Unsolicited written narratives as a methodological genre in terminal illness: challenges and limitations

In many voices: exploring end-of-life care through patient, caregiver and physician narratives

As the focus on end-of-life care intensifies, so too does the need to better understand the experiences of patients, caregivers and physicians. Delivering empathetic care requires a shared understanding of illness and its meaning and impact. The narratives of patients, caregivers and physicians each offer a distinct perspective on clinical experiences, yet comparative research is uncommon. This study compares written narratives about end-of-life illness and care by these groups.We created an archive of 332 first-person written narratives about end of life (patient=65, caregiver=156, physician=111) published between 1 January 2010 and 31 December 2019 through searching public domains (eg, national newspapers), personal blogs, and academic and literary journals in Canada. A comparative narrative analysis was conducted for patterns of content (eg, theme) and strategy (eg, characterisation).All three groups wrote about feeling gratitude. Patients also emphasised coping with change and carrying on. Caregivers further focused on grieving loss, and physicians most often wrote about valuing humanism. Physicians were most likely to ascribe agency to someone (ie, patients) or something (ie, death) other than themselves and to decentre themselves in the story. Patients and physicians most often made the patient the main character of their stories, while caregivers were as likely to centre the story on themselves as on the patient. Physicians were most likely to describe death as a source of tension, while patients and caregivers described the illness experience, often comparing it to battle. Physicians and caregivers tended to write testimonies, while patients wrote quests.Narrative research can illuminate unique aspects of end-of-life care. While death is a shared experience, each group approaches it differently. The disconnects have potential consequences for how end of life is experienced-whether patients' values are honoured, whether caregivers receive support, and whether physicians experience burn-out. We need to foster learning experiences that integrate these unique perspectives into medical education and practice, including leveraging the affordances of studying written narratives towards this end.

Moral aspects of filial concern for a parent living with dementia: Social imaginaries in contemporary narratives

Many adults face the difficulties of a parent living with dementia. Although not always caregiving for a parent living with dementia, they care about and are concerned for the vulnerability of their parent. This concern is invaluable but often an experience with a far-reaching impact. Qualitative research on filial concerns and experiences of caregiving has resulted in a vast body of knowledge about the experience of family carers. Far less research, however, has examined the moral concern of children. The aim of this study is to gain insight into the normative aspects of their concern. An international collection of 24 books written by adult children about their involvement with an ageing parent was analysed using the Dialogical Narrative Analysis method. Our study shows that the stories deal with children's moral questions about independence, identity, and suffering. These questions can be related to social imaginaries of individualism and progress. The two social imaginaries may have both positive and negative impacts on children's ability to cope with their concern for a parent living with dementia. The moral questions that arise from children's concern seem to originate from both the appeal of the vulnerable parent and from the social imaginaries. These moral sources may compete, resulting in moral friction. Children with a parent living with dementia deliberate upon the personal and societal held beliefs and need moral space to embody their concern.

"There Are Many of Us": Online Testimonies From "Pill Victims" as a New Form of Health Activism

The French pill scare is usually presented as a "media debate" triggered by the case of Marion Larat, a young woman who suffered a stroke attributed to the pill she was taking. This article intends to focus on a practice that preceded, accompanied, and followed this health scare: the publication of online testimonies of thrombotic reactions posted on the website of the French Association of Victims of Pulmonary Embolism and Stroke Associated with Hormonal Contraception (Avep). Through a discourse analysis, we intend to analyze these online public self-reports as an activist practice aimed at criticizing the dominant medical discourse on contraception. Four discursive frames emerged: unpreparedness of women and doctors, denial of blame and search for the cause, breaking the silence and building solidarity, and collective action. The first two frames concern the process women put in place to obtain the right to speak about and criticize a medical practice. The right to speak is achieved through a concise narrative style focusing on facts, bodily manifestations, and risk factors. The second pair refers to the formation of pill victims as subjects with an ambivalent status and ephemeral agency. The testimonies build what we call "lone solidarity", that is, the creation of a social bond and action around a common experience of witnessing medical injustice that develops without any exchange between members. This proves to be inclusive and viral, but at the same time fiercely anti-representational with respect to political struggles or social identification.

