungs transplanted. An exploratory model comparing a NHS lung transplant service that includes EVLP and standard lung transplants with one including only standard lung transplants resulted in an incremental cost-effectiveness ratio of £73,000. Interviews showed that patients had a good understanding of the need for, and the processes of, EVLP. If EVLP can increase the number of usable donor lungs and reduce waiting, it is likely to be acceptable to those waiting for lung transplantation. Study limitations include small numbers in the EVLP arm, limiting analysis to descriptive statistics and the EVLP protocol change during the study.

CONCLUSIONS

Overall, one-third of donor lungs subjected to EVLP were deemed suitable for transplant. Estimated survival over 12 months was lower than in the standard group, but the data were also consistent with no difference in survival between groups. Patients receiving these additional transplants experience a higher rate of early graft injury and need for unplanned ECMO support, at increased cost. The small number of participants in the EVLP arm because of early study termination limits the robustness of these conclusions. The reason for the increased PGD rates, high ECMO requirement and possible differences in lung injury between EVLP protocols needs evaluation.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN44922411.

FUNDING

This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 20, No. 85. See the NIHR Journals Library website for further project information.

Embodying health identities: A study of young people with asthma

The embodiment of health identities is a growing area of interest. Questions posed in this literature include: how important is the body in our understandings/experiences of health, how are everyday definitions of health and self embodied despite chronic illness, and how do social relations influence these interpretations? Mindful of such questions, this paper draws on a qualitative study of mild to moderate asthma among young people in Ireland. In-depth interviews were undertaken with 31 respondents aged between 5 and 17, including boys (n = 15) and girls (n = 16) from different class and ethnic backgrounds. Core themes included: the importance of play, physical activity and sport; diet/nutrition; and physical appearance. Asthma sometimes presented challenges in relation to specific domains, notably strenuous physical activity, though in many other respects its potential impact was discursively minimised. Attentive to various modalities of the lived body, we illustrate how health identities are negotiated among young people diagnosed with a chronic illness. Connections are also made with the sociology of childhood and (ill) health, which views young people as active agents.

Rethinking how we understand individual healthcare needs for people living with long-term conditions: a qualitative study

It has been suggested that we need to 'Think Differently' about how we organise care for people with long-term conditions. Current approaches prioritise reducing population disease burden, meaning health need is defined predominantly in terms of disease status, or even risk of disease. However, the result is care which overburdens some individuals. The World Health Organisation has described the need to view health as a 'resource for living' and not an end in itself. This study considers whether this view of health offers an alternative view of healthcare need in people living with long-term conditions. We know that chronic disease can be disruptive for some people; but not all. Our research question asked: Why do people experience long-term conditions differently, and what are the implications for understanding healthcare need? Our phenomenographic study involved qualitative interviews with 24 people living with at least one of the three conditions (diabetes, depression and chronic pain) and explored resources for and demands on daily living. Interviews all took place during 2012 and 2013. A narrative form analysis identified three patterns of illness experience (Gliding Swan, Stormy Seas and Stuck Adrift). Narrative content analysis revealed four factors explaining the variation: personalising care, existence of meaningful anchors, partnership and excess demands. We thus propose three new categories of healthcare need described by a consideration of health as a resource for living: Resilient, Vulnerable and Disconnected. We discuss how the emerging findings may offer scope to develop new needs assessment and patient-reported outcome measure tools. And so, offer a different way of thinking about the organisation for care for people with long-term conditions.

Presenting life with cystic fibrosis: a Q-methodological approach to developing balanced, experience-based prenatal screening information

BACKGROUND

Cystic fibrosis (CF) is one of the most common life-threatening genetically inherited conditions and prenatal screening for CF is available in many countries. Genetic counsellors and other health professionals are expected to provide information about the condition in a way that facilitates personal decision making. Knowing what information to deliver about complex genetic conditions to support informed screening decisions can be challenging for health professionals.

OBJECTIVE

To solicit views from those with personal experience with CF on which aspects of the condition they consider most important to include in prenatal screening materials.

