Surgical management of giant skin tumor - A case report

INTRODUCTION

Malignant non-melanoma skin cancers (NMSC) are of two main types: basal cell carcinoma (BCC) and squamous cell carcinoma (SCC). In rare occasions, some of the malignant skin lesions show histopathological characteristics of both BCC and SCC and are known as basosquamous carcinomas (BSC). In some cases of large tumors, extensive reconstructive surgery might be needed to correct the skin defect after the primary excision.

PRESENTATION OF CASE

We report a case of a 76-year-old Bulgarian male patient who presented with a neglected giant cutaneous tumor with more than a 15-year history of a growing mass in the right deltoid area. On physical exam an enormous exophytic ulcerated and crusted skin lesion measuring around 11×11cm was found. Wide local excision of the lesion with 10-mm resection margins and partial resection of the underlying deltoid muscle were performed due to signs of infiltration. A full-thickness total skin graft from the left inguinal area was harvested to cover the skin defect. Final histopathological examination showed metatypical carcinoma with mixed characteristics of SCC and BCC - BSC, with infiltration of the fatty tissue, deltoid muscle and clear margins of resection, staged as T4R0. Two and a half years after surgery there are no signs of upper arm motor dysfunction and no evidence of local recurrence and distant metastasis on a follow-up PET/CT.

DISCUSSION

Following current National Comprehensive Cancer Network's guidelines for primary treatment of BCC, surgical candidates should undergo standard excision with wider surgical margins, postoperative margin assessment and second intention healing, linear repair, or skin graft. Therapeutic strategy for non-operable cases includes administration of radiotherapy or system therapy in the face of Hedgehog pathway inhibitors and programmed cell death protein 1 inhibitor. They can provide an alternative solution to unresectable or difficult-to-treat locally advanced cases of BSC.

CONCLUSION

Similarly to BCC and SCC, the first-line treatment option for BCS is surgical excision, but surgical margins should be wider than those for low-risk BCC due to the infiltrative growth pattern of this tumor. Favorable esthetic outcome requires precise planning of the reconstructive technique.

Mixed methods feasibility and usability testing of a childhood obesity risk estimation tool

BACKGROUND

A Childhood Obesity Risk Estimation tool (SLOPE CORE) has been developed based on prediction models using routinely available maternity and early childhood data to estimate risk of childhood obesity at 4-5 years. This study aims to test the feasibility, acceptability and usability of SLOPE CORE within an enhanced health visiting (EHV) service in the UK, as one context in which this tool could be utilised.

METHODS

A mixed methods approach was used to assess feasibility of implementing SLOPE CORE. Health Visitors (HVs) were trained to use the tool, and in the processes for recruiting parents into the study. HVs were recruited using purposive sampling and parents by convenience sampling. HVs and parents were invited to take part in interviews or focus groups to explore their experiences of the tool. HVs were asked to complete a system usability scale (SUS) questionnaire.

RESULTS

Five HVs and seven parents took part in the study. HVs found SLOPE CORE easy to use with a mean SUS of 84.4, (n = 4, range 70-97.5) indicating excellent usability. Five HVs and three parents took part in qualitative work. The tool was acceptable and useful for both parents and HVs. Parents expressed a desire to know their child's risk of future obesity, provided this was accompanied by additional information, or support to modify risk. HVs appreciated the health promotion opportunity that the tool presented and felt that it facilitated difficult conversations around weight, by providing 'clinical evidence' for risk, and placing the focus of the conversation onto the tool result, rather than their professional judgement. The main potential barriers to use of the tool included the need for internet access, and concerns around time needed to have a sensitive discussion around a conceptually difficult topic (risk).

CONCLUSIONS

SLOPE CORE could potentially be useful in clinical practice. It may support targeting limited resources towards families most at risk of childhood obesity. Further research is needed to explore how the tool might be efficiently incorporated into practice, and to evaluate the impact of the tool, and any subsequent interventions, on preventing childhood obesity.

Exploring the use of social network interventions for adults with mental health difficulties: a systematic review and narrative synthesis

BACKGROUND

People with mental health difficulties often experience social isolation. The importance of interventions to enhance social networks and reduce this isolation is increasingly being recognised. However, the literature has not yet been systematically reviewed with regards to how these are best used. This narrative synthesis aimed to investigate the role of social network interventions for people with mental health difficulties and identify barriers and facilitators to effective delivery. This was undertaken with a view to understanding how social network interventions might work best in the mental health field.

METHODS

Systematic searches using combinations of synonyms for mental health difficulties and social network interventions were undertaken across 7 databases (MEDLINE, Embase, PsycINFO, CINAHL, Cochrane Library, Web of Science) and 2 grey literature databases (EThoS and OpenGrey) from their inception to October 2021. We included studies reporting primary qualitative and quantitative data from all study types relating to the use of social network interventions for people with mental health difficulties. The quality of included studies was assessed using the Mixed Methods Appraisal Tool. Data were extracted and synthesised narratively.

RESULTS

The review included 54 studies, reporting data from 6,249 participants. Social network interventions were generally beneficial for people with mental health difficulties but heterogeneity in intervention type, implementation and evaluation made it difficult to draw definitive conclusions. Interventions worked best when they (1) were personalised to individual needs, interests and health, (2) were delivered outside formal health services and (3) provided the opportunity to engage in authentic valued activities. Several barriers to access were identified which, without careful consideration could exacerbate existing health inequalities. Further research is required to fully understand condition-specific barriers which may limit access to, and efficacy of, interventions.

CONCLUSIONS

Strategies for improving social networks for people with mental health difficulties should focus on supporting engagement with personalised and supported social activities outside of formal mental health services. To optimise access and uptake, accessibility barriers should be carefully considered within implementation contexts and equality, diversity and inclusion should be prioritised in intervention design, delivery and evaluation and in future research.

The role of social networks in the self-management support for young women recently diagnosed with breast cancer

It is widely acknowledged that social network support plays an important role in the quality of life and illness management of breast cancer survivors. However, the factors and processes that enable and sustain such support are less well understood. This paper reports baseline findings from a prospective UK national cohort of 1,202 women with breast cancer (aged <50 years at diagnosis), recruited before starting treatment, conducted in 2016-2019. Descriptive, univariate and multivariate regression analyses explored associations between the individual, and network member characteristics, and the type of support provided. Social network members provided a substantial level of illness-related, practical and emotional support. Highest contribution was provided by friends, followed by close family members. The social network members of women who did not have a partner provided a higher level of support than those in networks with a partner. Women without higher education were more reliant on close family members than those with higher education, and this was more so for women without a partner. Women with higher education without a partner were more reliant on friends and were overall best supported. Women without higher education who did not have a partner were overall least well supported. They had much smaller networks, were highly reliant on close family members, and on high level contributions from all network members. There is a need to develop network-based interventions to support people with a cancer diagnosis, prioritising support for the groups identified as most at risk. Interventions that support engagement with existing network members during treatment, and those that help extend such networks after treatment, are likely to be of benefit. A network perspective can help to develop tailored support and interventions by recognising the interactions between network and individual level processes.

Household food insecurity risk indices for English neighbourhoods: Measures to support local policy decisions

BACKGROUND

In England, the responsibility to address food insecurity lies with local government, yet the prevalence of this social inequality is unknown in small subnational areas. In 2018 an index of small-area household food insecurity risk was developed and utilised by public and third sector organisations to target interventions; this measure needed updating to better support decisions in different settings, such as urban and rural areas where pressures on food security differ.