Things I need you to know: a qualitative analysis of advice-giving statements in early-onset colorectal cancer patients' personal accounts published online

OBJECTIVE

People with early-onset colorectal cancer (EOCRC), defined as colorectal cancer (CRC) before the age of 50, now constitute a significant patient population. In empirical and grey literature EOCRC patients report unsatisfactory experiences of care, especially in relation to protracted intervals from first help-seeking to diagnosis. This study is the first to investigate EOCRC patients' perspectives on ways to improve experiences of care. The objective is to provide foundational knowledge for the development of EOCRC-specific patient-reported experience measures (PREMs).

DESIGN

The study was designed as qualitative Internet Mediated Research, involving a thematic analysis of unsolicited narratives recounting personal experiences of EOCRC care. We examined advice-giving statements in 120 online texts written by EOCRC patients and survivors.

SETTING

The Internet is the broad research setting. The host websites of three prominent charitable CRC support organisations were selected as specific research sites: Bowel Cancer Australia, Bowel Cancer UK and Bowel Cancer New Zealand.

RESULTS

We found that 90% of texts comprised statements of advice to new patients about the importance of self-advocacy in achieving quality care. Four key contexts for self-advocacy were identified: (1) accessing relevant diagnostic services; (2) driving diagnostic investigations when symptoms are not resolved; (3) involvement in treatment decision-making and (4) proactivity about preferred outcomes. Over 30% of advice-giving texts also directed statements of advice to healthcare providers, indicating that their youthfulness had been a barrier to timely diagnosis.

CONCLUSION

Healthcare barriers to, and facilitators of, patient self-advocacy may be indicators of quality EORC care. There is a need for greater awareness of the impact of age bias on the responsiveness of clinicians and healthcare services in EOCRC care. Our findings support the development of EOCRC-specific PREMs that can guide age-appropriate policy and practice for this newly identified patient population.

Personal Narratives of Mental Illness: From Hostage to Survivor

This study has delved into personal narratives extracted from online blogs to build a systematic view of mental illness trajectory through the portrayal offered by bloggers. One hundred and thirty-three blogs were reviewed and narrative analysis was used to interpret a final sample of 12 blogs. The results offer two main narratives-the hostage and the survivor-which illustrate, within the context of social and self-stigma, the need for an identity reformulation in order to reach recovery. The two narratives also led to the design of a model for mental illness trajectory (MMIT). The breaking down of mental illness trajectory into phases could be advantageous to promoting tailored interventions for specific stages of recovery. The importance of referring to lived experience when trying to understand and develop better treatments for mental illness has been well established. This study contributes to the growing body of research that includes the voice of the person with mental illness offering not only a vivid portrayal of life with mental health issues but also an understanding of the trajectory to recovery.

Blogging through dementia: Reworking mainstream discourse through metaphor in online early-onset dementia narratives

Background

The depiction of dementia in public discourse tends to operate on two levels: the tragedy discourse or the living well with dementia discourse, where metaphors play a decisive role in the characterization of the condition and the voice of those living with the condition is usually underrepresented.

Purpose

This article analyzes whether and how mainstream discourse on dementia is reworked in first-person accounts of the disease online and explores the attitudes and assumptions about dementia that illness blogs reflect and defy.

Study design

Drawing on Conceptual Metaphor Theory, the article analyzes a corpus of 10 blogs (622 posts) written by individuals living with early-onset dementia to identify the metaphors used to depict dementia, its impact on the self and its social and relational aspects. Metaphor identification was based on the PRAGGLEJAZ metaphor identification procedure.

Results

The study demonstrates that across blogs no single metaphor alone is capable of capturing the complexity of the dementia experience; instead multiple metaphors are deployed to provide a characterization of the multiple faces of this condition. In this way blogs transcend and reshape the reductionist view of dementia that emerges from the either/or dichotomy of the tragedy versus living well with dementia discourses that dominate in media representations. By reshaping some of the metaphors used in mainstream discourse and introducing new ones, blog narratives draw attention to the complex nature of the experience of dementia, acknowledging both the suffering and social and functional losses that the condition brings, while also claiming recognition for personhood, agency, validation, and the aspiration to grow beyond the diagnosis and live a valued life as part of a family and community.