METHODS

Q-methodology; an approach to systematically explore variations in viewpoint that combines factor analytic techniques with qualitative approaches to pattern interpretation.

SETTING AND PARTICIPANTS

Twelve adults with CF and 18 parents of affected children were recruited from a regional centre in the UK.

RESULTS

Five distinct viewpoints on the items most and least important to include in screening information were identified: Factor 1 the normality of life with CF and increasing life expectancy; Factor 2 the hardships and reduced lifespan. Factor 3 medical interventions and the importance of societal support. Factor 4 longer-term consequences of CF. Factor 5 the ability to adjust to the condition.

DISCUSSION

The identification of five different views on what represented the most and least important information to include about CF highlights the challenge of portraying a complex genetic condition in a balanced and accurate manner. Novel ways in which Q-methodology findings can be used to meet this challenge are presented.

Well, I'm healthy, but…--lay perspectives on health among people with musculoskeletal disorders

PURPOSE

The purpose was to investigate lay perspectives on health among people with musculoskeletal disorders.

METHOD

Semi-structured interviews were performed with 39 women and 30 men, (aged 22-63 years) with long-term, non-specific musculoskeletal disorders in the neck, shoulder and/or low back. Data was analysed using qualitative content analysis.

RESULTS

These people experienced health as "having resources and opportunities to lead the life one wants". Three categories, "a good enough physical and psychological functioning, freedom of action, and a positive state of emotion and an enriching life", illustrate the different resources and opportunities that the informants described as important for them to perceive themselves as healthy. The informants also reflected on "being ill" and "being well" and what makes the difference. Five aspects influenced the dynamics of their health experiences: "body and soul, prognosis, character of symptoms, physical and social activity, and emotional state". Consequently, the informants expressed a holistic view of health, where the focus lies on the opportunity and the ability to lead their lives the way they want.

CONCLUSIONS

This study points at the value of taking lay perspectives on health into account, as it might increase the opportunity to design effective, personalized rehabilitation strategies.

IMPLICATIONS FOR REHABILITATION

Musculoskeletal disorders (MSDs) are difficult to cure and actions to alleviate suffering are of most importance to increase wellbeing and thereby work ability. Research on lay perspectives can contribute towards a deepened understanding of the health experiences of the affected, and thereby the development of the goals and activities of rehabilitation. Our models, that present the view of health and aspects important for achieving wellness among people with MSDs, can contribute in the development of multimodal rehabilitation. The results can also be useful as a base in the evaluation of clinical practice.

Impact of age at onset for children with renal failure on education and employment transitions

Previous medical research has shown that children with end-stage renal failure experience delay or underachievement of key markers of transition to adulthood. This article analyses 35 qualitative interviews with end-stage renal failure patients, aged 20-30 years, first diagnosed at 0-19 years of age, to explore how far delayed or underachievement in education and employment is related to their age at onset of end-stage renal failure. This study shows how unpredictable failures of renal replacement therapies, comorbidities and/or side effects of treatment in the early life course often coincided with critical moments for education and employment. Entering school, college, work-related training or employment, and disclosing health status or educational underachievement to an employer, were particularly critical, and those who were ill before puberty became progressively more disadvantaged in terms of successful transition into full-time employment, compared with those first diagnosed after puberty.

From children to young adults: cystic fibrosis and siblingship: a longitudinal study

AIM

To compare the results from our previous study in 1994/95 of children with cystic fibrosis (CF) at the age of 6-14 years and their healthy siblings with data from the same participants as young adults in regard to their self-esteem, life satisfaction and attitudes towards the CF siblingship situation.

METHODS

Thirty-seven sibling pairs participated. Three instruments were used: The 'As I see myself' self-evaluation questionnaire; the 'Ladder of life', assessing life satisfaction; and the 'Sibling Mirror', reflecting a person's feelings, when one's sibling or oneself has CF.

RESULTS

Contrary to 1994/95 study results, the female participants showed no signs of impaired self-esteem. Concerning life satisfaction, women in both groups and the men with CF have lower ratings than a healthy reference group. Individuals with CF look upon themselves today as independent, thoughtful and mature, but remember themselves as being active, spoiled or fussy. Healthy siblings consider themselves diplomatic, responsible, mature, important and loyal but remember themselves as angry, envious and neglected.

