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Moore TL. Resilience of individuals with chronic illness who reside in low resource communities: a concept analysis. INTERNATIONAL JOURNAL OF NURSING STUDIES ADVANCES 2024; 7:100215. [PMID: 39005946 PMCID: PMC11245916 DOI: 10.1016/j.ijnsa.2024.100215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2024] [Revised: 06/01/2024] [Accepted: 06/05/2024] [Indexed: 07/16/2024] Open
Abstract
Background Chronic illness diagnosis while living in low resourced communities creates ongoing adversity in the process of adaptation. Resilience is an important phenomenon of study to improve health outcomes. The subject in this particular population has been poorly studied. Objective To conceptualize resilience of individuals with chronic illness who reside in low resource communities. Design Concept analysis. Data sources Seminal works and current studies were searched in PubMed (including Medline), Science Direct, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), ProQuest, Google Scholar, OVID, Ebsco, and the Cochrane Database. Qualitative and quantitative studies that investigated individual resilience of adults in the setting of chronic illness who reside in low resource communities were included. Exclusions included children with chronic illness and resilience of communities and populations. Methods Walker and Avant's method of concept analysis was utilized. The key elements for conceptualizing resilience in the setting of chronic illness who reside in low resource communities included defining attributes, antecedents and consequences of resilience identified from the literature search. Results Analysis revealed three defining attributes: (1) reflection, contemplation, and the will to live despite adversity through hope; (2) personal transcendence through action; and (3) continuous personal transcendence and maintenance. Antecedents and consequences of resilience in the setting of chronic illness who reside in low resource communities were described and outlined. Conclusions The conceptualization of resilience in the setting of chronic illness who reside in low resource communities is based on the defining attributes, antecedents, and consequences that resulted in a preliminary conceptual model. The model can be further tested in diverse populations to add to the existing knowledge on the subject, and develop interventions to foster resilience aimed to improve health outcomes and quality of life.
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Milani A, Saiani L, Misurelli E, Lacapra S, Pravettoni G, Magon G, Mazzocco K. The relevance of the contribution of psychoneuroendocrinoimmunology and psychology of reasoning and decision making to nursing science: A discursive paper. J Adv Nurs 2024; 80:2943-2957. [PMID: 38318634 DOI: 10.1111/jan.16087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2023] [Revised: 11/20/2023] [Accepted: 01/21/2024] [Indexed: 02/07/2024]
Abstract
AIM Patients' death or adverse events appear to be associated with poor healthcare decision-making. This might be due to an inability to have an adequate representation of the problem or of the connections among problem-related elements. Changing how a problem is formulated can reduce biases in clinical reasoning. The purpose of this article is to explore the possible contributions of psychoneuroendocrinoimmunology (PNEI) and psychology of reasoning and decision-making (PRDM) to support a new nursing theoretical frame. DESIGN Discursive paper. METHOD This article discusses the main assumptions about nursing and nurses' ability to face patient's problems, suggesting a new approach that integrates knowledge from PNEI and PRDM. While PNEI explains the complexity of systems, highlighting the importance of systems connections in affecting health, PRDM underlines the importance of the informative context in creating a mental representation of the problem. Furthermore, PRDM suggests the need to pay attention to information that is not immediately explicit and its connections. CONCLUSION Nursing recognizes the patient-nurse relationship as the axiom that governs care. The integration of PNEI and PRDM in nursing theoretics allows the expansion of the axiom by providing essential elements to read a new type of relationship: the relationship among information. PNEI explains the relationships between biological systems and the psyche and between the whole individual and the environment; PRDM provides tools for the nurse's analytical thinking system to correctly process information and its connections. IMPACT ON NURSING PRACTICE A theoretical renewal is mandatory to improve nursing reasoning and nursing priority identification. Integrating PNEI and PRDM into nursing theoretics will modify the way professionals approach patients, reducing cognitive biases and medical errors. NO PATIENT OR PUBLIC CONTRIBUTION There was no patient or public involvement in the design or writing of this discursive article.
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Affiliation(s)
- Alessandra Milani
- Nursing Education, IEO, European Institute of Oncology IRCCS, Milan, Italy
- PhD Student, Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | | | - Eliana Misurelli
- Nursing Education, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Silvana Lacapra
- Nursing Education, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Gabriella Pravettoni
- Department of Oncology and Haemato-Oncology, University of Milan, Milan, Italy
- Applied Research Division for Cognitive and Psychological Science, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Giorgio Magon
- Nursing Manager, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Ketti Mazzocco
- Department of Oncology and Haemato-Oncology, University of Milan, Milan, Italy
- Applied Research Division for Cognitive and Psychological Science, IEO, European Institute of Oncology IRCCS, Milan, Italy
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Rabaey P, Decat P, Heytens S, Vogelaers D, Mariman A, Demeester T. Time-dependent complexity characterisation of activity patterns in patients with Chronic Fatigue Syndrome. Biopsychosoc Med 2024; 18:10. [PMID: 38566157 PMCID: PMC10986074 DOI: 10.1186/s13030-024-00305-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Accepted: 03/16/2024] [Indexed: 04/04/2024] Open
Abstract
BACKGROUND Chronic Fatigue Syndrome patients suffer from symptoms that cannot be explained by a single underlying biological cause. It is sometimes claimed that these symptoms are a manifestation of a disrupted autonomic nervous system. Prior works studying this claim from the complex adaptive systems perspective, have observed a lower average complexity of physical activity patterns in chronic fatigue syndrome patients compared to healthy controls. To further study the robustness of such methods, we investigate the within-patient changes in complexity of activity over time. Furthermore, we explore how these changes might be related to changes in patient functioning. METHODS We propose an extension of the allometric aggregation method, which characterises the complexity of a physiological signal by quantifying the evolution of its fractal dimension. We use it to investigate the temporal variations in within-patient complexity. To this end, physical activity patterns of 7 patients diagnosed with chronic fatigue syndrome were recorded over a period of 3 weeks. These recordings are accompanied by physicians' judgements in terms of the patients' weekly functioning. RESULTS We report significant within-patient variations in complexity over time. The obtained metrics are shown to depend on the range of timescales for which these are evaluated. We were unable to establish a consistent link between complexity and functioning on a week-by-week basis for the majority of the patients. CONCLUSIONS The considerable within-patient variations of the fractal dimension across scales and time force us to question the utility of previous studies that characterise long-term activity signals using a single static complexity metric. The complexity of a Chronic Fatigue Syndrome patient's physical activity signal does not suffice to characterise their high-level functioning over time and has limited potential as an objective monitoring metric by itself.
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Affiliation(s)
- Paloma Rabaey
- IDLab, Department of Information Technology, Ghent University - imec, Ghent, Belgium.
| | - Peter Decat
- Department of Public Health and Primary Care, Ghent University, Ghent, Belgium
| | - Stefan Heytens
- Department of Public Health and Primary Care, Ghent University, Ghent, Belgium
| | - Dirk Vogelaers
- Center of Integrative Medicine, Department of Physical Medicine and Rehabilitation, University Hospital Ghent, Ghent, Belgium
- Department of General Internal Medicine, AZ Delta, Roeselare, Belgium
| | - An Mariman
- Center of Integrative Medicine, Department of Physical Medicine and Rehabilitation, University Hospital Ghent, Ghent, Belgium
| | - Thomas Demeester
- IDLab, Department of Information Technology, Ghent University - imec, Ghent, Belgium
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Fanali A, Giorgi F, Tramonti F. Thick description and systems thinking: Reiterating the importance of a biopsychosocial approach to mental health. J Eval Clin Pract 2024; 30:309-315. [PMID: 36444133 DOI: 10.1111/jep.13800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Revised: 11/10/2022] [Accepted: 11/20/2022] [Indexed: 11/30/2022]
Abstract
STUDY AIMS The article aims at reiterating the importance of a biopsychosocial approach to mental health, taking stock of the critiques that have been raised and moving forward throughout a reconsideration of the theoretical background of systems thinking and emphasizing the relevance of the concept of thick description for the promotion of an adequate reflection on methodology and case formulation. LITERATURE REVIEW It is our opinion that the biopsychosocial approach is still a powerful framework for making sense of the growing data collected in the different fields related to mental health and for designing proper treatment plans. A crucial challenge for mental health is that of surpassing the dichotomies and ideological disputes that still contaminate the field with detrimental effects on the advancement of knowledge and on the integration and continuity of different kind of interventions. CONCLUSIONS The time is ripe for building bridges among neuroscience, humanities and social sciences, and this can only happen within the umbrella of a biopsychosocial perspective reinstated into its systems thinking background.
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Affiliation(s)
| | - Franco Giorgi
- Department of Neuroscience, University of Pisa, Pisa, Italy
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Sturmberg JP, Marcum JA. From cause and effect to causes and effects. J Eval Clin Pract 2024; 30:296-308. [PMID: 36779244 DOI: 10.1111/jep.13814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Revised: 01/27/2023] [Accepted: 01/29/2023] [Indexed: 02/14/2023]
Abstract
It is now-at least loosely-acknowledged that most health and clinical outcomes are influenced by different interacting causes. Surprisingly, medical research studies are nearly universally designed to study-usually in a binary way-the effect of a single cause. Recent experiences during the coronavirus disease 2019 pandemic brought to the forefront that most of our challenges in medicine and healthcare deal with systemic, that is, interdependent and interconnected problems. Understanding these problems defy simplistic dichotomous research methodologies. These insights demand a shift in our thinking from 'cause and effect' to 'causes and effects' since this transcends the classical way of Cartesian reductionist thinking. We require a shift to a 'causes and effects' frame so we can choose the research methodology that reflects the relationships between variables of interest-one-to-one, one-to-many, many-to-one or many-to-many. One-to-one (or cause and effect) relationships are amenable to the traditional randomized control trial design, while all others require systemic designs to understand 'causes and effects'. Researchers urgently need to re-evaluate their science models and embrace research designs that allow an exploration of the clinically obvious multiple 'causes and effects' on health and disease. Clinical examples highlight the application of various systemic research methodologies and demonstrate how 'causes and effects' explain the heterogeneity of clinical outcomes. This shift in scientific thinking will allow us to find the necessary personalized or precise clinical interventions that address the underlying reasons for the variability of clinical outcomes and will contribute to greater health equity.