METHODS

We held interviews with stakeholders (n = 14) and completed a scoping review to identify appropriate variables to create an updated risk measure. We then sourced a range of open access secondary data to develop an indices of food insecurity risk in English neighbourhoods. Following a process of data transformation and normalisation, we tested combinations of variables and identified the most appropriate data to reflect household food insecurity risk in urban and rural areas.

RESULTS

Eight variables, reflecting both household circumstances and local service availability, were separated into two domains with equal weighting for a new index, the Complex Index, and a subset of these to make up the Simple Index. Within the Complex Index, the Compositional Domain includes population characteristics while the Structural Domain reflects small area access to resources such as grocery stores. The Compositional Domain correlated well with free school meal eligibility (rs = 0.705) and prevalence of childhood obesity (rs = 0.641). This domain was the preferred measure for use in most areas when shared with stakeholders, and when assessed alongside other configurations of the variables. Areas of highest risk were most often located in the North of England.

CONCLUSION

We recommend the use of the Compositional Domain for all areas, with inclusion of the Structural Domain in rural areas where locational disadvantage makes it more difficult to access resources. These measures can aid local policy makers and planners when allocating resources and interventions to support households who may experience food insecurity.

Implementing a digital tool to support meaningful engagement with socially isolated or lonely older adults

Social isolation and loneliness are significant concerns in community dwelling older adults due to associated poorer health outcomes, inadequate crises responsiveness and increased societal burdens of care and cost. Generating Engagement in Networks Involvement (GENIE) is an online evidence-based, client-centred social network tool piloted by community-aged care services in Sydney, Australia. GENIE facilitates access to community resources, activities and people to extend or re-establish a client's social connections. This study aimed to identify GENIE's potential to maintain and promote social connections in older adults from the perspective of allied health professionals who could deliver GENIE. This qualitative exploratory study involved 33 participants on an emerging placement across two organisations who piloted GENIE. Data included consensus and priority statements produced from six nominal group technique-facilitated discussions, and an inductive thematic analysis of student documentation and all consensus statements. The main findings indicated that participants prioritised GENIE's clinical advantages, implementation barriers and recommendations for future implementation. The inductive thematic analysis revealed the two themes of practice applications, and client and professional experiences when using GENIE. As a time-efficient and personalised intervention, the research team concluded that GENIE could empower service providers to address the overarching needs of clients through rapidly connecting older adults to resources of their interests within the overburdened Australian-aged care system.

Adapting a social network intervention for use in secondary mental health services using a collaborative approach with service users, carers/supporters and health professionals in the United Kingdom

Background

Social integration, shared decision-making and personalised care are key elements of mental health and social care policy. Although these elements have been shown to improve service user and service-level outcomes, their translation into practice has been inconsistent and social isolation amongst service users persists.

Aim

To co-adapt, with service users, carers/supporters and health professionals, a web-based social network intervention, GENIE™, for use in secondary mental health services. The intervention is designed to support social activity and preference discussions between mental healthcare professionals and service users as a means of connecting individuals to local resources.

Methods

In Phase 1 (LEARN), we completed two systematic reviews to synthesise the existing evidence relating to the i) effectiveness and ii) the implementation of social network interventions for people with mental health difficulties. We undertook semi-structured interviews with a convenience sample of 15 stakeholders previously involved in the implementation of the intervention in physical healthcare settings. Interviews were also conducted with 5 national key stakeholders in mental health (e.g., policy makers, commissioners, third sector leads) to explore wider implementation issues.

In Phase 2 (ADAPT), we worked iteratively with eight service users, nine carers, six professionals/volunteers and our patient and public advisory group. We drew on a framework for experience-based co-design, consisting of a series of stakeholder consultation events, to discuss the use of the social network intervention, in mental health services. Participants also considered factors that could serve as enablers, barriers, and challenges to local implementation.

Results

Across the stakeholder groups there was broad agreement that the social network intervention had potential to be useful within mental health services. In terms of appropriate and effective implementation, such an intervention was predicted to work best within the care planning process, on discharge from hospital and within early intervention services. There were indications that the social connection mapping and needs assessment components were of most value and feasible to implement which points to the potential utility of a simplified version compared to the one used in this study. The training provided to facilitators was considered to be more important than their profession and there were indications that service users should be offered the opportunity to invite a carer, friend, or family member to join them in the intervention.

Conclusion

The GENIE™ intervention has been co-adapted for use in mental health services and a plan for optimal implementation has been co-produced. The next phase of the programme of work is to design and implement a randomised controlled trial to evaluate clinical and cost effectiveness of a simplified version of the intervention.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08521-1.

Supporting and enabling health research in a local authority (SERLA): an exploratory study

BACKGROUND

The use of research evidence to underpin public health practice and policy decisions in local government is strongly promoted but its implementation has not been straightforward. This study aimed to explore the factors, relationships and processes that contribute towards accessing, using, and generating research evidence that is relevant to local authority public health and social care and shapes its practice.

METHODS

Semi-structured individual interviews with elected councillors, officers directly involved with public health and social care and with community members from one urban unitary authority in South England were conducted. Interviews were audio recorded, transcribed verbatim and thematically analysed.

RESULTS

Fourteen participants took part in the semi-structured interviews. Local knowledge and evidence are prioritised, and anecdotal evidence is valued. The Director of Public Health was the principal source of information and support. Academics were rarely mentioned as information sources, and their involvement was ad hoc. The use of research evidence varied between individuals and departments, with wider engagement among public health specialists. Key barriers to the use of research evidence included access (not reported among public health professionals), research timeliness, local applicability, competence in finding and interpreting evidence and the role of research evidence within a political context. Public health and adult social care teams are not currently research active or research ready. Major barriers exist due to financial constraints and the socio-political context of local authorities. COVID-19 disrupted siloed ways of working, strengthening and opening potential collaborations within the local authority. This changed perspectives about the value of research but is likely time-limited unless underpinned by sustainable funding.

CONCLUSION

Creating strategic level roles within local government to work with the Director of Public Health to champion the research agenda and embedding researchers within and across teams would build capacity for local authorities to sustainably co-create, undertake, and use evidence to better inform future actions.

Understanding Online and Offline Social Networks in Illness Management of Older Patients With Asthma and Chronic Obstructive Pulmonary Disease: Mixed Methods Study Using Quantitative Social Network Assessment and Qualitative Analysis

Background

Individuals’ social networks and social support are fundamental determinants of self-management and self-efficacy. In chronic respiratory conditions, social support can be promoted and optimized to facilitate the self-management of breathlessness.

Objective

This study aimed to identify how online and offline social networks play a role in the health management of older patients with chronic respiratory conditions, explore the role of support from online peers in patients’ self-management, and understand the barriers to and potential benefits of digital social interventions.

Methods

We recruited participants from a hospital-run singing group to a workshop in London, the United Kingdom, and adapted PERSNET, a quantitative social network assessment tool. The second workshop was replaced by telephone interviews because of the COVID-19 lockdown. The transcripts were analyzed using thematic analysis.