Conclusions

Overall, this study demonstrates that metaphor is a useful tool for providing insights into people’s experience of dementia and that blogs are a platform where stereotypes may be defied and mainstream representations of dementia reworked offering a more holistic view of the condition and granting narrative agency to those who live with dementia.

From Lay Depression Narratives to Secular Ritual Healing: An Online Ethnography of Mental Health Forums

The article aims at analysing online depression forums enabling lay reinterpretation and criticism of expert biomedical discourses. Firstly, two contrasting interpretations of depression are reconstructed: expert psy-discourses are confronted with the phenomenological descriptions of lay experiences, with a special emphasis on online forums as empirical platforms hosting such debates. After clarifying the general theoretical stakes concerning contested 'depression narratives', the results of an online ethnography are introduced: the main topics appearing in online discussions are summarised (analysing how the abstract tensions between lay and expert discourses appear in the actual discussions), along with the idealtypical discursive logics (analysing pragmatic advises, attempts of reframing self-narratives and expressions of unconditional recognition). Finally, based on these analyses an attempt is made to explore the latent functionality of online depression forums by referring to a secular 'ritual healing' existing as an unreflected, contingent potential.

The social construction of multiple sclerosis in Israel: a cultural reading of illness narratives

PURPOSE

Illness narratives are cultural artifacts that reflect the ways through which a certain culture perceives and constructs a given illness. Against this backdrop, the study explored the social construction of MS in Israeli society.

MATERIALS AND METHODS

Thematic content analysis of all (70) illness narratives posted on the Israel MS Society's website between 2012-2018, was employed.

RESULTS

Five themes were identified in our analysis, according to chronological order: (1) "Becoming ill" - consisted of framing MS as a sudden affliction or constructing MS as a gradual development. (2) "Negative changes" depicted MS as inflicting negative bodily changes and a disruption to the social order. The "happy ending" of the narratives pertained to (3) "adjustments" to MS and, (4) "never giving up" to MS. These were facilitated by embracing (5) "positive thinking and optimism."

CONCLUSIONS

MS is perceived in Israel as a form of "deviance" and as a biomedical phenomenon. Rehabilitation and healthcare staff, therefore, need to actively engage in interventions that challenge and change the ways that MS is perceived, as well as to partner with people with MS, and disability advocates to reconstruct and design policies and services that reflect a more socio-political understanding of MS.Implications for rehabilitationIllness narratives by people with multiple sclerosis (MS) can teach us about the ways though which a given society perceives and constructs MS.This study analyzed online illness narratives by Israelis with MS; it shows that MS was predominantly constructed as a bio-medical phenomenon and as a form of social deviance.Rehabilitation and healthcare professionals need to actively engage in interventions that challenge and change the ways MS is perceived among the public, policy makers, and people with multiple sclerosis.Rehabilitation and healthcare professionals should collaborate with people with MS and disability advocates in order to reconstruct and shape policies and the planning of communities such that they address the socio-cultural barriers that people with MS face.

Internet Narratives Focused on Health Travelers' Experiences in India: Qualitative Analysis

Background

The medical tourism industry is currently popular in India, but there is no confirmation of the common perspectives among the country’s medical travelers.

Objective

This qualitative research study analyzed web-based narratives from health travelers visiting India and described the themes of their experiences. This study aimed to answer the following primary question: What can we learn about health travelers’ experiences in India from an analysis of their web-based narratives? The secondary questions were as follows: (1) What are the primary health care reasons for which patients in the examined narratives traveled to India? (2) What can be derived from the narratives regarding medical tourists’ satisfaction with the outcome and result of the treatment they received in India? (3) What are some positive and negative factors influencing medical tourists’ perceptions and overall experiences about their health travel to India? (4) What are the characteristics of medical tourists who write web-based narratives regarding their health experiences in India?

Methods

Publicly available narratives written by medical tourists who visited India were obtained from a Google search. The narratives included blog posts and discussion board posts by medical tourists. The analysis process consisted of initial open coding being conducted on the narratives to create initial codes and identify common themes with a focus on the primary research question and subquestions.