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Affiliation(s)
- Joachim P Sturmberg
- School of Medicine and Public Health, Faculty of Health and Medicine, University of Newcastle, Holgate, New South Wales, Australia
- Foundation President, International Society for Systems and Complexity Sciences for Health, Waitsfield, Vermont, USA
| | - James A Marcum
- Department of Philosophy, Baylor University, Waco, Texas, USA
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Sturmberg JP, Martin CM. From theory to practice: The pragmatic value of applying systems thinking and complexity sciences in healthcare. J Eval Clin Pract 2024; 30:149-152. [PMID: 38462994 DOI: 10.1111/jep.13979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Accepted: 02/27/2024] [Indexed: 03/12/2024]
Affiliation(s)
- Joachim P Sturmberg
- College of Health, Medicine and Wellbeing, University of Newcastle, Callaghan, NSW, Australia
- International Society for Systems and Complexity Sciences for Health, Waitsfield, Vermont, US
| | - Carmel M Martin
- Department of Medicine, Nursing and Allied Health Monash University, Clayton, Victoria, Australia
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Ye JC, Heng HH. The New Era of Cancer Cytogenetics and Cytogenomics. Methods Mol Biol 2024; 2825:3-37. [PMID: 38913301 DOI: 10.1007/978-1-0716-3946-7_1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/25/2024]
Abstract
The promises of the cancer genome sequencing project, combined with various -omics technologies, have raised questions about the importance of cancer cytogenetic analyses. It is suggested that DNA sequencing provides high resolution, speed, and automation, potentially replacing cytogenetic testing. We disagree with this reductionist prediction. On the contrary, various sequencing projects have unexpectedly challenged gene theory and highlighted the importance of the genome or karyotype in organizing gene network interactions. Consequently, profiling the karyotype can be more meaningful than solely profiling gene mutations, especially in cancer where karyotype alterations mediate cellular macroevolution dominance. In this chapter, recent studies that illustrate the ultimate importance of karyotype in cancer genomics and evolution are briefly reviewed. In particular, the long-ignored non-clonal chromosome aberrations or NCCAs are linked to genome or chromosome instability, genome chaos is linked to genome reorganization under cellular crisis, and the two-phased cancer evolution reconciles the relationship between genome alteration-mediated punctuated macroevolution and gene mutation-mediated stepwise microevolution. By further synthesizing, the concept of karyotype coding is discussed in the context of information management. Altogether, we call for a new era of cancer cytogenetics and cytogenomics, where an array of technical frontiers can be explored further, which is crucial for both basic research and clinical implications in the cancer field.
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Affiliation(s)
- Jing Christine Ye
- Department of Lymphoma/Myeloma, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Henry H Heng
- Molecular Medicine and Genetics, Wayne State University School of Medicine, Detroit, MI, USA.
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Milani A, Misurelli E, Bottaccioli AG, Bottaccioli F, Lacapra S, Ciccarelli C, Magon G, Mazzocco K. The iceberg of genomics: New perspectives in the use of genomics and epigenetics in oncology nursing clinical reasoning. A discursive paper. J Adv Nurs 2023; 79:4560-4567. [PMID: 37705490 DOI: 10.1111/jan.15858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 08/21/2023] [Accepted: 08/28/2023] [Indexed: 09/15/2023]
Abstract
BACKGROUND Although, there is a wealth of information in the medical literature on the usefulness of genomic testing in assessing risk and its application in medical oncology decision making, there are no theoretical reflections in the nursing field. AIM To understand the implications of molecular biology in nursing practice and highlight the role of Nursing Theory in guiding nurses' reasoning. MATERIALS AND METHODS Searching literature published between 2000 and 2022 in Medline and Google Scholar. Scientific evidence was analysed by the authors expert in different fields. RESULTS Based on the findings of the literature, concerns have been raised about the proper care of cancer patients who have a genomic risk profile determination. In particular, the absence of theoretical thinking and conceptual models that consider developments in molecular biology and their impact on nursing, in addition to the prevalence of heuristic thinking and the application of clinical patterns in nursing practice, could induce patient misjudgement with inadequate planning of preventive, curative, rehabilitative and educational nursing interventions. Nurses working in the field of oncology should be aware that the risk profile determined by genomics tests is merely the visible and stated portion of the cancer patient: the tip of iceberg. DISCUSSION This study demonstrates how genomic testing takes into account a fraction of genes discovered in tumour tissue to establish a risk profile. This subset differs, for example, from the social genome, which can determine the risk of dementia, cancer and cardiovascular disease, but in response to social adversity. Nursing theory, which views the environment as a metaparadigm, must consider a conceptual model that can integrate the findings of genomic testing with recommendations from studies on the social genome of humans to make it easier to build nursing treatments that can better reduce these risks. CONCLUSION A nursing theoretical discourse on genomics is a paramount requirement for developing effective nursing care.
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Affiliation(s)
- Alessandra Milani
- School of Nursing, European Institute of Oncology IRCCS, Milan, Italy
| | - Eliana Misurelli
- School of Nursing, European Institute of Oncology IRCCS, Milan, Italy
| | - Anna Giulia Bottaccioli
- Italian Society of Psychoneuroendocrineimmunology, Rome, Italy
- Department of Clinical Psychology, Università Vita e Salute, Milan, Italy
| | | | - Silvana Lacapra
- School of Nursing, European Institute of Oncology IRCCS, Milan, Italy
| | - Chiara Ciccarelli
- School of Nursing, European Institute of Oncology IRCCS, Milan, Italy
| | - Giorgio Magon
- Nursing Manager, European Institute of Oncology IRCCS, Milan, Italy
| | - Ketti Mazzocco
- Department of Oncology and Haemato-Oncology, University of Milan, Milan, Italy
- Division of Applied Research for Cognitive and Psychological Sciences, European Institute of Oncology IRCCS, Milan, Italy
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González-González E, Requena C. Practices of Self-Care in Healthy Old Age: A Field Study. Geriatrics (Basel) 2023; 8:geriatrics8030054. [PMID: 37218834 DOI: 10.3390/geriatrics8030054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 05/02/2023] [Accepted: 05/10/2023] [Indexed: 05/24/2023] Open
Abstract
Two competing psychological approaches for how to care for oneself to stay healthy in old age have coexisted and dominated the scientific literature. OBJECTIVE Identify the self-care practices of healthy older adults and establish the relationship between these practices and the cognitive processes involved. METHOD 105 healthy older people (83.91% women) recorded their self-care practices using the Care Time Test and underwent a cognitive evaluation. RESULTS The frequency and variety of different activities that participants spent performing on a day of the week where they had the fewest obligations are as follows: nearly 7 h on seven survival activities, 4 h and 30 min on three maintenance of functional independence activities and 1 h on one activity that promoted personal development. Older people who carry out activities in a developmental approach showed better everyday memory (8.63 points) and attention levels (7.00 points) than older people who carry out activities using a conservative approach (memory: 7.43; attention level: 6.40). CONCLUSION The results evidenced that the frequency and variety of activities that promote personal development are associated with better attention and memory performance.
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Affiliation(s)
| | - Carmen Requena
- Department of Psychology, Sociology and Philosophy, University of León, 24004 Leon, Spain
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10
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Sturmberg JP. Changing the paradigm of research. J Eval Clin Pract 2023. [PMID: 36871210 DOI: 10.1111/jep.13828] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Accepted: 02/23/2023] [Indexed: 03/06/2023]
Affiliation(s)
- Joachim P Sturmberg
- School of Medicine and Public Health, Faculty of Health and Medicine, University of Newcastle, Callaghan, New South Wales, Australia.,International Society for Systems and Complexity Sciences for Health, Waitsfield, Vermont, USA
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Borghmans F, Laletas S. Complex adaptive phenomenology: A conceptual framework for healthcare research. J Eval Clin Pract 2023. [PMID: 36740901 DOI: 10.1111/jep.13811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Accepted: 01/16/2023] [Indexed: 02/07/2023]
Abstract
RATIONALE Healthcare research exploring the lived experiences of health care professionals from different disciplines, such as nursing, medicine, and allied health, has repeatedly highlighted many methodological challenges, especially in understanding the individual human experience within complex systems. In response, complexity theory and phenomenological approaches emerged and evolved in ways that potentially offered researchers frameworks to inform an understanding of the individual human experience. However, while these two theoretical approaches inform a method of inquiry, there is a gap in understanding the phenomenon of 'being' and how this is embodied within complex systems such as the healthcare system. THE AIMS AND OBJECTIVES The aim of this paper is to present an integrated theoretical framework, namely complex adaptive phenomenology (CAP). CAP aims to address this inquiry gap by offering a structured conceptual framework wherein complexity theory and phenomenology are complementary but multi-dimensional. The key objective of CAP was to synthesize and integrate two methods of inquiry that examine the relational aspects of 'being', that is the gestalt of perception, action, and context, The authors argue that CAP is well-suited to complex research contexts such as healthcare. The framework focuses on the reciprocal, co-constructive relationships extant between perception, meaning, context, and action that shape experiences of 'being' within complex systems. Complexity theory's connectionist orientation explains the relationships that are formative of the experience of being, while phenomenology explores the manifestations of these formative relationships by attending to the notion of 'being' itself. CONCLUSION The authors propose that an integrated framework, of phenomenology and complexity theory, can provide a platform for deeper understandings of the experiences of health professionals and contribute to healthcare scholarship.