CONCLUSION

 The self-esteem of women in the sibling pairs (whether with CF or healthy sisters) has improved since their childhood. Overall, the results indicate that young adults with CF today are medically well controlled and psychosocially well adapted, albeit aware of their precarious future.

Self-care and cystic fibrosis: a review of research with adults

The issue of self-care is becoming increasingly central to both policy and practice in health and social care in the community. It is imperative therefore that research in this important area is drawn together and presented coherently so as to ensure that change can be informed by evidence and implemented sensitively. As cystic fibrosis (CF) has until recently been regarded as a paediatric condition, there is relatively little research that focuses on the self-care of adults. Although not entirely uncritical of traditional biomedicine, these studies focus on individual patient deficits and are directed primarily at facilitating their 'compliance'. After discussing some important methodological, evidential and theoretical limitations of this research, other recent CF literature will be considered that suggests the possibility of developing a 'social model' for self-care research. The proposed model is more pluralistic and less prescriptive than its predecessors and the resulting 'types' of self-care indicate that both old and new, mainstream and marginal discourses should co-exist. Indeed, recognising the legitimacy of distinct varieties of self-care not only guards against unwarranted moralising and pathologising but may also enable self-care support to be negotiated and tailored more appropriately.

What is the perceived nature of parental care and support for young people with cystic fibrosis as they enter adult health services?

The majority of those diagnosed with cystic fibrosis (CF) now live to adulthood. In response to increased survival age, transition services have been developed to ensure smooth transfer from paediatric to adult specialist healthcare, although the majority of treatment and care continues to be delivered in the home. However, little is known about how young adults and staff conceptualise the nature of the parental role after young people have left paediatric care. The aim of this study is to explore the nature of parental support that is perceived to be available at this time. As part of a larger study of transitional care, semi-structured interviews were conducted with 50 young people with CF aged 13-24 years (32 with experience of transition and/or adult CF services) and 23 specialist healthcare professionals (14 working in adult care) across two CF centres in Southeast England. Interviews took place in young people's homes or within CF services, using a topic guide and were recorded, transcribed and analysed thematically. Four domains of perceived parental support were identified by the young people interviewed, with varying degrees of continuity into adult care: (1) Providing non-clinical practical and emotional support; (2) Acting as 'troubleshooters' in times of health-related crisis; (3) Working in partnership with offspring in ongoing disease management in the home and clinic; (4) Acting as 'protectors' of their children. Young people and service staff expressed tensions in managing parental involvement in post-paediatric consultations and the degree to which parents should be aware of their offspring's deteriorating health and social concerns. Parental anxiety and over-involvement was perceived by many young people and staff as unsupportive. We suggest that although health and social care providers are mindful of the tensions that arise for those leaving paediatric services, the place of parental support in adult care is currently contentious for these 'new' ageing populations.

Problems and solutions: Accounts by parents and children of adhering to chest physiotherapy for cystic fibrosis

PURPOSE

Although chest physiotherapy is central to the management of cystic fibrosis (CF), adherence among children is problematic. This study explores accounts by parents and children of the difficulties of adhering to chest physiotherapy for cystic fibrosis, and identifies strategies used by families to overcome these.

METHODS

A qualitative study based on in-depth interviews with 32 children with a diagnosis of cystic fibrosis aged 7 - 17 years, and with 31 parents.

RESULTS

Physiotherapy was frequently described as restrictive, threatening to identity and boring, giving rise to feelings of unfairness, inequality, 'difference', and social stigma. Motivation to adhere was influenced by perceptions of effectiveness that depended on external signs evident during or after the physiotherapy. Motivation was enhanced where parents and children visualized the accumulation of mucus. Some parents had developed distraction techniques that improved the experience of chest physiotherapy but had few opportunities to share these with other parents.