Results

A total of 7 participants (2/7, 29%, men and 5/7, 71%, women), with an age range of 64 to 81 years, produced network maps that comprised between 5 and 10 individuals, including family members, health care professionals, colleagues, activity groups, offline and online friends, and peers. The visual maps facilitated reflections and enhanced participants’ understanding of the role of offline and online social networks in the management of chronic respiratory conditions. It also highlighted the work undertaken by the networks themselves in the self-management support. Participants with small, close-knit networks received physical, health, and emotional support, whereas those with more diverse and large networks benefited from accessing alternative and complementary sources of information. Participants in the latter type of network tended to communicate more openly and comfortably about their illness, shared the impact of their illness on their day-to-day life, and demonstrated distinct traits in terms of identity and perception of chronic disease. Participants described the potential benefits of expanding their networks to include online peers as sources of novel information, motivation, and access to supportive environments. Lack of technological skills, fear of being scammed, or preference for keeping illness-related problems for themselves and immediate family were reported by some as barriers to engaging with online peer support.

Conclusions

In this small-scale study, the social network assessment tool proved feasible and acceptable. These data show the value of using a social network tool as a research tool that can help assess and understand network structure and engagement in the self-management support and could be developed into an intervention to support self-management. Patients’ preferences to share illness experiences with their online peers, as well as the contexts in which this can be acceptable, should be considered when developing and offering digital social interventions. Future studies can explore the evolution of the social networks of older people with chronic illnesses to understand whether their willingness to engage with online peers can change over time.

Influence of social networks on cancer survivors' self-management support: A mixed methods study

Objective

The role of social networks, especially weaker ties (e.g. casual acquaintances and hobby groups), in self‐management of long‐term consequences of cancer is unexplored. This study aimed to explore the structure of cancer survivors' social networks and their contribution to self‐management support and health‐related quality of life (HRQoL).

Methods

The study used a sequential, exploratory mixed methods design. Phase 1 surveyed 349 lymphoma, colorectal, breast and prostate cancer survivors. Phase 2 analysed 20 semi‐structured interviews with respondents recruited from Phase 1.

Results

Phase 1 results suggested participants' HRQoL increased if they participated in an exercise group, if their self‐management skills increased, and social distress and negative illness perception decreased (p < 0.0005 adj. R² = 0.631). These findings were explored in Phase 2, identifying underlying mechanisms. Four themes were identified: disrupted networks after cancer treatment; navigating formal support and building individual capacity; peer networks and self‐management knowledge and linking networks to enable adaptation in recovery.

Conclusions

This study suggests engagement with community groups, particularly those not directly related to illness management and social interaction with weak ties, make a valuable contribution to self‐management support, increase HRQoL and enhance well‐being.

Assessing the effectiveness of social network interventions for adults with a diagnosis of mental health problems: a systematic review and narrative synthesis of impact

BACKGROUND

Social connections have been linked to the genesis and amelioration of mental health problems and thus have potential therapeutic value.

PURPOSE

To identify the current evidence base, assess risk of bias and synthesise findings on the effectiveness of social network interventions for people with mental health problems.

METHODS

Electronic databases (MEDLINE, Embase, PsycINFO, CINAHL, Cochrane Library, Web of Science, Scopus) and grey literature databases were systematically searched from inception to October 2021 using free text syntax combining synonyms for 'mental health problems' and 'social network interventions'. Articles were eligible for inclusion if they reported data from randomised controlled trials on the effectiveness of interventions designed to improve social networks for adults (18+) with mental health problems. Papers were independently reviewed for inclusion with conflicts resolved through consensus. Included papers were quality assessed and data extracted and synthesized narratively. Risk of bias was assessed using the Cochrane Risk of Bias Tool.

RESULTS

Nine studies randomising 2226 participants were included. Four focused on those with a diagnosis of schizophrenia or psychosis, one on major depressive disorder and four included all types of mental health diagnoses. The current evidence base is of unclear quality. However, interventions which focused on supporting social activities appear to hold the most promise for enhancing social networks. Data on cost-effectiveness and research acceptability were limited, but suggest the potential economic feasibility of and acceptability for evaluating these interventions.

CONCLUSION

There is emerging evidence that social network interventions can be effective in improving social connections for people with mental health problems. However, further evaluations with robust methodological approaches are required to inform evidence-based recommendations for health services.

Rural influences on the social network dynamics of district nursing services: A qualitative meta-synthesis

BACKGROUND AND AIMS

As demands on healthcare services grow, fiscal restrictions place increased emphasis on services outside of traditional healthcare settings. Previous research into long-term-conditions suggests that social network members (including weaker ties such as acquaintances, community groups, and healthcare professionals) play a key role in illness management. There is limited knowledge about the engagement of social networks in supporting people who are receiving medical interventions at home. This qualitative metasynthesis explores the work and the interactions between district nurses (DN) and informal network members supporting people who are receiving medical interventions at home and living in rural areas.

METHODS

A search was undertaken on CINAHL, Medline, and PsychINFO for qualitative research articles from 2009 to 2019. Studies that examined DN in rural locations and/or social network support in rural locations were eligible. Fourteen articles were selected.

RESULTS

Thematic analysis of results and discussion data from the studies resulted in four themes being developed: the development of both transactional and friend-like nurse-patient ties in rural localities, engagement of the wider network in the delivery of good care, blurring of professional boundaries in close community relationships, and issues accessing and navigating formal and informal support in the context of diminishing resources in rural areas.These findings suggest that DNs in rural localities work beyond professional specialties and experience to provide emotional support, help with daily tasks, and build links to communities. There was also evidence that nurses embedded within rural localities developed friend-like relationships with patients, and negotiated with existing support networks and communities to find support for the patient.

CONCLUSIONS

Findings indicated that developing strong links with patients and members of their networks does not automatically translate into positive outcomes for patients, and can be unsustainable, burdensome, and disruptive. DNs developing weak ties with patients and building awareness of the structure of individual networks and local sources of support offers avenues for sustainable and tailored community-based nursing support.

Resources in women's social networks for food shopping are more strongly associated with better dietary quality than people: A cross-sectional study

When healthy people are part of an individual's social network, those individuals will have better dietary quality. Little, however, is known about whether social networks for food shopping, including both people and resources (e.g. recipes, weight loss programmes and food advertisements) are associated with dietary quality. The aim of this study was to explore the relationship between social networks for food shopping and dietary quality, and whether this differs for people and resources, among women aged 18-45 years. A total of 129 participants completed a cross-sectional questionnaire including an ego-centric Social Network Exposure tool and short Food Frequency Questionnaire. Associations between dietary quality and type of network member, perceived healthiness and support for healthy shopping choices were explored using linear regression models. Analyses revealed that participants who nominated people in their food shopping social network that eat healthily or support healthy food shopping had better dietary quality (β = 0.16 SD per 1-point change on a 4-point scale, 95%CI -0.06, 0.39; β = 0.20, 95%CI -0.07, 0.46, respectively). Resources in participants' food shopping social networks which promote healthy eating or support healthy shopping were associated with better dietary quality. These associations remained robust after adjustment for confounding variables identified using a directed acyclic graph (β = 0.31 SD per 1-point change on a 4-point scale, 95%CI 0.03, 0.58; β = 0.44, 95%CI 0.09, 0.79 respectively). The results were strengthened when the outcome was multiplied by frequency of contact (β = 0.33, 95%CI 0.05, 0.61; β = 0.47, 95%CI 0.11, 0.83 respectively). This study suggests that resources which promote healthy eating and healthy food shopping have a stronger association with dietary quality than social support from people. Further research is required in a larger sample, including multiple time-points, to confirm these findings.