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Telles Correia D, Stoyanov D, Rocha Neto HG. How to define today a medical disorder? Biological and psychosocial disadvantages as the paramount criteria. J Eval Clin Pract 2022; 28:1195-1204. [PMID: 34105223 DOI: 10.1111/jep.13592] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2021] [Revised: 04/13/2021] [Accepted: 05/22/2021] [Indexed: 12/26/2022]
Abstract
BACKGROUND The 20th century has seen great developments in the concept of disease. Marked by the biopsychosocial paradigm, several strategies for disease definition were added to previous descriptive organic views, but a final concept is still out of reach. METHOD A critical review was carried out on thorough analysis of articles and textbooks to describe the main concepts and definitions of disease. RESULTS The concept 'disease' is a pragmatic construct, not a natural kind. Three main ways to define disease were identified, and characterized: Biological (disease as a lesion, disadvantage/deviation from normal and dysfunction), Psychosocial (distress and disability, existential potentials, descriptive prototype, and prototype typification), and values-based definition. CONCLUSION All the paradigms have advantages and flaws, but progressive use of all criteria in disease definition adds validity and reliability to diagnostic constructs. Such constructs must be, above all, useful for practice and research. Biological paradigm is relevant, but fails to cover all the complexity that involves human illness and the treatment process. An emphasis on distress, dysfunction, and carefully selected value-laden characteristics might be the right direction for useful diagnostic construct conceptions.
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Affiliation(s)
- Diogo Telles Correia
- Faculdade de Medicina, Clinica Universitária de Psiquiatria e Psicologia Médica, Universidade de Lisboa, Lisbon, Portugal
| | - Drozdstoy Stoyanov
- Division of Translational Neuroscience, Research Institute, Department of Psychiatry and Medical Psychology, Medical University of Plovdiv, Plovdiv, Bulgaria
| | - Helio G Rocha Neto
- Faculdade de Medicina, Clinica Universitária de Psiquiatria e Psicologia Médica, Universidade de Lisboa, Lisbon, Portugal.,Programa de Pós Graduação em Psiquiatria e Saúde Mental-PROPSAM, Instituto de Psiquiatria, Universidade Federal do Rio de Janeiro-UFRJ, Rio de Janeiro, Brazil
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Complexity theory in the management of patients with musculoskeletal pain. BIOMEDICA : REVISTA DEL INSTITUTO NACIONAL DE SALUD 2022; 42:563-573. [PMID: 36511673 PMCID: PMC9776532 DOI: 10.7705/biomedica.6440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Indexed: 12/14/2022]
Abstract
Nonlinear systems are not susceptible to research with a reductionist approach. In this sense, the complexity theory provides an alternative approach to quantify the importance of contextual factors in patients with musculoskeletal pain. The use of positive (placebo) or negative (nocebo) contextual factors in the therapeutic setting could largely account for the non-specific component of treatment efficacy, directly affecting the quality of patients’ health-related outcomes (e.g., pain, disability, or satisfaction). In recent years, there has been a better understanding of the effects of contextual factors. However, the knowledge and awareness of them is limited and heterogeneous among physical therapists, reducing their translational value in the field of physiotherapy.
The purpose of this essay is to describe the management of patients with musculoskeletal pain from the complexity theory perspective.
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Sturmberg J, Paul E, Van Damme W, Ridde V, Brown GW, Kalk A. The danger of the single storyline obfuscating the complexities of managing SARS-CoV-2/COVID-19. J Eval Clin Pract 2022; 28:1173-1186. [PMID: 34825442 DOI: 10.1111/jep.13640] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 11/11/2021] [Accepted: 11/12/2021] [Indexed: 12/15/2022]
Abstract
Chimamanda Ngozi Adichie showed how a single story is limited and thereby distorts the true nature of an issue. During this COVID-19 pandemic there have been, at least, three consecutive single stories-the 'lethal threat' story, followed by the 'economic threat' story, and finally the 'vaccine miracle' story. None of these single stories can convincingly and permanently capture the dynamics of the pandemic. This is because countries experienced different morbidity and mortality patterns, different socioeconomic disadvantage, age and vulnerability of population, timing and level of lockdown with economic variability, and, despite heavy promotion, vaccines were beset with a significant and variable degree of hesitancy. Lack of transparency, coherence and consistency of pandemic management-arising from holding on to single storylines-showed the global deficiency of public health policy and planning, an underfunding of (public) health and social services, and a growing distrust in governments' ability to manage crises effectively. Indeed, the global management has increased already large inequities, and little has been learnt to address the growing crises of more infectious and potentially more lethal virus mutations. Holding onto single stories prevents the necessary learnings to understand and manage the complexities of 'wicked' problems, whereas listening to the many stories provides insights and pathways to do so effectively as well as efficiently.
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Affiliation(s)
- Joachim Sturmberg
- Discipline of General Practice, College of Health, Medicine and Wellbeing, University of Newcastle, Newcastle, New South Wales, Australia.,Foundation President-International Society for Systems and Complexity Sciences for Health
| | - Elisabeth Paul
- School of Public Health, Université Libre de Bruxelles, Brussels, Belgium
| | - Wim Van Damme
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | - Valery Ridde
- CEPED, Institute for Research on Sustainable Development (IRD), ERL INSERM SAGESUD, IRD-Université de Paris, Paris, France
| | - Garrett W Brown
- Colead-Global Health, School of Politics and International Studies (POLIS), University of Leeds, Leeds, UK
| | - Andreas Kalk
- Kinshasa Country Office, Deutsche Gesellschaft für Internationale Zusammenarbeit, Kinshasa, Democratic Republic of the Congo
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Sturmberg JP, Martin CM. Complexity sciences: Applied philosophy to solve real-world wicked problems. J Eval Clin Pract 2022; 28:1169-1172. [PMID: 36345738 DOI: 10.1111/jep.13781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Accepted: 08/16/2022] [Indexed: 11/10/2022]
Affiliation(s)
- Joachim P Sturmberg
- College of Health, Medicine and Wellbeing, University of Newcastle, Newcastle, New South Wales, Australia.,International Society for Systems and Complexity Sciences for Health, Newcastle, New South Wales, Australia
| | - Carmel M Martin
- Department of Medicine, Nursing and Allied Health, Monash Health, Melbourne, Victoria, Australia
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Sturmberg JP, Kissling B, Kühlein T. Shared decision-making in the realm of uncertainty: The example of coronary artery disease through an EBM and complexity science lens. J Eval Clin Pract 2022. [PMID: 36419338 DOI: 10.1111/jep.13794] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Revised: 11/07/2022] [Accepted: 11/08/2022] [Indexed: 11/27/2022]
Abstract
Patients look to their clinicians for explanations and treatments that achieve predictable cures with certainty. Clinicians usually respond accordingly. Acknowledging uncertainty, while necessary, is difficult, anxiety-provoking and at times overwhelming for patients and clinicians alike. We here present three case studies to illustrate the uncertainties of managing patients with potentially life-threatening illnesses. Research aims to provide answers to clinical problems. But, conducting research almost inevitably entails a reduction of real-world complexities. Research ultimately can only provide 'partial or in general answers' mostly revealing new questions. Due to the complexity of clinical care, research cannot really achieve certainty and predictability for an individual within his specific living context and values. In an unavoidably uncertain environment, instead of oversimplifying, clinicians like patients-as far as possible-ought to better embrace a complexity thinking frame. This provides a deeper understanding how living bodies function as-a-whole within their living contexts. Uncertainty and unpredictability, being inherent elements of complexity thinking, cannot be overcome. However, it may be made easier to cope with uncertainty by at least adopting the thinking in probabilities for benefits and harms of patient related outcomes as introduced in Sackett's Evidence-Based Medicine framework. Through the lenses of evidence-based medicine and complexity sciences this paper critically explores the clinical management of three patients diagnosed as having coronary artery disease. They all received the same treatment even though they presented with very different clinical complaints arising from different disease manifestations. Looking at these case studies the authors reflect on the reasons behind this astonishing, but widely seen medical behaviour of 'one size fits all'. They critically reflect the importance of research and evidence in view of a person-centred solution.
