Transitions to adulthood: self-governance and disciplining in the making of patient citizens

Dialogued into being: Constructing knowledge about hand osteoarthritis from a polyphony of voices in healthcare encounters

PURPOSE

Multiple knowledge sources inform healthcare. In healthcare encounters, patients and health professionals' ideas intersect to understand illness and disease. Exploring what is thought of as legitimate knowledge, and where those reflections come from is central to the process of improving and developing healthcare. Within this context, we aim to explore how knowledge about hand osteoarthritis (OA) is constructed and negotiated in clinical consultations.

METHODOLOGY

The article is based on interviews with 21 patients and 14 health professionals in combination with observation in 16 clinical consultations. Reflexive thematic analysis was used to interpret the data.

RESULTS

We generated four themes from codes to tell an interpretive story about how hand OA meaning-making is "talked into being" in patient-provider encounters: from the dominant voice of health professionals, from patients as knowers in the chronic healthcare dialogue, from health professionals and patients constructing knowledge together and from the construction of knowledge in hybrid positions when patients are health professionals and health professionals have hand OA.

CONCLUSION

New knowledge about hand OA is co-constructed in the situated context of the clinical encounter through a polyphony of voices-some of which are dominant, while others occupy the periphery-within and between the interactants in dialgue.

Self-management interventions for children and young people with sickle cell disease: A systematic review

BACKGROUND

Increasing numbers of interventions are being developed to support self-management for children and young people (CYP) with sickle cell disease (SCD), but no systematic review has systematically synthesized this evidence regarding their characteristics, effectiveness, acceptability and feasibility for all published intervention types.

METHODS

The Joanna Briggs Institute guidelines for mixed-method reviews were followed. A systematic search of eight databases and key journals was conducted from their inception to November 2021. Primary research of self-management interventions targeting CYP with SCD aged 8-24 years and reporting any health/social outcome and acceptability data were included. Design-specific standardized critical appraisal instruments were used. Two independent reviewers screened and appraised the articles. A third reviewer resolved disagreements.

RESULTS

Of 1654 articles identified, 38 studies were included. Methodological quality was moderate. Most studies evaluated SCD education, psycho-behavioural, psychosocial and skills training and/or social support interventions. They appear to demonstrate short-term improvements in knowledge, social functioning and medical adherence outcomes. Interventions that were multifaceted in content, combined technological platforms and in-person group-based formats and involved peers, family and care providers were more acceptable and effective. The long-term impact of interventions was limited, including CYP's involvement in the intervention development and implementation.

CONCLUSIONS

There is inconclusive evidence for any self-management programme. Nonetheless, support from family, peers and care providers appears to be important for self-management interventions' effectiveness and acceptability. Future research needs to prioritize CYP involvement in both intervention design and delivery, their wider social context and include CYP with SCD from non-Black backgrounds.

PATIENT AND PUBLIC CONTRIBUTION

Three young people with SCD recruited acted as the review advisors. They were formally trained in the review process and involved in every aspect of the review: the design, conduct and interpretation of the findings. CYP involvement in the interventions' development and implementation was analysed as part of the review. This systematic review was conducted as part of a wider research project titled: Understanding fatigue experiences of CYP with SCD to guide the co-development of a fatigue self-management intervention. Two of the young advisors involved in the review were also involved in the development of the project funding application.

Illegitimate bodies? Turner syndrome and the silent interplay of age, gender, and generational positions

This paper focuses on the strength of social norms that define the right development of the body in time. It also analyzes how the social positions of age, gender and generation intertwine in the definition of such a legitimate body. The starting point is anthropological research carried out in France between 2018 and 2020 among girls and women affected by Turner syndrome, a rare genetic condition causing small stature, ovarian insufficiency, a delay or absence of puberty, and infertility. We first explore how measuring the body has become central in the social construction of the concept of age-appropriateness. We then present four women' narratives, which express various forms of desynchronization: the gap between physical appearance, chronological age and age status; the cleft between the physical development induced by hormone therapy and being in a particular stage in life; the difference between chronological and reproductive age; and lastly, the trouble in a generational position related to infertility. For women suffering from this genetic condition, the gap between bodies, time and social statuses associated with age, gender and generation, may engender a feeling of "being out of place." The alignment of body and time is then one of the bastions of essentialization and naturalization. Finally, we stress the complex interplay of bodily and social markers of age and gender, and their role in social relations as both a resource and a constraint. Thus, while the syndrome may cause distress and sometimes a lack of legitimacy, it also leads to a critical re-examination of hegemonic models of womanhood and their intersection with age positions.

Communicating and understanding pain: Limitations of pain scales for patients with sickle cell disorder and other painful conditions

Pain communication in healthcare is challenging. We examine use of pain scales to communicate pain severity via a case study of people with sickle cell disorder (SCD). We show how pain communication involves complex social interactions between patients, healthcare professionals and significant others - none of which are included in pain ratings. Failure to account for relational aspects of pain may cause problems for any patient. For SCD, mutual distrust shapes pain communication, further complicating clinical assessments. Moreover, SCD pain is particularly severe, making ratings hard to interpret compared with ratings from non-SCD patients, potentially exacerbating problems in managing pain relief.