Results

Although Mumbai, Chennai, and New Delhi were not the only destination cities mentioned, these were the most popular cities patients visited for care. The medical tourists, who stated their origin country, came from one of the following continents: Africa, Europe, North America, and Oceania. Dental care, Ayurveda treatment, and eye care were the most popular types of care that medical tourists sought. The results showed that most of the medical tourists were happy with the overall experience of receiving care in India. The most popular themes with regard to the patients’ satisfaction were low costs, good customer service, and services being offered that were unavailable in their home country. When negative feedback was provided, it was mainly concentrated on the overall environment of India being unorganized and unsanitary.

Conclusions

Primarily, the study’s findings can benefit health care providers and patients. Providers hosting medical tourists in India can use negative feedback to improve their services; similarly, providers who are losing patients to medical tourism can identify opportunities for improvement (ie, why are we losing patients). Indian providers hosting medical tourists should keep their prices competitive and continue to provide exceptional service; however, they should do their best to lessen the crowdedness of their facilities while making sure they are esthetically pleasing. Providers losing patients to medical tourism need to identify ways to ensure their services match the benefits that their international counterparts are providing, such as competitive pricing and expansion on the services provided.

Exploring Mental Health Issues through the Use of Blogs: A Scoping Review of the Research Evidence

The aim of this scoping review of the available research evidence was to explore the experiences and perceptions of people with mental health difficulties through the use of blogs. A search of relevant electronic databases was undertaken from January 2009 to February 2019. Selected studies included people who blog about their mental health difficulties online. The PRISMA system was used to present the results of the searches. Following the application of specific inclusion and exclusion criteria, the final number of included studies was eleven. Following data analysis, the subordinate categories in the public category were moderation, confidentiality and boundaries. The subordinate categories in the private sphere included catharsis, enhanced coping strategies and social connectedness. The implications for mental health practice developments and research, are presented and discussed.

Reading Between the Lines: A Five-Point Narrative Approach to Online Accounts of Illness

The successful delivery of patient-centered care hinges on clinical affiliation for patients' personal needs and experiences. Narrative competence is a mode of thinking and set of actions that widens the clinical gaze beyond logico-scientific cognition. In this article, we investigate a tool that enables clinicians to rehearse their skills in narrative competence. We apply the narrative competence framework developed by the founding practitioners of narrative medicine to personal accounts of illness and patienthood published on the Internet. We describe our use of the five-point framework in the close reading of 214 accounts by people with the life-threatening skin cancer melanoma.

Thematic analysis of blog narratives written by people with Alzheimer's disease and other dementias and care partners

Limited research takes a socio-biographical approach to study the experiences and perspectives of individuals affected by Alzheimer’s disease and related dementias. The purpose of this study was to thematically analyze blog narratives written by people with Alzheimer’s disease and related dementia and care partners in order to increase understanding of their experiences. Nineteen blogs written by people with Alzheimer’s disease and related dementia and 44 blogs written by care partners were analyzed. The first two authors utilized line-by-line open coding to analyze five posts from each group for the development of a codebook. Using NVivo software, the first author proceeded to code the remaining blogs for emergent themes and subcategories. Emergent themes included (1) effects of Alzheimer’s disease and related dementia on the person with Alzheimer’s disease and related dementia and/or the care partner; (2) seeing the positives; (3) feeling out of control; (4) advocacy and empowerment; (5) coping mechanisms and compensatory strategies; and (6) candid descriptions of experiences with Alzheimer’s disease and related dementia. These themes also encompassed numerous subcategories that are discussed in this paper. Results from this study provide insights into the experiences of individuals affected by Alzheimer’s disease and related dementia. Writers discussed several topics that are consistent with research on illness narratives of individuals with chronic diseases, including loss of identity, strategies for coping, and poignant descriptions of life with the disease. This study provides information in the form of overlapping themes from first-person perspectives of numerous individuals affected by Alzheimer’s disease and related dementia. This type of data is crucial to understand the experiences of people who live with ADRD.