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Affiliation(s)
- Joachim P Sturmberg
- School of Medicine and Public Health, Faculty of Health and Medicine, University of Newcastle, Callaghan, New South Wales, Australia
| | | | - Thomas Kühlein
- Allgemeinmedizinisches Institut, Universitätsklinikum Erlangen, Erlangen, Germany
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Sturmberg J. There is More to 'Making Connections to Improve Health Outcomes'. Glob Adv Health Med 2022; 11:2164957X221126675. [PMID: 36160085 PMCID: PMC9500305 DOI: 10.1177/2164957x221126675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 08/18/2022] [Accepted: 08/25/2022] [Indexed: 11/26/2022] Open
Abstract
Langevin1 rightly points to the reductionist mindset being the stumbling block for providing person-centered care. While considering the interconnections between the various domains underpinning health is a necessary first step towards more person-centered care, it ultimately is not sufficient. Person-centered care arises from the appreciation of the interdependencies and interactions between the various domains across its large-scale supersystems as much as its small-scale subsystems. Viewed with a complex-adaptive systems mindset health and disease are the phenotypical outcome categorisations of a person’s whole-of-systems dynamics across all scales of organisation.2,3
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Affiliation(s)
- Joachim Sturmberg
- College of Health, Medicine and Wellbeing, University of Newcastle, Callaghan, NSW, Australia.,International Society for Systems and Complexity Sciences for Health
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18
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Kromme NMH, Ahaus KTB, Gans ROB, van de Wiel HBM. Internists’ ambivalence toward their role in health counseling and promotion: A qualitative study on the internists’ beliefs and attitudes. PLoS One 2022; 17:e0273848. [PMID: 36048849 PMCID: PMC9436108 DOI: 10.1371/journal.pone.0273848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Accepted: 08/16/2022] [Indexed: 11/18/2022] Open
Abstract
Crucial to its success is that physicians enhance their competence in Lifestyle Medicine and take on their role as Health Advocates in Health Counseling and Promotion (HC&P). However, studies on patients’ views of lifestyle counseling in clinical practice demonstrate that many patients neither perceived a need to adopt a healthy lifestyle nor having had any discussion with their physician about their lifestyle. This study is part of a participatory action research project focusing on identifying areas of improvement for health promotion in the practice of internists. Within this project, we interviewed 28 internists from six different subspecialties of an academic medical center in the Netherlands. This study aims to gain insight into how internists understand their role in HC&P by a qualitative analysis of their beliefs and attitudes in the interview data. Participants claimed that promoting a healthy lifestyle is important. However, they also reflected a whole system of beliefs that led to an ambivalent attitude toward their role in HC&P. We demonstrate that little belief in the success of HC&P nurtured ambivalence about the internists’ role and their tasks and responsibilities. Ambivalence appeared to be reinforced by beliefs about the ability and motivation of patients, the internists’ motivational skills, and the patient-doctor relationship, and by barriers such as lack of time and collaboration with General Practitioners. When participants viewed HC&P as a part of their treatment and believed patients were motivated, they were less ambivalent about their role in HC&P. Based on our data we developed a conceptual framework that may inform the development of the competences of the Health Advocate role of internists in education and practice.
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Affiliation(s)
- Nicolien M. H. Kromme
- Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
- * E-mail:
| | - Kees T. B. Ahaus
- Erasmus School of Health Policy & Management Health Services Management & Organization (HSMO), Rotterdam, The Netherlands
| | - Reinold O. B. Gans
- Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Harry B. M. van de Wiel
- Wenckebach Institute, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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19
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Almarcha M, González I, Balagué N, Javierre C. Prescribing or co-designing exercise in healthy adults? Effects on mental health and interoceptive awareness. Front Behav Neurosci 2022; 16:944193. [PMID: 35967899 PMCID: PMC9366851 DOI: 10.3389/fnbeh.2022.944193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2022] [Accepted: 07/04/2022] [Indexed: 11/28/2022] Open
Abstract
Universal exercise recommendations for adults neglect individual preferences, changing constraints, and their potential impact on associated health benefits. A recent proposal suggests replacing the standardized World Health Organisation (WHO) exercise recommendations for healthy adults by co-designed interventions where individuals participate actively in the decisions about the selected physical activities and the effort regulation. This study contrasts the effects on mental health and interoceptive awareness of a co-designed and co-adapted exercise intervention with an exercise program based on the WHO recommendations for healthy adults. Twenty healthy adults (10 men and 10 women, 40–55 y.o.) participated voluntarily in the research. They were randomly assigned to a co-designed exercise intervention (CoD group) and a prescribed exercise program (WHO group). Supervised online by specialized personal trainers, both programs lasted 9 weeks and were equivalent in volume and intensity. The effects of the exercise intervention were tested through personal interviews, questionnaires (DASS-21 and MAIA) and a cardiorespiratory exercise test. Intragroup differences (pre-post) were assessed using the Mann-Whitney Wilcoxon test and intergroup differences through Student’s t-tests. Effect sizes were calculated through Cohen’s d. Interviews were analyzed through thematic analysis. Eleven participants completed the intervention (CoD = 8, WHO = 5). Both groups improved, but non significantly, their cardiorespiratory testing results, and no differences were found between them post-intervention. Mental health was only enhanced in the CoD group (p < 0.001), and interoceptive awareness improved in seven of the eight scales in the CoD group (p < 0.001) and only in 3 scales in the WHO group (p < 0.01). In conclusion, the co-designed intervention was more effective for developing mental health, interoceptive awareness, autonomy, and exercise self-regulation than the WHO-based exercise program.
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Affiliation(s)
- Maricarmen Almarcha
- Complex Systems in Sport Research Group, Institut Nacional d’Educació Física de Catalunya, University of Barcelona, Barcelona, Spain
| | - Ignacio González
- Institut Nacional d’Educació Física de Catalunya, University of Barcelona, Barcelona, Spain
| | - Natàlia Balagué
- Complex Systems in Sport Research Group, Institut Nacional d’Educació Física de Catalunya, University of Barcelona, Barcelona, Spain
- *Correspondence: Natàlia Balagué,
| | - Casimiro Javierre
- Departament de Ciències Fisiològiques, Facultat de Medicina i Ciències de la Salut, University of Barcelona, Barcelona, Spain
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Huston P. A Sedentary and Unhealthy Lifestyle Fuels Chronic Disease Progression by Changing Interstitial Cell Behaviour: A Network Analysis. Front Physiol 2022; 13:904107. [PMID: 35874511 PMCID: PMC9304814 DOI: 10.3389/fphys.2022.904107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Accepted: 05/27/2022] [Indexed: 11/13/2022] Open
Abstract
Managing chronic diseases, such as heart disease, stroke, diabetes, chronic lung disease and Alzheimer’s disease, account for a large proportion of health care spending, yet they remain in the top causes of premature mortality and are preventable. It is currently accepted that an unhealthy lifestyle fosters a state of chronic low-grade inflammation that is linked to chronic disease progression. Although this is known to be related to inflammatory cytokines, how an unhealthy lifestyle causes cytokine release and how that in turn leads to chronic disease progression are not well known. This article presents a theory that an unhealthy lifestyle fosters chronic disease by changing interstitial cell behavior and is supported by a six-level hierarchical network analysis. The top three networks include the macroenvironment, social and cultural factors, and lifestyle itself. The fourth network includes the immune, autonomic and neuroendocrine systems and how they interact with lifestyle factors and with each other. The fifth network identifies the effects these systems have on the microenvironment and two types of interstitial cells: macrophages and fibroblasts. Depending on their behaviour, these cells can either help maintain and restore normal function or foster chronic disease progression. When macrophages and fibroblasts dysregulate, it leads to chronic low-grade inflammation, fibrosis, and eventually damage to parenchymal (organ-specific) cells. The sixth network considers how macrophages change phenotype. Thus, a pathway is identified through this hierarchical network to reveal how external factors and lifestyle affect interstitial cell behaviour. This theory can be tested and it needs to be tested because, if correct, it has profound implications. Not only does this theory explain how chronic low-grade inflammation causes chronic disease progression, it also provides insight into salutogenesis, or the process by which health is maintained and restored. Understanding low-grade inflammation as a stalled healing process offers a new strategy for chronic disease management. Rather than treating each chronic disease separately by a focus on parenchymal pathology, a salutogenic strategy of optimizing interstitial health could prevent and mitigate multiple chronic diseases simultaneously.
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Affiliation(s)
- Patricia Huston
- Department of Family Medicine, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
- Institut du Savoir Montfort (Research), University of Ottawa, Ottawa, ON, Canada
- *Correspondence: Patricia Huston, , orcid.org/0000-0002-2927-1176
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21
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Paul E, Brown GW, Kalk A, Van Damme W, Ridde V, Sturmberg J. "When My Information Changes, I Alter My Conclusions." What Can We Learn From the Failures to Adaptively Respond to the SARS-CoV-2 Pandemic and the Under Preparedness of Health Systems to Manage COVID-19? Int J Health Policy Manag 2022; 11:1241-1245. [PMID: 33300759 PMCID: PMC9808188 DOI: 10.34172/ijhpm.2020.240] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Accepted: 11/21/2020] [Indexed: 01/12/2023] Open
Affiliation(s)
- Elisabeth Paul
- School of Public Health, Université libre de Bruxelles, Brussels, Belgium
| | | | - Andreas Kalk
- Deutsche Gesellschaft für Internationale Zusammenarbeit, Kinshasa Country Office, Kinshasa, Democratic Republic of the Congo
| | - Wim Van Damme
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | - Valéry Ridde
- CEPED, Institute for Research on Sustainable Development (IRD), IRD-Université de Paris, Paris, France
| | - Joachim Sturmberg
- School of Medicine and Public Health, Faculty of Health and Medicine, University of Newcastle, Callaghan NSW, Australia
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22
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Montull L, Slapšinskaitė-Dackevičienė A, Kiely J, Hristovski R, Balagué N. Integrative Proposals of Sports Monitoring: Subjective Outperforms Objective Monitoring. SPORTS MEDICINE - OPEN 2022; 8:41. [PMID: 35348932 PMCID: PMC8964908 DOI: 10.1186/s40798-022-00432-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Accepted: 02/26/2022] [Indexed: 12/20/2022]
Abstract
Current trends in sports monitoring are characterized by the massive collection of tech-based biomechanical, physiological and performance data, integrated through mathematical algorithms. However, the application of algorithms, predicated on mechanistic assumptions of how athletes operate, cannot capture, assess and adequately promote athletes' health and performance. The objective of this paper is to reorient the current integrative proposals of sports monitoring by re-conceptualizing athletes as complex adaptive systems (CAS). CAS contain higher-order perceptual units that provide continuous and multilevel integrated information about performer-environment interactions. Such integrative properties offer exceptional possibilities of subjective monitoring for outperforming any objective monitoring system. Future research should investigate how to enhance this human potential to contribute further to athletes' health and performance. This line of argument is not intended to advocate for the elimination of objective assessments, but to highlight the integrative possibilities of subjective monitoring.