A Web-Based Social Network Tool (GENIE) for Supporting Self-management Among High Users of the Health Care System: Feasibility and Usability Study

Background

Primary care providers are well positioned to foster self-management through linking patients to community-based health and social services (HSSs). This study evaluated a web-based tool—GENIE (Generating Engagement in Network Involvement)—to support the self-management of adults. GENIE empowers patients to leverage their personal social networks and increase their access to HSSs. GENIE maps patients’ personal social networks, elicits preferences, and filters local HSSs from a community service directory based on patient’s interests. Trained volunteers (an extension of the primary care team) conducted home visits and conducted surveys related to life and health goals in the context of the Health TAPESTRY (Teams Advancing Patient Experience: Strengthening Quality) program, in which the GENIE tool was implemented. GENIE reports were uploaded to an electronic medical record for care planning by the team.

Objective

This study aims to explore patients’, volunteers’, and clinicians’ perceptions of the feasibility, usability, and perceived outcomes of GENIE—a tool for community-dwelling adults who are high users of the health care system.

Methods

This study involved 2 primary care clinician focus groups and 1 clinician interview (n=15), 1 volunteer focus group (n=3), patient telephone interviews (n=8), field observations that captured goal-action sequences to complete GENIE, and GENIE utilization statistics. The patients were enrolled in a primary care program—Health TAPESTRY—and Ontario’s Health Links Program, which coordinates care for the highest users of the health care system. NVivo 11 (QSR International) was used to support qualitative data analyses related to feasibility and perceived outcomes, and descriptive statistics were used for quantitative data.

Results

Most participants reported positive overall perceptions of GENIE. However, feasibility testing showed that participants had a partial understanding of the tool; volunteer facilitation was critical to support the implementation of GENIE; clinicians perceived their navigation ability as superior to that of GENIE supported by volunteers; and tool completion took 39 minutes, which made the home visit too long for some. Usability challenges included difficulties completing some sections of the tool related to medical terminology and unclear instructions, limitations in the quality and quantity of HSSs results, and minor technological challenges. Almost all patients identified a community program or activity of interest. Half of the patients (4/8, 50%) followed up on HSSs and added new members to their network, whereas 1 participant lost a member. Clinicians’ strengthened their understanding of patients’ personal social networks and needs, and patients felt less social isolation.

Conclusions

This study demonstrated the potential of GENIE, when supported by volunteers, to expand patients’ social networks and link them to relevant HSSs. Volunteers require training to implement GENIE for self-management support, which may help overcome the time limitations faced by primary care clinicians. Refining the filtering capability of GENIE to address adults’ needs may improve primary care providers’ confidence in using such tools.

Integrating a Web-Based Self-Management Tool (Managing Joint Pain on the Web and Through Resources) for People With Osteoarthritis-Related Joint Pain With a Web-Based Social Network Support Tool (Generating Engagement in Network Involvement): Design, Development, and Early Evaluation

BACKGROUND

Joint pain caused by osteoarthritis (OA) is highly prevalent and can be extremely debilitating. Programs to support self-management of joint pain can be effective; however, most programs are designed to build self-efficacy and rarely engage social networks. Digital interventions are considered acceptable by people with joint pain. However, many existing resources are not accessible for or developed alongside people with lower health literacy, which disproportionately affects people with OA.

OBJECTIVE

This study aims to design and develop an accessible digital self-management tool for people with joint pain and integrate this with an existing social network activation tool (Generating Engagement in Network Involvement [GENIE]) and to explore the feasibility of these linked tools for supporting the management of joint pain.

METHODS

The study was conducted in 2 phases: a design and development stage and a small-scale evaluation. The first phase followed the person-based approach to establish guiding principles for the development of a new site (Managing joint Pain On the Web and through Resources [EMPOWER]) and its integration with GENIE. People with joint pain were recruited from libraries, a community café, and an exercise scheme to take part in 3 focus groups. EMPOWER was tested and refined using think-aloud interviews (n=6). In the second phase, participants were recruited through the web via libraries to participate in a small-scale evaluation using the LifeGuide platform to record use over a 1-month period. Participants (n=6) were asked to complete evaluation questionnaires on their experiences. The NASSS (nonadoption, abandonment, scale-up, spread, and sustainability) framework was used to explore the feasibility of the sites.

RESULTS

The focus groups established guiding principles for the development of the tool. These included ensuring accessibility and relevance for people with OA-related joint pain and recognizing that joint pain is the reason for seeking support, trust, social facilitation, and goal setting. Think-aloud interviews identified issues with user experience and site navigation and the need for professional input for referral and goal setting, confusion, and tensions over the role of GENIE and site connectivity. Participants expected the sites to be specific to their pain-related needs. EMPOWER was accessed 18 times; 6 users registered with the site during the evaluation study. Participants mostly explored information pages on being active and being a healthy weight. Only one participant undertook goal setting and 4 participants visited the GENIE website.

CONCLUSIONS

Using the NASSS framework, we identified the complexity associated with integrating EMPOWER and GENIE. The value proposition domain highlighted the technical and conceptual complexity associated with integrating approaches. Although identified as theoretically achievable, the integration of differing propositions may have caused cognitive and practical burdens for users. Nevertheless, we believe that both approaches have a distinct role in the self-management of joint pain.

Implementing a social network intervention: can the context for its workability be created? A quasi-ethnographic study

Background

Policy makers and researchers recognise the challenges of implementing evidence-based interventions into routine practice. The process of implementation is particularly complex in local community environments. In such settings, the dynamic nature of the wider contextual factors needs to be considered in addition to capturing interactions between the type of intervention and the site of implementation throughout the process. This study sought to examine how networks and network formation influence the implementation of a self-management support intervention in a community setting.

Methods

An ethnographically informed approach was taken. Data collection involved obtaining and analysing documents relevant to implementation (i.e. business plan and health reports), observations of meetings and engagement events over a 28-month period and 1:1 interviews with implementation-network members. Data analysis utilised the adaptive theory approach and drew upon the Consolidated Framework for Implementation Research. The paper presents the implementation events in chronological order to illustrate the evolution of the implementation process.

Results

The implementation-network was configured from the provider-network and commissioning-network. The configuration of the implementation-network was influenced by both the alignment between the political landscape and the intervention, and also the intervention having a robust evidence base. At the outset of implementation, the network achieved stability as members were agreed on roles and responsibilities. The stability of the implementation-network was threatened as progress slowed. However, with a period of reflection and evaluation, and with a flexible and resilient network, implementation was able to progress.

Conclusions

Resilience and creativity of all involved in the implementation in community settings is required to engage with a process which is complex, dynamic, and fraught with obstacles. An implementation-network is required to be resilient and flexible in order to adapt to the dynamic nature of community contexts. Of particular importance is understanding the demands of the various network elements, and there is a requirement to pause for "reflection and evaluation" in order to modify the implementation process as a result of learning.

Findings from a pilot randomised trial of a social network self-management intervention in COPD

BACKGROUND

Self-Management Support (SMS), refers to the actions taken by individuals to recognise and manage their own health. It is increasingly recognised that individuals with chronic obstructive pulmonary disease (COPD) require additional support with their Self-management. Emerging evidence suggests that the use of a social network intervention can improve health outcomes and increase quality of life. In order to understand the potential benefits of SMS in COPD, the GENIE (Generating Engagement in Network Support) SMS tool was implemented and evaluated in a COPD primary care context. The GENIE intervention is a social networking tool that consists of 3 parts; a concentric circle modelling to map existing social networks; a questions sections to elicit preferences for activities; a map of selected resources is then produced, aligned with the user's interests and suggestions for connections to existing network members and to new resources.