"At the End We Feel Forgotten": Needs, Concerns, and Advice from Blogs of Dementia Family Caregivers

Illness blogs have been used by many individuals to describe their experiences, share knowledge, and gather support. The purpose of this study was to identify needs, concerns, and advice from the blogs of caregivers caring for a person with dementia at the end of life (EOL). A qualitative thematic analysis was performed of 192 blog postings from six dementia family caregivers during the EOL. A Google search using a systematic identification method was followed. Caregivers were females caring for mothers (n = 5) and husbands (n = 1). Themes varied by EOL stage within the contextual environment of Grief/Loss, Family, and Spirituality. Pre-death themes were Care Transitions and Quality; dying were Physical and Emotional Aspects; and post-death were Relief and Remembering. Four additional themes transitioned across stages: Decision-Making, Health Care Providers, Advice, and Caregiver Support. Findings suggest caregiver needs, concerns, and advice vary by EOL stage. Implications for tailored interventions should be considered.

What does patient feedback reveal about the NHS? A mixed methods study of comments posted to the NHS Choices online service

OBJECTIVE

To examine the key themes of positive and negative feedback in patients' online feedback on NHS (National Health Service) services in England and to understand the specific issues within these themes and how they drive positive and negative evaluation.

DESIGN

Computer-assisted quantitative and qualitative studies of 228 113 comments (28 971 142 words) of online feedback posted to the NHS Choices website. Comments containing the most frequent positive and negative evaluative words are qualitatively examined to determine the key drivers of positive and negative feedback.

PARTICIPANTS

Contributors posting comments about the NHS between March 2013 and September 2015.

RESULTS

Overall, NHS services were evaluated positively approximately three times more often than negatively. The four key areas of focus were: treatment, communication, interpersonal skills and system/organisation. Treatment exhibited the highest proportion of positive evaluative comments (87%), followed by communication (77%), interpersonal skills (44%) and, finally, system/organisation (41%). Qualitative analysis revealed that reference to staff interpersonal skills featured prominently, even in comments relating to treatment and system/organisational issues. Positive feedback was elicited in cases of staff being caring, compassionate and knowing patients'' names, while rudeness, apathy and not listening were frequent drivers of negative feedback.

CONCLUSIONS

Although technical competence constitutes an undoubtedly fundamental aspect of healthcare provision, staff members were much more likely to be evaluated both positively and negatively according to their interpersonal skills. Therefore, the findings reported in this study highlight the salience of such 'soft' skills to patients and emphasise the need for these to be focused upon and developed in staff training programmes, as well as ensuring that decisions around NHS funding do not result in demotivated and rushed staff. The findings also reveal a significant overlap between the four key themes in the ways that care is evaluated by patients.

"The Church of Online Support": Examining the Use of Blogs Among Family Caregivers of Persons With Dementia

Many individuals, including dementia caregivers, use blogs to share their experiences. These blogs contain rich narratives representing an untapped resource for understanding the psychosocial impact of caring for a person with dementia at the family level. The present study used blogs written by caregivers of persons with dementia to explore how these individuals leveraged this medium as part of the caregiving experience. Blogs written by self-identified informal caregivers of persons with dementia were identified using a systematic search method, and data were analyzed using a qualitative thematic analysis. Four themes emerged from the narratives: social support through communication and engagement, information gathering and seeking, reminiscing and legacy building, and altruism. By understanding the ways in which individuals providing care for persons with dementia use social media as part of the caregiving experience, family nurses can develop interventions and services aimed at improving caregiver burden and quality of life.

Depression Narratives in Blogs: A Collaborative Quest for Coherence

People with depression often suffer from severe social seclusion, and the lack of an agreed upon etiology for depression makes it difficult to satisfactorily narrate and "ritually control" it. Focusing on blogs by women with major depression, I delineate the ways in which bloggers publicly express and collaboratively reconstruct their depression narratives. Specifically, using thematic analysis, I argue that depression blogs uniquely bridge between the seclusion that characterizes depression and the exposure offered in blogs, and thus offer people a rare opportunity to publicly share very intimate depression narratives, form communal bonds with their readers, and collaboratively revise their narratives. Depression blogs are also shown to function as "narrative sandboxes"-protected spaces in which bloggers can temporarily and experimentally add or remove different sections from their illness narratives, assess the compatibility of different cultural frameworks, and interchangeably use various metaphors, in an attempt to satisfactorily explain depression.