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Affiliation(s)
- Lluc Montull
- Complex Systems in Sport Research Group, Institut Nacional d'Educació Física de Catalunya (INEFC), Universitat de Barcelona, Barcelona, Spain
- University School of Health and Sport, University of Girona, Girona, Spain
| | - Agne Slapšinskaitė-Dackevičienė
- Complex Systems in Sport Research Group, Institut Nacional d'Educació Física de Catalunya (INEFC), Universitat de Barcelona, Barcelona, Spain
- Department of Sports Medicine, Faculty of Nursing and Faculty of Public Health, Health Research Institute, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - John Kiely
- Institute of Coaching and Performance, School of Sport and Wellbeing, University of Central Lancashire, Preston, PR1 2HE, UK
| | - Robert Hristovski
- Complex Systems in Sport Research Group, Faculty of Physical Education, Sport and Health, Ss. Cyril and Methodius University in Skopje, Skopje, Macedonia
| | - Natàlia Balagué
- Complex Systems in Sport Research Group, Institut Nacional d'Educació Física de Catalunya (INEFC), Universitat de Barcelona, Barcelona, Spain.
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Zhao J. Is there such a thing as a symptom cluster: the paradigm shift in symptom science requires a philosophical level reflection. Asia Pac J Oncol Nurs 2022; 9:100056. [PMID: 35633916 PMCID: PMC9130072 DOI: 10.1016/j.apjon.2022.03.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 03/13/2022] [Indexed: 11/28/2022] Open
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DeHaven MJ, Gimpel NA, Kitzman H. Working with communities: Meeting the health needs of those living in vulnerable communities when Primary Health Care and Universal Health Care are not available. J Eval Clin Pract 2021; 27:1056-1065. [PMID: 33051956 DOI: 10.1111/jep.13495] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 09/10/2020] [Accepted: 09/21/2020] [Indexed: 01/01/2023]
Abstract
RATIONALE, AIMS, AND OBJECTIVES The health care delivery model in the United States does not work; it perpetuates unequal access to care, favours treatment over prevention, and contributes to persistent health disparities and lack of insurance. The vast majority of those who suffer from preventable diseases and health disparities, and who are at greatest risk of not having insurance, are low-income minorities (Native Americans, Hispanics, and African-Americans) who live in high risk and vulnerable communities. The historical lack of support in the United States for Universal Health Care (UHC) and Primary Health Care (PHC)-with their emphasis on health care for all, population health, and social determinants of health-requires community health scientists to develop innovative local solutions for addressing unmet community health needs. METHODS We developed a model community health science approach for improving health in fragile communities, by combining community-oriented primary care (COPC), community-based participatory research (CBPR), asset-based community development, and service learning principles. During the past two decades, our team has collaborated with community residents, local leaders, and many different types of organizations, to address the health needs of vulnerable patients. The approach defines health as a social outcome, resulting from a combination of clinical science, collective responsibility, and informed social action. RESULTS From 2000 to 2020, we established a federally funded research programme for testing interventions to improve health outcomes in vulnerable communities, by working in partnership with community organizations and other stakeholders. The partnership goals were reducing chronic disease risk and multimorbidity, by stimulating lifestyle changes, increasing healthy behaviours and health knowledge, improving care seeking and patient self-management, and addressing the social determinants of health and population health. Our programmes have also provided structured community health science training in high-risk communities for hundreds of doctors in training. CONCLUSION Our community health science approach demonstrates that the factors contributing to health can only be addressed by working directly with and in affected communities to co-develop health care solutions across the broad range of causal factors. As the United States begins to consider expanding health care options consistent with PHC and UHC principles, our community health science experience provides useful lessons in how to engage communities to address the deficits of the current system. Perhaps the greatest assets US health care systems have for better addressing population health and the social determinants of health are the important health-related initiatives already underway in most local communities. Building partnerships based on local resources and ongoing social determinants of health initiatives is the key for medicine to meaningfully engage communities for improving health outcomes and reducing health disparities. This has been the greatest lesson we have learned the past two decades, has provided the foundation for our community health science approach, and accounts for whatever success we have achieved.
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Affiliation(s)
- Mark J DeHaven
- Academy for Research on Community Health, Engagement, and Services (ARCHES), University of North Carolina at Charlotte, Charlotte, North Carolina, USA
| | - Nora A Gimpel
- Department of Family and Community Medicine, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Heather Kitzman
- Robbins Institute for Health Policy & Leadership, Baylor Scott & White Health and Wellness, Dallas, Texas, USA
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25
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Sturmberg JP, Martin CM. Universal health care - A matter of design and agency? J Eval Clin Pract 2021; 27:1011-1017. [PMID: 32267086 DOI: 10.1111/jep.13395] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Accepted: 03/16/2020] [Indexed: 11/30/2022]
Abstract
Universal health care (UHC) is primarily a financing concern, whereas primary health care (PHC) is primarily concerned with providing the right care at the right time to achieve the best possible health outcomes for individuals and communities. A recent call for contributions by the WHO emphasized that UHC can only be achieved through PHC, and that to achieve this goal will require the strengthening of the three pillars of PHC - (a) enabling primary care and public health to integrate health services, (b) empowering people and communities to create healthy living conditions, and (c) integrating multisectoral policy decisions to ensure UHC that achieves the goal of "health for all." "Pillars" - as a static metaphor - sends the wrong signal to the research and policy-making community. It, in fact, contradicts the WHO's own view, namely that there is "the need to strengthen comprehensive primary health care systems based on local priorities, needs and contexts … [that are] co-developed by people who are engaged in their own health." What we really need to develop PHC as the basis to achieve the goal of UHC is a dynamic agency to drive a "system-as-a-whole framework" that simultaneously takes into account finance, individual, and local needs. Health systems are socially constructed organizational systems that are "functionally layered" in a hierarchical fashion - governments and/or funders at the top-level not only promote the goals of the system (policies) but also constrain the system (rules, regulations, resources) in its ability to deliver. Hence, there is a need to focus on two key system features - political leadership and dynamic bottom-up agency that maintains everyone's focus on the goal to be achieved, and a limitation of system constraints so that communities can shape best adapted primary care services that truly meet the needs of their individuals, families, and community.
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Affiliation(s)
- Joachimh P Sturmberg
- School of Medicine and Public Health Faculty of Health and Medicine, University of Newcastle, Callaghan, Australia
| | - Carmel M Martin
- Department of Medicine, Nursing and Allied Health Monash Health Clayton, Clayton, Australia
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Sturmberg JP, Getz LO, Stange KC, Upshur REG, Mercer SW. Beyond multimorbidity: What can we learn from complexity science? J Eval Clin Pract 2021; 27:1187-1193. [PMID: 33588522 DOI: 10.1111/jep.13521] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Accepted: 11/12/2020] [Indexed: 12/18/2022]
Abstract
Multimorbidity - the occurrence of two or more long-term conditions in an individual - is a major global concern, placing a huge burden on healthcare systems, physicians, and patients. It challenges the current biomedical paradigm, in particular conventional evidence-based medicine's dominant focus on single-conditions. Patients' heterogeneous range of clinical presentations tend to escape characterization by traditional means of classification, and optimal management cannot be deduced from clinical practice guidelines. In this article, we argue that person-focused care based in complexity science may be a transformational lens through which to view multimorbidity, to complement the specialism focus on each particular disease. The approach offers an integrated and coherent perspective on the person's living environment, relationships, somatic, emotional and cognitive experiences and physiological function. The underlying principles include non-linearity, tipping points, emergence, importance of initial conditions, contextual factors and co-evolution, and the presence of patterned outcomes. From a clinical perspective, complexity science has important implications at the theoretical, practice and policy levels. Three essential questions emerge: (1) What matters to patients? (2) How can we integrate, personalize and prioritize care for whole people, given the constraints of their socio-ecological circumstances? (3) What needs to change at the practice and policy levels to deliver what matters to patients? These questions have no simple answers, but complexity science principles suggest a way to integrate understanding of biological, biographical and contextual factors, to guide an integrated approach to the care of people with multimorbidity.