CONCLUSION

The experience of physiotherapy is problematic to some parents and children. Furthermore, motivation to overcome these problems may be undermined by perceptions of ineffectiveness. Distraction techniques that change the value that the child places on the time spent doing physiotherapy and that reduces their perception of its duration may improve experience and adherence. The potential of visualization techniques to promote adherence should be investigated further.

How do adults with cystic fibrosis cope following a diagnosis of diabetes?

AIM

This paper is a report of a study examining the experience of adults with cystic fibrosis in adapting to the diagnosis of diabetes, a second chronic illness.

BACKGROUND

Diabetes is a common complication of cystic fibrosis; the onset signifies the development of a second chronic illness. Both cystic fibrosis and diabetes are complex conditions, which require daily treatment schedules as part of their management. However, it is unclear how people already living with cystic fibrosis respond to the diagnosis of diabetes.

METHOD

A qualitative method was chosen to obtain an 'insider' experience of adjusting to a second chronic illness. Semi-structured interviews were conducted in 2004 with 22 adults with cystic fibrosis-related diabetes. The data were analysed using interpretative phenomenological analysis.

FINDINGS

Four recurring themes were identified: emotional response to diagnosis of diabetes, looking for an understanding, learning to live with diabetes, and limiting the impact of diagnosis. Having cystic fibrosis appeared helpful in limiting the impact of the diagnosis of diabetes. Juggling conflicting dietary demands of cystic fibrosis and diabetes coupled with the lack of practical professional advice available was seen as one of the biggest challenges in adapting to diabetes.

CONCLUSION

Healthcare professionals need increased awareness of diabetes amongst adults with cystic fibrosis and provide adequate support and structured evidence-based education throughout the course of the illness, particularly in relation to diet. Nevertheless, patients' familiarity with regular daily routines and problem-solving attitudes, already developed in the context of cystic fibrosis, may be drawn on to limit the impact of diabetes.

Pain experience and the imagined researcher

Little attention has been paid to what happens communicatively when members of the general population attempt to complete a postal survey. The questions - here, on the experience of pain - encapsulate health researchers' views of useful indicators of the scope of pain experience, hence displaying an 'official' representation of experienced pain, limitation, and disability. The respondent faces the double task of aligning their personal experience with this representation in a way that is meaningful and true both to their own experience and to the perceived demands of the questionnaire. For this to succeed, context is often crucial. The paper explores sources and indications of tension in this endeavour as part of a communicative process. Beginning from the observation that respondents frequently write unsolicited comments on their questionnaires, the paper proposes that the need for communication beyond the requested tick in the box treats the questionnaire as an attempt at dialogue with a figure I call 'the imagined researcher'. The paper discusses the communicative task that confronts respondents and the implications of 'the imagined researcher' for the research process.

Exploring one's own human condition: adults affected by cystic fibrosis

Drawing on a sample of 11 interviews in France with adults affected by cystic fibrosis, and applying grounded-theory analysis, I describe illness-related learning processes in the case of persons affected by a genetic disorder with early onset. Three outcomes might be of interest to health professionals. First, the diagnosis of genetic disease does not imply that the patients consider themselves to be ill. The meaning of being affected by a genetic disorder has to be understood. Second, these patients gain a particular knowledge of their illness that helps them undertake or avoid certain actions to achieve goals they consider important, through a process I call "critical internalization." Third, these patients exhibit similarities with Freidson's classical medical practitioner's clinical mind, although health is not at all their main priority.

From child to adult: An exploration of shifting family roles and responsibilities in managing physiotherapy for cystic fibrosis