Using online blogs to explore positive outcomes after burn injuries

This study uses blog analysis, a new and novel technique, to explore the positive outcomes experienced by burn survivors. This study examined 10 burn survivor blogs to offer a unique, longitudinal insight into burn survivor recovery. Using thematic analysis, three themes emerged: shift in self-perception, enhanced relationships and a change in life outlook. Many of these themes contained stories and experiences unique to a traumatic burn injury, suggesting that standardised trauma scales are not effectively measuring the impact of a burn in this population. Reflections on blog analysis are discussed, along with a recommendation that health researchers utilise the vast amount of data available from online blogs.

Dual, Yet Dueling Illnesses: Multiple Chronic Illness Experience at Midlife

The prevalence of multiple chronic illnesses is increasing dramatically, especially among those in middle adulthood, yet much prior research has focused on the experience of multiple morbidity among older adults. We examined the online illness narratives (blogs) of 10 men and women aged 36 to 59 to better understand the experience of living with multiple chronic illnesses at midlife. Multiple morbidity presents distinct challenges to those at midlife: (a) diagnosis and management of multiple illnesses, (b) need for information, (c) identity dilemmas and threats to self-image, and (d) stigma and social rejection. Relinquishing the work identity was especially difficult for participants because it threatened to foreshorten middle adulthood and push them prematurely into late adulthood. Participants used their blogs to revise their identities, alleviate isolation, and inform and guide others.

Spirituality and/or religious faith: A means for coping with the effects of amyotrophic lateral sclerosis/motor neuron disease?

OBJECTIVE

The notion of spirituality/religious belief is recognized internationally as a domain within end-of-life care and is important in patients' and carers' quality-of-life. When faced with incurable illness, patients often become more philosophical about their life; many seek comfort in spiritual or religious philosophies. Our intention was to understand how personal spirituality and religious faith might help those living with amyotrophic lateral sclerosis/motor neuron disease (ALS/MND) cope with their impending death.

METHOD

Unsolicited narratives (internet and print-published) written by individuals diagnosed with the terminal condition of ALS/MND were analyzed thematically. Narratives from 161 individuals diagnosed with ALS/MND written over a period of 37 years (from 1968 to 2005) were included.

RESULTS

Our findings reveal that religious faith sustains and helps people to avoid despair, and personal spirituality helps them make sense of what is happening to them.

SIGNIFICANCE OF RESULTS

The use of personal narratives by people with ALS/MND has provided a vehicle for sharing their deepest spiritual and religious thoughts with others. The place of spirituality and religious faith within ALS/MND care should not be underestimated. Assessment of religious or spiritual needs should become a routine part of practice and is the responsibility of all members of the multidisciplinary team.

Proud2Bme: Exploratory research on care and control in young women's online eating disorder narratives

Illness narratives have been studied to understand the patient's point of view. These narratives are becoming more prolific, accessible, and specialized, thanks to the improved Internet access and the growth of health-specific online communities. This article analyses illness narratives posted on a Dutch eating disorder website hosted by a treatment centre. Specifically, we look at 'care of the self' and 'control'. The young women wrote about controlling situations with disordered eating as a self-care tool, about being controlled by the disorder and about regaining control over the disorder. The website, with the opportunity for constant, unseen supervision, coercion through comments, and steering through edits and comments, revealed various modalities of control. While issues of control and eating disorders have been explored by others, little work has been done on how the control experienced by the young women (coercion on the individual, the body as the object of control, and the modality of pressure and supervision) interact, how control is presented in stories for a recovery-focused, monitored website, and how the website directs the content. As recovery-focused, therapist-led website is likely to continue growing, understanding how and why young women talk about care and control in the context of such websites is an important topic.

Troubling fragments and small stories: an analysis of public commentary on nursing through a web blog

In recent years the media in the United Kingdom has engaged in intense debate on standards of nursing care in the National Health Service (NHS). Much of the public engagement with this debate has been carried out through social media, including blogs and micro blogs. In this manuscript we analyse a single episode of public commentary appearing on a web blog about standards of nursing in the NHS. The blog entries featured brief stories and fragments of stories about care experiences, and perceptions of nursing care. Content analysis of the published narratives identified a troubling undercurrent of indifference experienced by patients, clients and their families. These stories represent a counter narrative to contemporary grand narratives of nursing, and as such, they sit on the outer edges of contemporary professional discourse. Increasing use of social media such as web blogs provides patients and carers with a public forum for comment that makes failures (or perceived failures) more visible to more people. Web blogs provide an important new mechanism through which patients and carers can have a voice about their own experiences of nursing care, and wider health care.