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Affiliation(s)
- Joachim P Sturmberg
- School of Medicine and Public Health, Faculty of Health and Medicine, University of Newcastle, Newcastle, New South Wales, Australia.,Foundation President, International Society for Systems and Complexity Sciences for Health, Waitsfield, Vermont
| | - Linn O Getz
- General Practice Research Unit, Department of Public Health and Nursing, Norwegian University of Science and Technology, Trondheim, Norway
| | - Kurt C Stange
- Department of Family Medicine & Community Health, Epidemiology & Biostatistics, Oncology and Sociology, Center for Community Health Integration, Case Western Reserve University, Cleveland, Ohio, USA
| | - Ross E G Upshur
- Department of Family and Community Medicine, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Stewart W Mercer
- Department of Primary Care and Multimorbidity, Usher Institute, College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, UK
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Lawless MT, Tieu M, Feo R, Kitson AL. Theories of self-care and self-management of long-term conditions by community-dwelling older adults: A systematic review and meta-ethnography. Soc Sci Med 2021; 287:114393. [PMID: 34534780 DOI: 10.1016/j.socscimed.2021.114393] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2021] [Revised: 09/02/2021] [Accepted: 09/08/2021] [Indexed: 02/03/2023]
Abstract
RATIONALE The proportion of older adults living with long-term conditions (LTCs) is increasing. Self-care and self-management approaches are seen as valuable in helping older people with LTCs to manage their health and care, yet the theoretical overlaps and divergences are not always clear. OBJECTIVES The objectives of this review were to: (1) systematically identify and appraise studies of self-care or self-management of LTCs by community-dwelling older adults (aged ≥60 years) either informed by, applying, creating, or testing theory; (2) explore similarities or points of convergence between the identified theories; and (3) use a meta-ethnographic approach to synthesise the theories and group related concepts into core constructs. METHODS We conducted a systematic theory synthesis, searching six electronic databases. Three reviewers independently screened titles and abstracts followed by full texts and two reviewers appraised study quality. Theoretical data were synthesised within and across individual theories using meta-ethnographic line-of-argument synthesis. RESULTS A total of 141 articles (138 studies) and 76 theories were included in the review. Seven core constructs were developed: (1) temporal and spatial context; (2) stressors; (3) personal resources; (4) informal social resources; (5) formal social resources; (6) behavioural adaptations; and (7) quality of life outcomes. A line of argument was developed that conceptualised older adults' self-care and self-management as a dynamic process of behavioural adaptation, enabled by personal resources and informal and formal social resources, aimed at alleviating the impacts of stressors and maintaining quality of life. CONCLUSION This synthesis provides an overview of theories used in research on older adults' LTC self-care and self-management. Our synthesis describes the complex interplay of intrinsic and extrinsic factors influencing self-care and self-management behaviours and provides considerations for future research, intervention design, and implementation. The utility of the constructs in research and practice requires further attention and empirical validation.
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Affiliation(s)
- Michael T Lawless
- College of Nursing and Health Sciences, Flinders University, Bedford Park, SA, 5042, Australia; Caring Futures Institute, Flinders University, Bedford Park, SA, 5042, Australia.
| | - Matthew Tieu
- College of Nursing and Health Sciences, Flinders University, Bedford Park, SA, 5042, Australia; College of Humanities, Arts, and Social Sciences, Flinders University, Bedford Park, SA, 5042, Australia
| | - Rebecca Feo
- College of Nursing and Health Sciences, Flinders University, Bedford Park, SA, 5042, Australia; Caring Futures Institute, Flinders University, Bedford Park, SA, 5042, Australia
| | - Alison L Kitson
- College of Nursing and Health Sciences, Flinders University, Bedford Park, SA, 5042, Australia; Caring Futures Institute, Flinders University, Bedford Park, SA, 5042, Australia
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Peek CJ, Westfall JM, Stange KC, Liaw W, Ewigman B, DeVoe JE, Green LA, Polverento ME, Bora N, deGruy FV, Harper PG, Baker NJ. Shared Language for Shared Work in Population Health. Ann Fam Med 2021; 19:450-457. [PMID: 34546952 PMCID: PMC8437558 DOI: 10.1370/afm.2708] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Revised: 01/11/2021] [Accepted: 01/25/2021] [Indexed: 11/09/2022] Open
Abstract
People working on behalf of population health, community health, or public health often experience confusion or ambiguity in the meaning of these and other common terms-the similarities and differences and how they bear on the tasks and division of labor for care delivery and public health. Shared language must be clear enough to help, not hinder people working together as they ultimately come to mutual understanding of roles, responsibilities, and actions in their joint work. Based on an iterative lexicon development process, the authors developed and propose a definitional framework as an aid to navigating among related population and community health terms. These terms are defined, similarities and differences clarified, and then organized into 3 categories that reflect goals, realities, and ways to get the job done. Goals include (a) health as well-being for persons, (b) population health as that goal expressed in measurable terms for groups, and (c) community health as population health for particular communities of interest, geography, or other defining characteristic-groups with shared identity and particular systemic influences on health. Realities are social determinants as influences, health disparities as effects, and health equity as both a goal and a design principle. Ways to get the job done include health care delivery systems for enrollees and public health in population-based civic activities-with a broad zone of collaboration where streams of effort converge in partnership with served communities. This map of terms can enable people to move forward together in a broad zone of collaboration for health with less confusion, ambiguity, and conflict.
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Affiliation(s)
- C J Peek
- Department of Family Medicine and Community Health, University of Minnesota, Minneapolis, Minnesota
| | | | - Kurt C Stange
- Case Western Reserve University Center for Community Health Integration, Cleveland, Ohio
| | - Winston Liaw
- Health Systems and Population Health Sciences, University of Houston College of Medicine, Houston, Texas
| | - Bernard Ewigman
- Department of Family Medicine, North-Shore University Health System & the Pritzker School of Medicine, University of Chicago, Chicago, Illinois
| | - Jennifer E DeVoe
- Department of Family Medicine, Oregon Health & Science University, Portland, Oregon
| | - Larry A Green
- Department of Family Medicine, University of Colorado School of Medicine, Aurora, Colorado
| | - Molly E Polverento
- Department of Family Medicine, College of Human Medicine, Michigan State University, East Lansing, Michigan
| | - Nirali Bora
- Kent County Health Department, Grand Rapids, Michigan
| | - Frank V deGruy
- Department of Family Medicine, University of Colorado School of Medicine, Aurora, Colorado
| | - Peter G Harper
- Department of Family Medicine and Community Health, University of Minnesota, Minneapolis, Minnesota
| | - Nancy J Baker
- Department of Family Medicine and Community Health, University of Minnesota, Minneapolis, Minnesota
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Sturmberg JP, Martin CM. Implementing cardiovascular disease preventive care guidelines in general practice: an opportunity missed. Med J Aust 2021; 215:189-189.e1. [PMID: 34291471 DOI: 10.5694/mja2.51193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Joachim P Sturmberg
- University of Newcastle, Newcastle, NSW.,International Society for Systems and Complexity Sciences for Health, Waitsfield, VT, USA
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30
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[Complexity theory and the hypertensive patient]. Semergen 2021; 47:404-410. [PMID: 33836976 DOI: 10.1016/j.semerg.2020.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Revised: 12/15/2020] [Accepted: 12/21/2020] [Indexed: 11/21/2022]
Abstract
Hypertension is the main cause of death worldwide and the approach that the Family Physician makes of hypertensive patients, given his or her key role as a gateway to the health system, is a crucial determinant in their evolution. On the other hand, Complexity theory contributes to the understanding on how systems grow, adapt and evolve. The hypertensive patient, given his character of biological and social being, can be understood and approached as a complex system. Understanding the characteristics of these systems contributes to considering the patient from another perspective, more satisfactory both for himself and for the professional who assists him. This review analyzes the characteristics of the complex system «hypertensive patient» and the tools that allow us to account for and interact with this complexity. An approach from multiple perspectives, migrating from the classic reductionist models to others that take into account the dynamic interrelationships that are at stake, would be a useful strategy for the Family Physician in the challenge of achieving adequate control of blood pressure in his or her patients.
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Martin C, Hinkley N, Stockman K, Campbell D. Potentially preventable hospitalizations-The 'pre-hospital syndrome': Retrospective observations from the MonashWatch self-reported health journey study in Victoria, Australia. J Eval Clin Pract 2021; 27:228-235. [PMID: 32857482 PMCID: PMC7984178 DOI: 10.1111/jep.13460] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 07/15/2020] [Accepted: 07/19/2020] [Indexed: 12/11/2022]
Abstract
RATIONALE, AIMS, AND OBJECTIVES HealthLinks: Chronic Care is a state-wide public hospital initiative designed to improve care for cohorts at-risk of potentially preventable hospitalizations at no extra cost. MonashWatch (MW) is an hospital outreach service designed to optimize admissions in an at-risk cohort. Telehealth operators make regular phone calls (≥weekly) using the Patient Journey Record System (PaJR). PaJR generates flags based on patient self-report, alerting to a risk of admission or emergency department attendance. 'Total flags' of global health represent concerns about self-reported general health, medication, and wellness. 'Red flags' represent significant disease/symptoms concerns, likely to lead to hospitalization. METHODS A time series analysis of PaJR phone calls to MW patients with ≥1 acute non-surgical admissions in a 20-day time window (10 days pre-admission and 10 days post-discharge) between 23 December 2016 and 11 October 2017. Pettitt's hypothesis-testing homogeneity measure was deployed to analyse Victorian Admitted Episode/Emergency Minimum Datasets and PaJR data. FINDINGS A MW cohort of 103 patients (mean age 74 ± 15 years; with 59% males) had 263 admissions was identified. Bed days ranged from <1 to 37.3 (mean 5.8 ± 5.8; median 4.1). The MW cohort had 7.6 calls on average in the 20-day pre- and post-hospital period. Most patients reported significantly increased flags 'pre-hospital' admission: medication issues increased on day 7.0 to 8.5; total flags day 3, worse general health days 2.5 to 1.8; and red flags of disease symptoms increased on day 1. These flags persisted following discharge. DISCUSSION/CONCLUSION This study identified a 'pre-hospital syndrome' similar to a post-hospital phase aka the well-documented 'post-hospital syndrome'. There is evidence of a 10-day 'pre-hospital' window for interventions to possibly prevent or shorten an acute admission in this MW cohort. Further validation in a larger diverse sample is needed.