Although chest physiotherapy is central to the management of cystic fibrosis many report problems with adherence. Research in other long-term conditions suggests that non-adherence may be exacerbated as the child grows older and self-care responsibilities are transferred to the young person. We explored the nature and variation in roles of family members, how responsibility was transferred from the parent/family to the child, and what factors aided or hindered this process. We conducted in-depth interviews with 32 children with a diagnosis of cystic fibrosis aged 7-17 years, and with 31 parents attending cystic fibrosis clinics in two Scottish regions. Family responsibilities were primarily focused on mothers. The level and nature of involvement varied along a continuum that separated into six parental and five child roles and changed over time. However, this movement was frequently reversed during periods of illness or mistrust. The day to day experience of such a transfer was not straightforward, linear or unproblematic for any of the family members. Three factors were identified as assisting the transfer of responsibility: parents' perceptions of the benefits of transferring responsibility, children's perceptions of the benefits, and the available physical, social and psychological resources to support such a transfer. The principles and lessons from "concordance" (a therapeutic alliance based on a negotiation between equals and which may lead to agreement on management or agreement to differ) may provide a foundation for newly developing relationships between parents and their children emerging into adulthood. Further research is required to develop more specifically the content and structure of required support, its effectiveness in achieving more concordant relationships, and the resulting impact on adherence, perceived health and well-being from the perspective of the young person and parent.

Adherence to chest physiotherapy in adults with cystic fibrosis

Chest physiotherapy (CP) is seen as a cornerstone of Cystic Fibrosis (CF) treatment. However, previous studies have suggested that adherence to CP is low. This study of adults with CF (N = 563) investigated CP adherence and associated factors. Only 29.5 per cent reported undertaking daily CP. Predictors of adherence included problems with fitting CP into lifestyle, a perception that CP does not help, physical consequences of CP, doing exercises instead and doing CP as and when necessary. These variables accounted for 45 per cent of the variance in adherence. Content analysis revealed a number of themes related to adherence to CP. Future studies should explore the benefits of daily CP and attempt to devise simple interventions to maximize adherence to CP.

Focus group research and "the patient's view"

A clear emphasis on the patient's view is discernible in the health services research literature of the past decades. Such a switch to patients' perspectives has been greatly facilitated by a wider acceptance and use of qualitative methods. In particular, focus groups are often used to uncover the range and depth of experiences of health services users and chronically ill individuals. Although this method contributes to a better understanding of patients' perspectives and practices, a number of analytical considerations have been overlooked. The aim of this paper is to consider how to conceptualise and analyse interactions in focus group research. We argue that focus groups are social spaces in which participants co-construct the "patient's view" by sharing, contesting and acquiring knowledge. Focus groups conducted with home care patients in Quebec, Canada (on antibiotic intravenous therapy, parenteral nutrition, peritoneal dialysis and oxygen therapy) are used to illustrate three interactive processes at work in focus groups: (1) establishing oneself as experienced and knowledgeable; (2) establishing oneself as in search of information and advice; and (3) validating or challenging one another's knowledge claims. We develop an analytical template focused on the subtle dynamics underpinning the various and at times competing claims of patients. This template acknowledges the processes through which participants attribute authority to the claims of others, including the focus group moderator. We find that focus group research does not derive epistemological authority simply from the identity of its participants. Rather, an emerging consensus about what constitutes the patient's view is the result of context-dependent social interactions that need to be scrutinised.

Young people living with cystic fibrosis: an insight into their subjective experience

The aim of this article is to explore the experiences of young people living with cystic fibrosis and the impact of these experiences on their compliance to treatment regimen. Thirty-one young adults participated in semi-structured interviews which were transcribed and the data collected analysed using interpretative phenomenology. Emerging themes underlined just how complex it is to manage life with a chronic illness as demanding as cystic fibrosis. A strong emphasis emerged from the participants about their desire to integrate into society and to be seen to be normal and this was seen as in conflict with some aspects of their recommended ongoing treatment. The findings suggested that complete compliance is rare and is affected by a multitude of factors, set within the context of each individual's unique life experience. Healthcare professionals need to understand, not just the objective medical condition in delivering care, but they also need to develop an insight into the subjective experience of living with illnesses such as cystic fibrosis. Their central concern should not be to maximise compliance but rather to support the making of informed decisions about broader lifestyles and health behaviours.

Diagnostic Knowledge in the Genetic Economy and Commerce

On 5 December 2002 the Australian Senate passed the Research Involving Embryos and Prohibition of Human Cloning Bill 2002, which regulates stem cell research. The bill introduces some restrictions with regard to the use of stored frozen embryos, which are not destined to be implanted. The bill states that only frozen embryos created before April 2002 can be used for research purposes, provided that the individuals whom these embryos relate to give their consent. The alternative to this restriction would have been no research at all, and this would have happened if the law had been stopped. The Australian scientists regarded the new law as a compromise that would undoubtedly slow down research, but not entirely stop it.