METHODS

A pilot, parallel, single blind, block randomised controlled trial. Patients with COPD ranging from mild-very severe were recruited. Participants provided written consent and were then randomised to either the intervention or usual care. The primary aim was to understand the clinical benefit through the analysis of health status, symptom burden and quality of life. The secondary outcome measure was health utilisation. NHS cost differences were reported between groups using the GENIE intervention over usual care.

RESULTS

The GENIE pilot results demonstrate maintenance in health status and clinical symptoms with a decrease in anxiety. An overall increase in quality of life was observed, these findings did not reach significance. A cost reduction was demonstrated in inpatient stay with no difference in primary care costs. Overall a cost reduction in NHS service utilisation was indicated in the intervention group.

CONCLUSION

This pilot study indicated that using a social network intervention can encourage the development of new social connections and extend existing support networks for COPD patients. Increasing network support in this population is of benefit to both patients and NHS providers in terms of cost reductions and enhancing wellbeing. This broadens the understanding of possible new approaches to SMS in community COPD patients, which could now be investigated in a larger population over a longer period.

TRIAL REGISTRATION

Clinical Trials.gov PRS National Library of Medicine. Protocol ID number: 19175, Clinical Trial ID: NCT02935452.

Mediating engagement in a social network intervention for people living with a long-term condition: A qualitative study of the role of facilitation

Background

Successful facilitation of patient‐centred interventions for self‐management support has traditionally focussed on individual behaviour change. A social network approach to self‐management support implicates the need for facilitation that includes an orientation to connecting to and mobilizing support and resources from other people and the local environment.

Objective

To identify the facilitation processes through which engagement with a social network approach to self‐management is achieved.

Method

Thematic analysis was used to analyse data from a longitudinal study design using quasi‐ethnographic methods comprising non‐participant observation, video and qualitative interviews involving 30 participants living with a long‐term condition recruited from a marginalized community.

Results

Findings centred on three themes about the social network approach facilitation processes: reversing the focus on the self by bringing others into view; visualization and reflection as a mediator of positive disruption and linking to new connections; personalized matching of valued activities as a means of realizing preference elicitation.

Discussion and conclusions

Engagement processes with a social network approach illuminated the relevance of cognizance of an individual's immediate social context and forefronting social participation with others as the bases of self‐management support of a long‐term condition. This differs from traditional guided facilitation of health behaviour interventions that frame health as a matter of personal choice and individual responsibility.

The work and relatedness of ties mediated online in supporting long-term condition self-management

The 'care transition' is characterised by reduced state involvement in chronic illness management in response to socio-political movements aimed at meeting the challenges presented by an increased prevalence of chronic illness. Amongst these changes has been online communities' rising importance in everyday interactions and attention is being increasingly paid towards the ways online contacts might contribute to self-management. Whilst research has illuminated the relevance of personal networks in long-term condition management, it is relevant to extend this work to consider the place of ties mediated online in this bricolage of support, including better understanding the work drawn from them and the strategies involved in eliciting it. This study examined the work and relatedness of 30 participants, who used online communities. Participants were asked about the role of on and offline ties and ego network mapping was used to frame conversations about the nature of this support. The context of engagement followed three main themes. Participants drew from online communities in response to deficits in offline support, they used online ties to leverage support or action from offline ties and they used online ties to substitute offline support, with less intimate online ties.

Findings from an exploration of a social network intervention to promote diet quality and health behaviours in older adults with COPD: a feasibility study

Background

Diet quality in older people with chronic obstructive pulmonary disease (COPD) is associated with better health and lung function. Social factors, such as social support, social networks and participation in activities, have been linked with diet quality in older age. A social network tool—GENIE (Generating Engagement in Network Involvement)—was implemented in a COPD community care context. The study aimed to assess the feasibility of the GENIE intervention to promote diet quality and other health behaviours in COPD.

Methods

Twenty-two community-dwelling older adults with COPD were recruited from a local COPD service. Participants were offered usual care or the GENIE intervention. Process evaluation methods were used to assess intervention implementation, context and mechanisms of impact; these included observations of patient interactions with the intervention, documented in observational field notes and in films of a patient group discussion. Diet quality was assessed by food frequency questionnaire; ‘prudent’ diet scores were used to describe diet quality at baseline and at 3-month follow-up. Change in diet quality was expressed per month, from baseline to follow-up.

Results

Feasibility data showed that the GENIE intervention could be implemented in this sample of community-living older people. The intervention was acceptable to clinicians and older people with COPD, especially for those with less severe disease, when facilitated appropriately and considering the levels of literacy of participants. There was no significant change in diet quality in the intervention group over the follow-up period (median change in prudent diet score per month (interquartile range (IQR), 0.03 (− 0.24–0.07)), whereas an overall fall in diet quality was observed in the control group (− 0.15 (− 0.24–0.03)).

Conclusion

The process evaluation findings suggest that this intervention is feasible and acceptable to both patients and clinicians. Although the sample size achieved in this study was small, findings suggest that the intervention may have a protective effect against declines in diet quality, and other health behaviours, in an older COPD population. Findings from this feasibility study indicate that further evaluation of the GENIE intervention is warranted in a larger study, with a longer follow-up.

Trial registration

ClinicalTrials.gov, NCT02935452. NIH U.S. National Library of Medicine. Registered 17 October 2016.

The contribution of internet use in personal networks of support for long-term condition self-management

Objectives

To describe the individual and network characteristics of the personal communities of people using the internet and the role of offline support, network resources and community participation in using the internet for condition management.

Methods

Secondary analysis of survey data using logistic regression analysis to determine the factors associated with differential internet use for condition management. This study involved 300 participants from 19 primary care providers in Manchester in 2010 and 2011.

Results

Using the internet is associated with age, deprivation, education and having access to a personal network member who understands how to fix computer problems. Those using the internet for condition management received more offline emotional work. No associations were found between using the internet for health and other types of offline support. Those using the internet for support reported lower levels of happiness.

Conclusion

Network processes and engagement shape online contact and use of resources for condition management. Those with access to personal networks who provide emotional work are likely to make use of online resources during non-crisis situations, suggesting that these resources act as an extension of offline network support. Those with greater levels of unhappiness may more frequently look to the internet for support.

The role of collective efficacy in long-term condition management: A metasynthesis

Social networks have been found to have a valuable role in supporting the management of long-term conditions. However, the focus on the quality and how well self-management interventions work focus on individualised behavioural outcomes such as self-efficacy and there is a need for understanding that focuses on the role of wider collective processes in self-management support. Collective efficacy presents a potentially useful candidate concept in the development and understanding of self-management support interventions. To date it has mainly been utilised in the context of organisations and neighbourhoods related to social phenomena such as community cohesion. Drawing on Bandura's original theorisation this meta-synthesis explores how studies of collective efficacy might illuminate collective elements operating within the personal communities of people with long-term conditions. A qualitative meta-synthesis was undertaken. Studies published between 1998 and 2018 that examined collective efficacy in relation to health and well-being using qualitative and mixed methods was eligible for inclusion. Timing of engagement with others, building trust in the group, and legitimising ongoing engagement with the group arised as central elements of collective efficacy. The two themes forming third order constructs were related to the presence of continuous interaction and ongoing relational work between members of the group. Collective efficacy can develop and be sustained over time in a range of situations where individuals may not have intense relationships with one another and have limited commitment and contact with one another. Extending this to the personal communities of people with long-term conditions it may be the case that collective efficacy enables a number of engagement opportunities which can be oriented towards assisting with support from networks over a sustained length of time. This may include negotiating acceptable connections to resources and activities which in turn may help change existing practice in ways that improve long-term condition management.