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Affiliation(s)
- Carmel Martin
- Community Health, Monash Health, Dandenong, Victoria, Australia.,Monash University, Melbourne, Victoria, Australia
| | - Narelle Hinkley
- MonashWatch and HealthLinks Chronic Care, Community Health, Monash Health, Dandenong, Victoria, Australia
| | - Keith Stockman
- Staying Well Program, Northern Health, Northern Hospital, Epping, Victoria, Australia
| | - Donald Campbell
- Staying Well Program, Northern Health, Northern Hospital, Epping, Victoria, Australia
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32
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Sturmberg JP. Health and Disease Are Dynamic Complex-Adaptive States Implications for Practice and Research. Front Psychiatry 2021; 12:595124. [PMID: 33854446 PMCID: PMC8039389 DOI: 10.3389/fpsyt.2021.595124] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2020] [Accepted: 03/01/2021] [Indexed: 11/14/2022] Open
Abstract
Interoception, the ability to convey one's overall physiological state, allows people to describe their health along an experiential continuum, from excellent, very good, good, fair to poor. Each health state reflects a distinct pattern of one's overall function. This assay provides a new frame of understanding health and disease as complex-adaptive system states of the person as-a-whole. It firstly describes how complex patterns can emerge from simple equations. It then discusses how clinical medicine in certain domains has started to explore the pattern characteristics resulting in the heterogeneity of disease, and how this better understanding has improved patient management. The experiential state of health can be surprising to the observer-some are in good health with disabling disease, others are in poor health without the evidence of any. The main part of the assay describes the underlying complexity principles that contribute to health, and synthesizes available evidence from various research perspectives to support the philosophic/theoretical proposition of the complex-adaptive nature of health. It shows how health states arise from complex-adaptive system dynamics amongst the variables of a hierarchically layered system comprising the domains of a person's macro-level external environment to his nano-level biological blueprint. The final part suggests that the frame of health as a dynamic complex-adaptive state defines a new paradigm, and outlines ways of translating these expanded understandings to clinical practice, future research, and health system design.
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Affiliation(s)
- Joachim P. Sturmberg
- Faculty of Health and Medicine, School of Medicine and Public Health, University of Newcastle, Callaghan, NSW, Australia
- International Society for Systems and Complexity Sciences for Health, Waitsfield, VT, United States
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33
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Abstract
Home-based teleworking, associated with sedentary behavior, may impair self-reported adult health status. Current exercise recommendations, based on universal recipes, may be insufficient or even misleading to promote healthy teleworking. From the Network Physiology of Exercise perspective, health is redefined as an adaptive emergent state, product of dynamic interactions among multiple levels (from genetic to social) that cannot be reduced to a few dimensions. Under such a perspective, fitness development is focused on enhancing the individual functional diversity potential, which is better achieved through varied and personalized exercise proposals. This paper discusses some myths related to ideal or unique recommendations, like the ideal exercise or posture, and the contribution of recent computer technologies and applications for prescribing exercise and assessing fitness. Highlighting the need for creating personalized working environments and strengthening the active contribution of users in the process, new recommendations related to teleworking posture, home exercise counselling, exercise monitoring and to the roles of healthcare and exercise professionals are proposed. Instead of exercise prescribers, professionals act as co-designers that help users to learn, co-adapt and adequately contextualize exercise in order to promote their somatic awareness, job satisfaction, productivity, work–life balance, wellbeing and health.
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34
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Meade RD, Akerman AP, Notley SR, McGinn R, Poirier P, Gosselin P, Kenny GP. Physiological factors characterizing heat-vulnerable older adults: A narrative review. ENVIRONMENT INTERNATIONAL 2020; 144:105909. [PMID: 32919284 DOI: 10.1016/j.envint.2020.105909] [Citation(s) in RCA: 96] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 05/24/2020] [Accepted: 06/17/2020] [Indexed: 05/26/2023]
Abstract
More frequent and intense periods of extreme heat (heatwaves) represent the most direct challenge to human health posed by climate change. Older adults are particularly vulnerable, especially those with common age-associated chronic health conditions (e.g., cardiovascular disease, hypertension, obesity, type 2 diabetes, chronic kidney disease). In parallel, the global population is aging and age-associated disease rates are on the rise. Impairments in the physiological responses tasked with maintaining homeostasis during heat exposure have long been thought to contribute to increased risk of health disorders in older adults during heatwaves. As such, a comprehensive overview of the provisional links between age-related physiological dysfunction and elevated risk of heat-related injury in older adults would be of great value to healthcare officials and policy makers concerned with protecting heat-vulnerable sectors of the population from the adverse health impacts of heatwaves. In this narrative review, we therefore summarize our current understanding of the physiological mechanisms by which aging impairs the regulation of body temperature, hemodynamic stability and hydration status. We then examine how these impairments may contribute to acute pathophysiological events common during heatwaves (e.g., heatstroke, major adverse cardiovascular events, acute kidney injury) and discuss how age-associated chronic health conditions may exacerbate those impairments. Finally, we briefly consider the importance of physiological research in the development of climate-health programs aimed at protecting heat-vulnerable individuals.
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Affiliation(s)
- Robert D Meade
- Human and Environmental Physiology Research Unit, School of Human Kinetics, University of Ottawa, Ottawa, Ontario, Canada
| | - Ashley P Akerman
- Human and Environmental Physiology Research Unit, School of Human Kinetics, University of Ottawa, Ottawa, Ontario, Canada
| | - Sean R Notley
- Human and Environmental Physiology Research Unit, School of Human Kinetics, University of Ottawa, Ottawa, Ontario, Canada
| | - Ryan McGinn
- Department of Anesthesiology and Pain Medicine, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
| | - Paul Poirier
- Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, Québec, Québec, Canada
| | - Pierre Gosselin
- Institut National de Santé Publique du Québec and Université Laval, Québec, Québec, Canada
| | - Glen P Kenny
- Human and Environmental Physiology Research Unit, School of Human Kinetics, University of Ottawa, Ottawa, Ontario, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.
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35
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McDonough LK, Meredith KT, Nikagolla C, Middleton RJ, Tan JK, Ranasinghe AV, Sierro F, Banati RB. The water chemistry and microbiome of household wells in Medawachchiya, Sri Lanka, an area with high prevalence of chronic kidney disease of unknown origin (CKDu). Sci Rep 2020; 10:18295. [PMID: 33106529 PMCID: PMC7589467 DOI: 10.1038/s41598-020-75336-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 10/12/2020] [Indexed: 01/08/2023] Open
Abstract
Chronic kidney disease (CKD) of unknown etiology (CKDu) mostly affects agricultural communities in Central America, South Asia, Africa, but likely also in North America and Australia. One such area with increased CKDu prevalence is the Medawachchiya District Secretariat Division of the Anuradhapura District in the North Central Province of Sri Lanka. Recent research has focused on the presence of various microbial pathogens in drinking water as potential causal or contributing factors to CKDu, yet no study to date has performed a more comprehensive microbial and water chemistry assessment of household wells used for domestic water supply in areas of high CKDu prevalence. In this study, we describe the chemical composition and total microbial content in 30 domestic household wells in the Medawachchiya District Secretariat Division. While the chemical composition in the tested wells mostly lies within standard drinking water limits, except for high levels of fluoride (F), magnesium (Mg), sodium (Na), chloride (Cl) and calcium (Ca) in some samples, we find a frequent presence of cyanotoxin-producing Microcystis, confirming earlier studies in Sri Lanka. Since the total microbial content of drinking water also directly influences the composition of the human gut microbiome, it can be considered an important determinant of health. Several bacterial phyla were previously reported in the gut microbiome of patients with CKD. Using these bacteria phyla to define operational taxonomic units, we found that these bacteria also occur in the microbiome of the sampled well water. Based on available environmental data, our study demonstrates associations between the abundances of these bacteria with geographical distribution, well water temperature and likely fertilizer use in the local surface water catchment area of the individual household wells. Our results reinforce the recommendation that household wells with stagnant or infrequently used water should be purged prior to use for drinking water, bathing and irrigation. The latter is suggested because of the reported potential accumulation of bacterial toxins by agricultural crops. The observation that bacteria previously found in chronic kidney disease patients are also present in household wells requires a more detailed systematic study of both the human gut and drinking water microbiomes in CKDu patients, in relation to disease prevalence and progression.
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Affiliation(s)
- Liza K McDonough
- Australian Nuclear Science and Technology Organisation (ANSTO), New Illawarra Rd, Lucas Heights, NSW, 2234, Australia. .,School of Biological, Earth and Environmental Sciences, UNSW Sydney, Sydney, NSW, 2052, Australia.