Trials and tribulations: understanding motivations for clinical research participation amongst adults with cystic fibrosis

In the context of understanding motivations for clinical research participation, many authors consider issues such as informed consent and how patients perceive the research method and process. However, many investigations focus only on one method of research, most commonly the randomised controlled trial. Understanding how chronically ill members of one specific patient group respond to all requests for research participation are rare. Cystic fibrosis (CF), a genetic condition whereby those affected are used to taking a wide array of treatments and attending a specialist care centre over many years, and are generally knowledgeable about their condition, represents an ideal case for investigating how staff requests for clinical research participation are accepted or declined. Using Bloor's systems of relevance framework for risk behaviour and risk reduction, specialist CF centre patients' motivations for participation or non-participation in clinical research can be understood. The framework takes into account two sets of conceptual oppositions: habituation and calculation, constraint and volition. These oppositions represent a range along a continuum of risk behaviour rather than being absolute distinctions. Decisions to participate are influenced mainly by the patient's state of health at the time of request, the nature of the trial and the social context within which sufferers are placed. Understanding why chronically ill patients refuse some requests and yet accept others may assist researchers in designing protocols that take these factors into account and achieve the desired numbers of participants whilst protecting those in vulnerable positions.

How place matters: unpacking technology and power in health and social care

The devolution of care into nontraditional community-based settings has led to a proliferation of sites for health and social care. Despite recent (re)formulations of 'evidence-based' approaches that stress the importance of optimizing interventions to best practice by taking into account the uniqueness of place, there is relatively little guidance in the literature and few attempts to systematically 'unpack' key dimensions of settings most relevant to policy, practice and research. In this paper, we explore how place matters for health and social care. In effect, we propose making place the lens through which to view practice, and not simply an interesting sideline focus. We focus specifically on (a) the emplacement of power relations in health and social care in and across settings; and (b) the pervasive (and often unrecognised) influence of technology on and in place (both 'mundane' and more visible 'high' technologies) as arguably among the most significant and pervasive (and often overlooked) dimensions of place pertinent to health and social care in both traditional (institutional) and nontraditional (community) settings. Drawing on diverse disciplinary literatures, we seek to make visible certain issues and bodies of work that health professionals may not be aware of, and which often remain inaccessible to practitioners and applied researchers on account of their density, complexity, and specialised terminology. In particular, drawing on the rich tradition of cultural studies, we advance the culture of place as a rubric for understanding the complex interrelationship between power, technology, culture, and place. Several fruitful avenues for place-sensitive research of health and social care practice (and its effects) are suggested.

Living with motor neurone disease: lives, experiences of services and suggestions for change

Palliative care involves the complete, holistic care of people with progressive illness and their families. People living with motor neurone disease (MND) require a range of multidisciplinary palliative care services. However, there are significant gaps in our understanding of these people's lives, experiences of services and their suggestions for service change. The present study addressed the following questions: (1) What are the lived experiences of people living with MND? (2) What are people's experiences of services? and (3) Can improvements to care be identified? A qualitative research design was adopted using semi-structured interviews. The topic guide was developed from existing literature. The study was based in three boroughs in London, UK. People living with MND and professionals were drawn from a database at King's College Hospital, and additionally, through 'snowball' sampling. Nine people with MND, five carers/family members and 15 professionals took part in the interviews. These interviews were audio-taped, transcribed and checked for accuracy against the original recordings. Themes within the interviews were coded and grouped. The analysis was facilitated with the NVIVO computer software package. The findings are presented within three substantive groups: (1) the impact of MND on people's lives (the physical impacts of the illness, including increasing disability; social issues, including restrictions on social activities; and adjustments to people's lives, including methods of coping with the illness); (2) experiences of services (accessing service entitlements, information sources, professionals' attitudes and approaches, and professionals' knowledge and understanding of MND); and (3) suggestions for service change (better information and communication, including information on service entitlements; improved knowledge amongst professionals about MND; and some suggestions for service restructuring). This study brings a fresh approach to understanding the impacts of MND and the ways in which services can be improved to meet people's needs. The paper concludes with methodological considerations, the implications of the findings for practitioners and policy makers, and suggestions for further research.