Study protocol for 'The Project About Loneliness and Social networks (PALS)': a pragmatic, randomised trial comparing a facilitated social network intervention (Genie) with a wait-list control for lonely and socially isolated people

INTRODUCTION

Loneliness and social isolation have been identified as significant public health concerns, but improving relationships and increasing social participation may improve health outcomes and quality of life. The aim of the Project About Loneliness and Social networks (PALS) study is to assess the effectiveness and cost-effectiveness of a guided social network intervention within a community setting among individuals experiencing loneliness and isolation and to understand implementation of Generating Engagement in Network Involvement (Genie) in the context of different organisations.

METHODS AND ANALYSIS

The PALS trial will be a pragmatic, randomised controlled trial comparing participants receiving the Genie intervention to a wait-list control group. Eligible participants will be recruited from organisations working within a community setting: any adult identified as socially isolated or at-risk of loneliness and living in the community will be eligible. Genie will be delivered by trained facilitators recruited from community organisations. The primary outcome will be the difference in the SF-12 Mental Health composite scale score at 6-month follow-up between the intervention and control group using a mixed effects model (accounting for clustering within facilitators and organisation). Secondary outcomes will be loneliness, social isolation, well-being, physical health and engagement with new activities. The economic evaluation will use a cost-utility approach, and adopt a public sector perspective to include health-related resource use and costs incurred by other public services. Exploratory analysis will use a societal perspective, and explore broader measures of benefit (capability well-being). A qualitative process evaluation will explore organisational and environmental arrangements, as well as stakeholder and participant experiences of the study to understand the factors likely to influence future sustainability, implementation and scalability of using a social network intervention within this context.

ETHICS AND DISSEMINATION

This study has received NHS ethical approval (REC reference: 18/SC/0245). The findings from PALS will be disseminated widely through peer-reviewed publications, conferences and workshops in collaboration with our community partners.

TRIAL REGISTRATION NUMBER

ISRCTN19193075.

Development of a measure of collective efficacy within personal networks: A complement to self-efficacy in self-management support?

OBJECTIVE

To develop and evaluate the Collective Efficacy of Networks (CENS) questionnaire to measure perceived collective efficacy within personal social networks.

METHODS

A mixed methods approach was used, guided by theory and with extensive input from adults with long-term conditions who completed the initial questionnaire (n = 78) with test-retest assessed at 2 weeks (n = 68). A second sample (n = 85) completed a postal questionnaire including CENS, theoretically linked constructs (self-efficacy, social support) and health outcomes (loneliness, mental and physical health).

RESULTS

Principal components analysis demonstrated a two-factor structure with 12-items selected to represent Network responsiveness (8 items, Cronbach's alpha = 0.896) and Access to collective efficacy (4 items, Cronbach's alpha = .773). Good test-retest reliability was established for both subscales (r_icc = .793-.853). Network responsiveness was associated with self-efficacy (r = 342, p = . < 001) and social support (r = .407, p < .001) and predicted reduced loneliness. Access to collective efficacy significantly predicted better mental health; the predictive validity of the subscales improved when combined with self-efficacy.

CONCLUSION

The CENS is an acceptable and psychometrically robust measure of collective efficacy in personal social networks.

PRACTICE IMPLICATIONS

Measuring collective efficacy with self-efficacy will provide useful information for researchers and policymakers interested in capacity for self-management and social determinants of behaviour change.

Help seeking for antibiotics; is the influence of a personal social network relevant?

BACKGROUND

Health policy focuses on reducing antibiotic prescribing that in order to succeed requires the public to hold similar attitudes towards judicious use. Social network influences on health behaviour and attitudes are well established and yet these influences are not sufficiently acknowledged in the UK's antibiotic stewardship programmes. Therefore, the aim of this study was to evaluate individuals' attitudes and behaviours towards antibiotics and also identify the social network influences on these in the process of help seeking for self-limiting illnesses.

METHODS

From a social network approach the methods used were a personal community mapping exercise which was carried out ahead of a semi-structured interview. A purposive sample was drawn from across the Wessex region and participants were recruited via GP practices and pharmacists. In total 14 adults, and 10 parents of children, who had received a prescription for antibiotics for a self-limiting illness within the 3 months preceding the interview were recruited and interviewed.

RESULTS

Three network types were identified; diverse, family and friend and restricted. The type of network an individual has appears to have an influence on antibiotic attitudes and behaviours. Most notably, the more diverse a network the more likely the individual will delay in help seeking from healthcare professionals as they draw upon self-care strategies advised by network members. The role of the GP varies according to network type too. Individuals' with diverse networks draw upon GP network members to provide clarity and certainty following a period of self-care. People with restricted networks are more reliant upon the GP, seek help quicker and also more likely to prioritise the GPs advice over other sources of information.

CONCLUSION

The understanding a social network approach brings to help seeking behaviour for antibiotics could help practitioners modify their consultation approach to mitigate some uncertainties and perceptions around prescribing behaviour.

BAP1 complex promotes transcription by opposing PRC1-mediated H2A ubiquitylation

In Drosophila, a complex consisting of Calypso and ASX catalyzes H2A deubiquitination and has been reported to act as part of the Polycomb machinery in transcriptional silencing. The mammalian homologs of these proteins (BAP1 and ASXL1/2/3, respectively), are frequently mutated in various cancer types, yet their precise functions remain unclear. Using an integrative approach based on isogenic cell lines generated with CRISPR/Cas9, we uncover an unanticipated role for BAP1 in gene activation. This function requires the assembly of an enzymatically active BAP1-associated core complex (BAP1.com) containing one of the redundant ASXL proteins. We investigate the mechanism underlying BAP1.com-mediated transcriptional regulation and show that it does not participate in Polycomb-mediated silencing. Instead, our results establish that the function of BAP1.com is to safeguard transcriptionally active genes against silencing by the Polycomb Repressive Complex 1.

In Drosophila, the Calypso–ASX complex catalyzes H2A deubiquitination and aids Polycomb in transcriptional silencing. Here the authors show that the orthologous complex, BAP1.com, promotes gene activation by counteracting PRC1-mediated gene silencing.

Identifying the processes of change and engagement from using a social network intervention for people with long-term conditions. A qualitative study

Background

Personal and community networks are recognized as influencing and shaping self‐management activities and practices. An acceptable intervention which facilitates self‐management by mobilizing network support and improves network engagement has a positive impact on health and quality of life. This study aims to identify the processes through which such changes and engagement take place.

Methods

The study was conducted in the south of England in 2016‐2017 and adopted a longitudinal case study of networks design. Purposive sample of respondents with long‐term conditions (n = 15) was recruited from local groups. Barriers and facilitators to implementation were explored in interviews with key stakeholders (5).

Results

Intervention engagement leads to a deepening of relationships within networks, adding new links and achieving personal objectives relevant for improving the health and well‐being of users and network members. Such changes are supported through two pathways: the mobilization of network capabilities and by acting as a nudge. The first is a gradual process where potentially relevant changes are further contemplated by forefronting immediate concerns and negotiating acceptable means for achieving change, prioritizing objective over subjective valuations of support provided by network members and rehearsing justifications for keeping the status quo or adopting change. The second pathway changes are enacted through the availability of a potential fit between individual, network and environmental conditions of readiness.