| | - Karina T Meredith
- Australian Nuclear Science and Technology Organisation (ANSTO), New Illawarra Rd, Lucas Heights, NSW, 2234, Australia
| | - Chandima Nikagolla
- School of Civil and Environmental Engineering, Science and Engineering Faculty, Queensland University of Technology, Brisbane, QLD, 4000, Australia
| | - Ryan J Middleton
- Australian Nuclear Science and Technology Organisation (ANSTO), New Illawarra Rd, Lucas Heights, NSW, 2234, Australia
| | - Jian K Tan
- Australian Nuclear Science and Technology Organisation (ANSTO), New Illawarra Rd, Lucas Heights, NSW, 2234, Australia.,Charles Perkins Centre, University of Sydney, Sydney, NSW, Australia.,Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Asanga V Ranasinghe
- National Renal Disease Prevention and Research Unit, Ministry of Health, Colombo 10, Sri Lanka
| | - Frederic Sierro
- Australian Nuclear Science and Technology Organisation (ANSTO), New Illawarra Rd, Lucas Heights, NSW, 2234, Australia.,Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Richard B Banati
- Australian Nuclear Science and Technology Organisation (ANSTO), New Illawarra Rd, Lucas Heights, NSW, 2234, Australia.,Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
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36
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Sturmberg JP. Want improved quality? Improve your systems. J Eval Clin Pract 2020; 26:1530-1533. [PMID: 32808746 DOI: 10.1111/jep.13461] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2020] [Revised: 07/13/2020] [Accepted: 07/17/2020] [Indexed: 12/20/2022]
Affiliation(s)
- Joachim P Sturmberg
- School of Medicine and Public Health, Faculty of Health and Medicine, University of Newcastle, Australia.,Foundation President, International Society for Systems and Complexity Sciences for Health, Waitsfield, Vermont, USA
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37
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DeHaven MJ, Gimpel NA, Gutierrez D, Kitzman-Carmichael H, Revens K. Designing health care: A community health science solution for reducing health disparities by integrating social determinants and the effects of place. J Eval Clin Pract 2020; 26:1564-1572. [PMID: 32157768 DOI: 10.1111/jep.13366] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Accepted: 01/21/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND In the United States chronic illnesses have become a way of life for multiple generations - they are the number one cause of death and disability (accounting for more than 70% of deaths), 60% of American adults have at least one chronic disease, and 40% have multiple chronic conditions. Although multiple factors contribute to the growth in chronic disease prevalence, a major factor has been overreliance on health care systems for promoting health and preventing disease. Large health care systems are ill equipped for this role since they are designed to detect, treat, and manage disease, not to promote health or address the underlying causes of disease. METHODS Improving health outcomes in the U.S. will require implementing broad-based prevention strategies combining biological, behavioral, and societal variables that move beyond clinical care. According to community medicine, clinical care alone cannot create, support, or maintain health. Rather, health can only ensue from combining clinical care with epidemiology and community organization, because health is a social outcome resulting from a combination of clinical science, collective responsibility, and informed social action. RESULTS During the past 20 years, our team has developed an operational community medicine approach known as community health science. Our model provides a simple framework for integrating clinical care, population health, and community organization, using community-based participatory research (CBPR) practices for developing place-based initiatives. In the present paper, we present a brief overview of the model and describe its evolution, applications, and outcomes in two major urban environments. CONCLUSION The paper demonstrates means for integrating the social determinants of health into collaborative place-based approaches, for aligning community assets and reducing health disparities. It concludes by discussing how asset-based community development can promote social connectivity and improve health, and how our approach reflects the emerging national consensus on the importance of place-based population system change.
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Affiliation(s)
- Mark J DeHaven
- Public Health Sciences, University of North Carolina at Charlotte, Charlotte, North Carolina
| | - Nora A Gimpel
- Community Health, UT Southwestern Medical Center, Dallas, Texas
| | | | | | - Keri Revens
- Research and Evaluation, Camino Community Center, Charlotte, North Carolina
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38
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Sturmberg JP, Martin CM. COVID-19 - how a pandemic reveals that everything is connected to everything else. J Eval Clin Pract 2020; 26:1361-1367. [PMID: 32633056 PMCID: PMC7362160 DOI: 10.1111/jep.13419] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 05/09/2020] [Accepted: 05/11/2020] [Indexed: 01/10/2023]
Affiliation(s)
- Joachim P Sturmberg
- School of Medicine and Public Health, Faculty of Health and Medicine, University of Newcastle, Callaghan, New South Wales, Australia.,International Society for Systems and Complexity Sciences for Health, Waitsfield, VT, USA
| | - Carmel M Martin
- Department of Medicine, Nursing and Allied Health Monash University, Clayton, Victoria, Australia
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39
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A Proof-of-Concept System Dynamics Simulation Model of the Development of Burnout and Recovery Using Retrospective Case Data. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17165964. [PMID: 32824546 PMCID: PMC7459661 DOI: 10.3390/ijerph17165964] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 08/11/2020] [Accepted: 08/13/2020] [Indexed: 01/05/2023]
Abstract
The phenomenon of burnout is a complex issue, which despite major efforts from researchers and organizations remains hard to prevent. The current literature highlights an increasing global prevalence of employees that are dealing with burnout. What has been largely missing is a more systemic, dynamic, and personal perspective on the interactions of the key determinants of burnout. Burnout can be seen as the outcome of a complex system involving feedback loops between individual mental models, individual behavior, and external social influences. Understanding the feedback loops involved may enable employees and organizations to intervene in burnout trajectories early and effectively. System dynamics (SD) modeling is a methodology that can describe the structure and behavior of a complex system. The current paper describes the development of an SD model of burnout. First, an expert- and literature-informed causal loop diagram (CLD) of burnout is developed. Then, a novel approach is developed to collect personal retrospective scenario data. Finally, the CLD and data are translated into a quantitative SD model. The potential of the SD model is illustrated by simulating the behavior of three realistic personas during the onset of and recovery from burnout. The process of development of an SD model of burnout is presented and the strengths and limitations of the approach are discussed.
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40
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Sturmberg JP. From probability to believability. J Eval Clin Pract 2020; 26:1081-1086. [PMID: 31140703 DOI: 10.1111/jep.13186] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2019] [Accepted: 05/05/2019] [Indexed: 12/26/2022]
Affiliation(s)
- Joachim P Sturmberg
- A/Prof of General Practice, School of Medicine and Public Health, University of Newcastle, Callaghan, New South Wales, 2308, Australia.,International Society for Systems and Complexity Sciences for Health
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41
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Dynamic thinking and complexity: considerations for health promotion. JOURNAL OF COMPLEXITY IN HEALTH SCIENCES 2020. [DOI: 10.21595/chs.2020.21514] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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42
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Sturmberg JP. Approaching complexity-Start with awareness. J Eval Clin Pract 2020; 26:1030-1033. [PMID: 31922325 DOI: 10.1111/jep.13355] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2019] [Accepted: 01/02/2020] [Indexed: 12/22/2022]
Affiliation(s)
- Joachim P Sturmberg
- School of Medicine and Public Health, University of Newcastle, Callaghan, New South Wales, Australia.,International Society for Systems and Complexity Sciences for Health
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43
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Sturmberg JP. Evidence-based medicine-Not a panacea for the problems of a complex adaptive world. J Eval Clin Pract 2019; 25:706-716. [PMID: 30887648 DOI: 10.1111/jep.13122] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2019] [Accepted: 02/13/2019] [Indexed: 12/26/2022]
Abstract
The recent sacking of Peter Gøtzsche from the Cochrane Collaboration Board raised strong responses and highlights the neglected issue about priorities-maintaining the reputation of the organization or vigorously debating the merits of scientific approaches to find answers to complex problems? The Cochrane approach hales the randomized trial (RCT) as the gold standard research approach and affirms that meta-analysis provides the ultimate proof (or platinum standard) to settle contentious issues confronting the clinician. However, most published medical research is wrong, and critics coined the acronym GIGO (garbage in, garbage out) as a meme to highlight the risks of blind faith in the hyped-up procedures of the EBM movement. This paper firstly explores the differences between the prevailing scientific method arising from the linear cause-and-effect assumption and the complex adaptive systems science methods arising from observations that most phenomena emerge from nonlinearity in networked systems. Most medical conditions are characterized by necessary features that by themselves are not sufficient to explain their nature and behaviour. Such nonlinear phenomena require modelling approaches rather than linear statistical and/or meta-analysis approaches to be understood. These considerations also highlight that research is largely stuck at the data and information levels of understanding which fails clinicians who depend on knowledge-the synthesis of information-to apply in an adaptive way in the clinical encounter. Clinicians are constantly confronted with the linked challenges of doing things right and doing the right thing for their patients. EBM and Cochrane with their restrictive approaches are the antithesis to a practice of medicine that is responsive to constantly changing patient needs. As such, the EBM/Cochrane crisis opens a window of opportunity to re-examine the nature of health, illness and disease, and the nature of health care and its systems for the benefits of its professionals and their patients. We are at the cusp of a paradigmatic shift towards an understanding a praxis of health care that takes account of its complexities.
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Affiliation(s)
- Joachim P Sturmberg
- School of Medicine and Public Health, University of Newcastle, Wamberal, NSW, Australia
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44
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Sturmberg JP, Bircher J. Better and fulfilling healthcare at lower costs: The need to manage health systems as complex adaptive systems. F1000Res 2019; 8:789. [PMID: 31839925 PMCID: PMC6900806 DOI: 10.12688/f1000research.19414.1] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/23/2019] [Indexed: 12/14/2022] Open
Abstract
Rising healthcare costs are major concerns in most high-income countries. Yet, political measures to reduce costs have so far remained futile and have damaged the best interests of patients and citizen. We therefore explored the possibilities to analyze healthcare systems as a socially constructed complex adaptive system (CAS) and found that by their very nature such CAS tend not to respond as expected to top-down interventions. As CAS have emergent behaviors, the focus on their drivers - purpose, economy and behavioral norms - requires particular attention. First, the importance of understanding the purpose of health care as improvement of health and its experience has been emphasized by two recent complementary re-definitions of health and disease. The economic models underpinning today's healthcare - profit maximization - have shifted the focus away from its main purpose. Second, although economic considerations are important, they must serve and not dominate the provision of healthcare delivery. Third, expected health professionals' behavioral norms - to first consider the health and wellbeing of patients - have been codified in the universally accepted Declaration of Geneva 2017. Considering these three aspects it becomes clear that complex adaptive healthcare systems need mindful top-down/bottom-up leadership that supports the nature of innovation for health care driven by local needs. The systemic focus on improving people's health will then result in significant cost reductions.
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Affiliation(s)
- Joachim P. Sturmberg
- School of Medicine and Public Health, Faculty of Health and Medicine, University of Newcastle, Holgate, NSW, 2250, Australia
- International Society for Systems and Complexity Sciences for Health, Waitsfield, VT, USA
| | - Johannes Bircher
- Hepatology Department of Biomedical Research, University of Bern, Bern, Switzerland
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