Patients' perspectives on high-tech home care: a qualitative inquiry into the user-friendliness of four technologies

BACKGROUND

The delivery of technology-enhanced home care is growing in most industrialized countries. The objective of our study was to document, from the patient's perspective, how the level of user-friendliness of medical technology influences its integration into the private and social lives of patients. Understanding what makes a technology user-friendly should help improve the design of home care services.

METHODS

Four home care interventions that are frequently used and vary in their technical and clinical features were selected: Antibiotic intravenous therapy, parenteral nutrition, peritoneal dialysis and oxygen therapy. Our qualitative study relied on the triangulation of three sources of data: 1) interviews with patients (n = 16); 2) interviews with carers (n = 6); and 3) direct observation of nursing visits of a different set of patients (n = 16). Participants of varying socioeconomic status were recruited through primary care organizations and hospitals that deliver home care within 100 km of Montreal, the largest urban area in the province of Quebec, Canada.

RESULTS

The four interventions have both a negative and positive effect on patients' lives. These technologies were rarely perceived as user-friendly, and user-acceptance was closely linked to user-competence. Compared with acute I.V. patients, who tended to be passive, chronic patients seemed keener to master technical aspects. While some of the technical and human barriers were managed well in the home setting, engaging in the social world was more problematic. Most patients found it difficult to maintain a regular job because of the high frequency of treatment, while some carers found their autonomy and social lives restricted. Patients also tended to withdraw from social activities because of social stigmatization and technical barriers.

CONCLUSIONS

While technology contributes to improving the patients' health, it also imposes significant constraints on their lives. Policies aimed at developing home care must clearly integrate principles and resources supporting the appropriate use of technology. Close monitoring of patients should be part of all technology-enhanced home care programs.

The use of technology at home: what patient manuals say and sell vs. what patients face and fear

Over the past 15 years, the use of specialised medical equipment by patients at home has increased in most industrialised countries. Adopting a conceptual framework that brings together two research perspectives, i.e. the sociology of technology and the sociology of illness, this paper empirically examines why and how patients use health technology at home and in the broader social world. Our study compares and contrasts the use of four interventions: antibiotic intravenous therapy, parenteral nutrition, peritoneal dialysis and oxygen therapy. We conducted interviews with patients (n = 16) and caregivers (n = 6), and made direct observations of home visits by nurses (n = 16). The content and structure of patient manuals distributed by major manufacturers and hospitals were analysed (n = 26). The aim of our study was to determine how technology was supposed to be used versus how it was actually used. This study shows that patients are deeply ambivalent about the benefits and drawbacks of technology, and that these advantages and disadvantages are shaped by the various places in which the technology is used. While technology can be pivotal in making patients autonomous and able to participate in the social world, it also imposes heavy restrictions that are intimately interwoven with the nature of the particular disease and with the patient's personal life trajectory.

Only when I cough? Adults' disclosure of cystic fibrosis

Cystic fibrosis has traditionally been conceptualized as a fatal childhood disease. In contrast, survival age has been increasing steadily such that adults now routinely seek to gain employment and form close relationships, situations that might require telling others about the disease. Here, the author examines three situations of disclosure based on interviews with 31 adults with the disease. First, in a low-risk situation, for example a short period of social contact, a low level of intimacy exists between the adult with cystic fibrosis and another. Here the disease may be concealed easily with little risk of discovery. Second, in a medium-risk situation, the perceived reaction of the other begins to influence the decision to disclose, as the level of intimacy becomes higher. Last, in high-risk situations, such as employment, the consequences of disclosing or concealing CF are most severe. However, a multiplicity of factors, including perceived social support and disease progression, are seen to influence adults' decisions to disclose their disease.