Biopsychosocial factors related to transition among adolescents and young adults with sickle cell disease: A systematic review

It is critical to support adolescents and young adults (AYAs) with sickle cell disease (SCD) during transition to adult healthcare. We provide a systematic review of literature related to biopsychosocial influences on transition among AYAs with SCD. Data sources included studies published between January 2010 and May 2020. Forty-four studies were included. Biopsychosocial factors related to improved transition outcomes included older AYA age, greater disease severity, intact neurocognitive functioning, and greater pain coping skills. Financial and insurance barriers were noted. The importance of cultural considerations and provider communication were noted across two qualitative studies. Ten studies assessed efficacy of transition interventions, with 80 % resulting in improvements; however, retention in programs was low and gaps in knowledge and skills remained. Incorporation of early, ongoing assessments of transition readiness and barriers into culturally-tailored interventions aimed at improving transition outcomes is recommended. Examination of longitudinal relationships and interactions across biopsychosocial influences is needed.

Understanding adolescent health risk behaviour and socioeconomic position: A grounded theory study of UK young adults

Health risk behaviours such as tobacco smoking, excessive alcohol consumption, drug use, unhealthy diet and unprotected sexual intercourse contribute to the global burden of non-communicable diseases and are often initiated in adolescence. An individualistic focus on 'health risk behaviours' has resulted in behaviour change strategies that are potentially ineffective and increase inequalities. We conducted a grounded theory study of 25 young adults to increase the limited qualitative evidence base surrounding young people, health risk behaviours and socioeconomic inequalities. We found that health risk behaviours were perceived as class markers, manifesting as class stigma, leading some participants from lower socioeconomic backgrounds to employ strategies to avoid such behaviours. Peers and family were core constructs for understanding the relationship between health risk behaviours and socioeconomic life trajectories. However, individualism and choice were consistently expressed as the overriding narrative for understanding health risk behaviour and socioeconomic position during the transition to adulthood. The use of 'personal responsibility' discourse by young adults, we argue, highlights the need for a public health focus on achieving structural changes as opposed to individualised approaches to avoid reinforcing neoliberal ideologies that serve to marginalise and maintain social inequalities.

Understanding the health-care experiences of people with sickle cell disorder transitioning from paediatric to adult services: This Sickle Cell Life, a longitudinal qualitative study

Background

Transitions from paediatric to adult health-care services cause problems worldwide, particularly for young people with long-term conditions. Sickle cell disorder brings particular challenges needing urgent action.

Objectives

Understand health-care transitions of young people with sickle cell disorder and how these interact with broader transitions to adulthood to improve services and support.

Methods

We used a longitudinal design in two English cities. Data collection included 80 qualitative interviews with young people (aged 13–21 years) with sickle cell disorder. We conducted 27 one-off interviews and 53 repeat interviews (i.e. interviews conducted two or three times over 18 months) with 48 participants (30 females and 18 males). We additionally interviewed 10 sickle cell disease specialist health-care providers. We used an inductive approach to analysis and co-produced the study with patients and carers.

Results

Key challenges relate to young people’s voices being ignored. Participants reported that their knowledge of sickle cell disorder and their own needs are disregarded in hospital settings, in school and by peers. Outside specialist services, health-care staff refuse to recognise patient expertise, reducing patients’ say in decisions about their own care, particularly during unplanned care in accident and emergency departments and on general hospital wards. Participants told us that in transitioning to adult care they came to realise that sickle cell disorder is poorly understood by non-specialist health-care providers. As a result, participants said that they lack trust in staff’s ability to treat them correctly and that they try to avoid hospital. Participants reported that they try to manage painful episodes at home, knowing that this is risky. Participants described engaging in social silencing (i.e. reluctance to talk about and disclose their condition for fear that others will not listen or will not understand) outside hospital; for instance, they would avoid mentioning cell sickle disorder to explain fatigue. Their self-management tactics include internalising their illness experiences, for instance by concealing pain to protect others from worrying. Participants find that working to stay healthy is difficult to reconcile with developing identities to meet adult life goals. Participants have to engage in relentless self-disciplining when trying to achieve educational goals, yet working hard is incompatible with being a ‘good adult patient’ because it can be risky for health. Participants reported that they struggle to reconcile these conflicting demands.

Limitations

Our findings are derived from interviews with a group of young people in England and reflect what they told us (influenced by how they perceived us). We do not claim to represent all young people with sickle cell disorder.

Conclusions

Our findings reveal poor care for young people with sickle cell disorder outside specialist services. To improve this, it is vital to engage with young people as experts in their own condition, recognise the legitimacy of their voices and train non-specialist hospital staff in sickle cell disorder care. Young people must be supported both in and outside health-care settings to develop identities that can help them to achieve life goals.

Future work

Future work should include research into the understanding and perceptions of sickle cell disease among non-specialist health-care staff to inform future training. Whole-school interventions should be developed and evaluated to increase sickle cell disorder awareness.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 44. See the NIHR Journals Library website for further project information.