Conclusions

The two pathways of network mobilization identified in this study illuminate the individual, network and environmental level processes involved in moving from cognitive engagement with the intervention to adopting changes in existing practice.

The process of incorporating insulin pumps into the everyday lives of people with Type 1 diabetes: A critical interpretive synthesis

BACKGROUND

Insulin pump therapy (IPT) is a technological advancement that has been developed to help people manage Type 1 diabetes (T1D). However, ways of managing diabetes requiring the implementation of health technologies bring new complexities and a need to understand the factors which enable people with T1D to incorporate a novel device. This new comprehension could provide an exemplar for people with long-term conditions to incorporate new technologies more generally.

OBJECTIVE

To determine what influences the incorporation, adaptation and use of IPT into the everyday lives of people living with diabetes.

DESIGN

Critical interpretive synthesis (CIS) using systematic searches undertaken in 7 electronic databases of literature, published 2008 onwards.

RESULTS

A total of 4998 titles were identified, 274 abstracts reviewed, 39 full articles retrieved and 22 papers selected for analysis. Three themes emerged which were of relevance to the introduction and use of IPT; Tensions between expectations and experiences in adoption and early adaptation; Negotiation of responsibility and accessing support; Reflexivity, active experimentation and feedback.

CONCLUSIONS

This CIS builds on earlier reviews on lived experiences of IPT. Novel insights are offered through examination of the experiences of pump users from children through to adults, their families and health-care professionals. Expectations of what the device can do to improve self-management impacts on the early stages of adoption as the reality of the technology requires substantial thought and action. Areas for intervention to improve IPT incorporation include establishing who is responsible for management tasks of the device and enabling navigation to further means of support and resources.

How do people with long-term mental health problems negotiate relationships with network members at times of crisis?

Background

Social network processes impact on the genesis and management of mental health problems. There is currently less understanding of the way people negotiate networked relationships in times of crisis compared to how they manage at other times.

Objective

This paper explores the patterns and nature of personal network involvement at times of crises and how these may differ from day‐to‐day networks of recovery and maintenance.

Method

Semi‐structured interviews with 25 participants with a diagnosis of long‐term mental health (MH) problems drawn from recovery settings in the south of England. Interviews centred on personal network mapping of members and resources providing support. The mapping interviews explored the work of network members and changes in times of crisis. Interviews were recorded, transcribed and analysed using a framework analysis.

Results

Three key themes were identified: the fluidity of network relationality between crisis and recovery; isolation as a means of crises management; leaning towards peer support. Personal network input retreated at times of crisis often as result of “ejection” from the network by participants who used self‐isolation as a personal management strategy in an attempt to deal with crises. Peer support is considered useful during a crisis, whilst the role of services was viewed with some ambiguity.

Conclusions

Social networks membership, and type and depth of involvement, is subject to change between times of crisis and everyday support. This has implications for managing mental health in terms of engaging with network support differently in times of crises versus recovery and everyday living.

Interventions and working relationships of voluntary organisations for diabetes self-management: A cross-national study

BACKGROUND

Diabetes has become a challenging health priority globally. Given the tensions of financially burdened health systems in Europe the mobilisation of community resources like voluntary organisations and community groups is seen as a health policy strategy to sustain the management of long-term conditions like diabetes. However, little is known about how this is happening in practice in Europe.

OBJECTIVES

To explore diabetes self-management interventions undertaken or promoted by voluntary organisations and community groups in Europe; and describe the types of working relationships between these organisations, European health systems and users when implementing diabetes self-management programmes in different areas.

DESIGN

A mixed method study (survey/qualitative interviews) was undertaken. This research formed part of a European project (7th Framework programme of the European Commission) exploring the link between resources, like community organisations, and peoples' capacities to manage long-term conditions.

SETTINGS

Six European countries (Bulgaria, Greece, Norway, Spain, the Netherlands and the United Kingdom) participated in the study. Three areas: deprived urban area, a relatively affluent urban area and a deprived rural area were purposefully selected.

PARTICIPANTS

Through a purposeful sample and bottom up strategies 749 representatives of voluntary organisations and community groups were recruited from the geographical areas above. Organisations with at least three members, existing for at least one year that could provide information or other type of support directly or indirectly relevant to patients with diabetes were included.

METHODS

Participants completed a 15 item questionnaire for the survey (n=749) and a voice recorded semi structured interview (n=300). Data collection focused on the type of activities and roles developed to promote health, and relationships and communication channels between organisations, health services and users. Descriptive and comparative statistical and qualitative content analyses were used.

RESULTS

Participants perceived they had better reach of people with health needs than health providers, filled the administration gaps left in their capacity to deal with basic diabetes practical needs, humanized care, and acted as mediators between services and communities. There were significant differences between countries in relation to the types of activities (p-value<0.001), roles (p-value<0.001) and funding sources (p-value<0.001) of organisations concerning diabetes self-management. In non-affluent countries organisations tend to promote social activities twice more often.

CONCLUSIONS

Community and voluntary organisations provide complimentary and on-going support in diabetes management. This involves a shift from focusing on the illness to also longing for social cohesion, sense of community and wellbeing in diabetes health practices and policies.

The articulation of neoliberalism: narratives of experience of chronic illness management in Bulgaria and the UK

The shift from social democratic to a neoliberal consensus in modern welfare capitalist states is characterised by an emphasis on individual responsibility, consumer choice, market rationality and growing social inequalities. There has been little exploration of how neoliberalism has shaped the environment within which chronic illness is experienced and managed. This article explores the different articulations of neoliberalism manifest in the arena of personal illness management in Bulgaria and the UK. People with type 2 diabetes discussed their experiences in terms of struggling with diet, diabetes as a personal failure, integrating illness management and valued activities, and the trustworthiness of the healthcare system. The UK narratives were framed within an individual responsibility discourse while in Bulgaria lack of resources dominated discussions, which were framed as structurally generated and unrelated to individual capabilities and choices. Respondents faced personal management challenges related to consumer and healthcare market failures in both countries. Differences in market regulation and emerging stakeholder and interest coalitions influenced users' expectations and their navigation and adaption to market failures in managing their everyday illnesses. The UK and Bulgarian articulations of neoliberalism can be described differently: the first as a logic of managed choice and the second as a logic of unmanaged consumerism.

PRC2 is dispensable for HOTAIR-mediated transcriptional repression

Long non‐coding RNAs (lncRNAs) play diverse roles in physiological and pathological processes. Several lncRNAs have been suggested to modulate gene expression by guiding chromatin‐modifying complexes to specific sites in the genome. However, besides the example of Xist, clear‐cut evidence demonstrating this novel mode of regulation remains sparse. Here, we focus on HOTAIR, a lncRNA that is overexpressed in several tumor types and previously proposed to play a key role in gene silencing through direct recruitment of Polycomb Repressive Complex 2 (PRC2) to defined genomic loci. Using genetic tools and a novel RNA‐tethering system, we investigated the interplay between HOTAIR and PRC2 in gene silencing. Surprisingly, we observed that forced overexpression of HOTAIR in breast cancer cells leads to subtle transcriptomic changes that appear to be independent of PRC2. Mechanistically, we found that artificial tethering of HOTAIR to chromatin causes transcriptional repression, but that this effect does not require PRC2. Instead, PRC2 recruitment appears to be a consequence of gene silencing. We propose that PRC2 binding to RNA might serve functions other than chromatin targeting.