In the words of the medical tourist: an analysis of Internet narratives by health travelers to Turkey

Background

Patients regularly travel to the West for advanced medical care, but now the trend is also shifting in the opposite direction. Many people from Western countries now seek care outside of their country. This phenomenon has been labeled medical tourism or health travel. Information regarding health travelers’ actual outcomes, experiences, and perceptions is lacking or insufficient. However, advanced Internet technology and apps provide information on medical tourism and are a vehicle for patients to share their experiences. Turkey has a large number of internationally accredited hospitals, is a top tourism destination, and is positioning itself to attract international patients.

Objective

The objective of this research was to identify the important individual characteristics of health travelers, outline the push and pull factors for seeking health care in Turkey, identify satisfaction with the outcomes and the results of these individuals’ treatments, and note positive and negative factors influencing their perceptions and overall experiences about patients’ health travel.

Methods

This research uses qualitative data from Internet narratives of medical tourists to Turkey. Ethical considerations of using Internet narratives were reviewed. Narratives for analysis were obtained by using the Google search engine and using multiple search terms to obtain publicly posted blogs and discussion board postings of health travelers via purposeful sampling. Narratives were included if they were written in English, described travel to Turkey for health care, and were publicly accessible. Exclusion criteria included narratives that were on medical tourism facilitator or provider promotional websites, not in English, and did not describe an experience of a medical tourist. Medical tourists’ written words were analyzed in an iterative analytic process using narrative analysis theory principles. Three stages of coding (open, axial, and selective) were conducted to identify characteristics and themes using qualitative analysis software.

Results

The narrative posts of 36 individuals undergoing 47 procedures who traveled to Turkey for medical care between 2007 and 2012 were analyzed. The narratives came from 13 countries, not including the narratives for which patient origin could not be determined. Travelers were predominantly from Europe (16/36, 44%) and North America (10/36, 28%). Factors driving travelers away from their home country (push factors) were cost and lack of treatment options or insufficient insurance coverage in their home country. Leading factors attracting patients to destination (pull factors) were lower costs, physician’s expertise and responsiveness, and familiarity or interest in Turkey. Health travelers to Turkey were generally satisfied with the outcomes of their procedures and care provided by their physicians, many noting intent to return. Communication challenges, food, transportation, and gaps in customer service emerged as key areas for improvement.

Conclusions

This analysis provides an understanding of the insights of medical tourists through the words of actual health travelers. This nonintrusive methodology provides candid insights of common themes of health travelers and may be applied to study other patient experiences. The findings of this research expands the body of knowledge in medical tourism and serves as a platform for further qualitative and quantitative research on health travelers’ experiences.

Narrating dementia: self and community in an online forum

In this article, I examine how individuals diagnosed with early-onset Alzheimer's disease use illness narratives to construct community. The ability to narrate is a fundamental component of the self. Using 354 posts by 32 members of an Internet forum, I argue that people with Alzheimer's, whose ability to narrate, and thus create a self, was compromised, nonetheless managed to tell stories of redemption out of which a salvaged self emerged. Narratives are essential for the construction of self, but as I show in this article, they are also essential for the construction of community. Forum members shared stories, gave advice, offered encouragement, and commiserated about their symptoms in ways that generated solidarity. Internet forums provide a venue for people with illnesses who are unable to leave the home to construct community.

"Hoping to see the future I prefer": an element of life-world for older women living alone

We interact with Dorcy's earlier work in Advances in Nursing Science on hope, noting that scholars have emphasized hope in suffering rather than exploring hoping in everyday life. We did a secondary analysis of 4 descriptive phenomenological studies with older women (N = 81, aged 75-98). Findings included a 4-level taxonomy of life-world. Four future-related subelements (such as, having a future I cannot see, down the road) intersected with the element hoping to see the future I prefer. Five of its subelements were common across the sample, including hoping that I do not get to that point. Findings have implications for expanding scholarship pertaining to hoping.