Social Network Type and Long-Term Condition Management Support: A Cross-Sectional Study in Six European Countries

Background

Network types and characteristics have been linked to the capacity of inter-personal environments to mobilise and share resources. The aim of this paper is to examine personal network types in relation to long-term condition management in order to identify the properties of network types most likely to provide support for those with a long-term condition.

Method

A cross-sectional observational survey of people with type 2 diabetes using interviews and questionnaires was conducted between April and October 2013 in six European countries: Greece, Spain, Bulgaria, Norway, United Kingdom, and Netherlands. 1862 people with predominantly lower socio-economic status were recruited from each country. We used k-means clustering analysis to derive the network types, and one-way analysis of variance and multivariate logistic regression analysis to explore the relationship between network type socio-economic characteristics, self-management monitoring and skills, well-being, and network member work.

Results

Five network types of people with long-term conditions were identified: restricted, minimal family, family, weak ties, and diverse. Restricted network types represented those with the poorest self-management skills and were associated with limited support from social network members. Restricted networks were associated with poor indicators across self-management capacity, network support, and well-being. Diverse networks were associated with more enhanced self-management skills amongst those with a long-term condition and high level of emotional support. It was the three network types which had a large number of network members (diverse, weak ties, and family) where healthcare utilisation was most likely to correspond to existing health needs.

Discussion

Our findings suggest that type of increased social involvement is linked to greater self-management capacity and potentially lower formal health care costs indicating that diverse networks constitute the optimal network type as a policy in terms of the design of LTCM interventions and building support for people with LTCs.

Stakeholders in support systems for self-care for chronic illness: the gap between expectations and reality regarding their identity, roles and relationships

Background and objective

The spread of self‐care holds the promise of containing chronic illness burden. Falling within the framework of a FP7 collaborative research project, this paper reports the views of key informants from six countries regarding who the main stakeholders are at different levels in the support system for self‐care for patients with chronic illness (SSSC) and how they accomplish their role and collaborate.

Methods

90 Interviews with purposefully selected key informants from Bulgaria, Greece, the Netherlands, Norway, Spain and United Kingdom were conducted. Interviews involved government and local authorities, politicians, academics, health professionals and private sector representatives. Interviewers followed an expert opinion‐based guide. Analysis involved a cross‐country examination with thematic analysis and framework method techniques.

Results

Key informants described the ideal SSSC as inclusive, interdependent and patient‐centred. The following main stakeholders in SSSC were identified: patients, governments, health‐care professionals, associations, private companies and the media. In the current SSSCs, collaboration among stakeholders within and across different levels was said to be lacking. Patients were seen as playing a passive subordinate role based on the following: their own attitudes; the paternalistic and medicalized attitudes of the health‐care professionals; their misrepresentation by patient associations; and their exposure to the damaging influences of media and industries.

Conclusions

Making SSSC patient‐centred constitutes the greatest challenge for European authorities. Strategies must be revised for promoting patient participation. They should undergo changes so as to promote industry and media social responsibility and patient association advocacy capacity.

Long-Term Condition Self-Management Support in Online Communities: A Meta-Synthesis of Qualitative Papers

Background

Recent years have seen an exponential increase in people with long-term conditions using the Internet for information and support. Prior research has examined support for long-term condition self-management through the provision of illness, everyday, and emotional work in the context of traditional offline communities. However, less is known about how communities hosted in digital spaces contribute through the creation of social ties and the mobilization of an online illness “workforce.”

Objective

The aim was to understand the negotiation of long-term condition illness work in patient online communities and how such work may assist the self-management of long-term conditions in daily life.

Methods

A systematic search of qualitative papers was undertaken using various online databases for articles published since 2004. A total of 21 papers met the inclusion criteria of using qualitative methods and examined the use of peer-led online communities for those with a long-term condition. A qualitative meta-synthesis was undertaken and the review followed a line of argument synthesis.

Results

The main themes identified in relation to the negotiation of self-management support were (1) redressing offline experiential information and knowledge deficits, (2) the influence of modeling and learning behaviors from others on self-management, (3) engagement that validates illness and negates offline frustrations, (4) tie formation and community building, (5) narrative expression and cathartic release, and (6) dissociative anonymity and invisibility. These translated into a line of argument synthesis in which four network mechanisms for self-management support in patient online communities were identified. These were (1) collective knowledge and identification through lived experience; (2) support, information, and engagement through readily accessible gifting relationships; (3) sociability that extends beyond illness; and (4) online disinhibition as a facilitator in the negotiation of self-management support.

Conclusions

Social ties forged in online spaces provide the basis for performing relevant self-management work that can improve an individual’s illness experience, tackling aspects of self-management that are particularly difficult to meet offline. Membership in online groups can provide those living with a long-term condition with ready access to a self-management support illness workforce and illness and emotional support. The substitutability of offline illness work may be particularly important to those whose access to support offline is either limited or absent. Furthermore, such resources require little negotiation online because information and support is seemingly gifted to the community by its members.

Implementing a social network intervention designed to enhance and diversify support for people with long-term conditions. A qualitative study

BACKGROUND

For people with long-term conditions, social networks provide a potentially central means of mobilising, mediating and accessing support for health and well-being. Few interventions address the implementation of improving engagement with and through social networks. This paper describes the development and implementation of a web-based tool which comprises: network mapping, user-centred preference elicitation and need assessment and facilitated engagement with resources. The study aimed to determine whether the intervention was acceptable, implementable and acted to enhance support and to add to theory concerning social networks and engagement with resources and activities.

METHODS

A longitudinal design with 15 case studies used ethnographic methods comprising video, non-participant observation of intervention delivery and qualitative interviews (baseline, 6 and 12 months). Participants were people with type 2 diabetes living in a marginalised island community. Facilitators were local health trainers and care navigators. Analysis applied concepts concerning implementation of technology for self-management support to explain how new practices of work were operationalised and how the technology impacted on relationships fit with everyday life and allowed for visual feedback.

RESULTS

Most participants reported identifying and taking up new activities as a result of using the tool. Thematic analysis suggested that workability of the tool was predicated on disruption and reconstruction of networks, challenging/supportive facilitation and change and reflection over time concerning network support. Visualisation of the network enabled people to mobilise support and engage in new activities. The tool aligned synergistically with the facilitators' role of linking people to local resources.

CONCLUSIONS

The social network tool works through a process of initiating positive disruption of established self-management practice through mapping and reflection on personal network membership and support. This opens up possibilities for reconstructing self-management differently from current practice. Key facets of successful implementation were: the visual maps of networks and support options; facilitation characterised by a perceived lack of status difference which assisted engagement and constructive discussion of support and preferences for activities; and background work (a reliable database, tailored preferences, option reduction) for facilitator and user ease of use.

Maternal LSD1/KDM1A is an essential regulator of chromatin and transcription landscapes during zygotic genome activation

Upon fertilization, the highly specialised sperm and oocyte genomes are remodelled to confer totipotency. The mechanisms of the dramatic reprogramming events that occur have remained unknown, and presumed roles of histone modifying enzymes are just starting to be elucidated. Here, we explore the function of the oocyte-inherited pool of a histone H3K4 and K9 demethylase, LSD1/KDM1A during early mouse development. KDM1A deficiency results in developmental arrest by the two-cell stage, accompanied by dramatic and stepwise alterations in H3K9 and H3K4 methylation patterns. At the transcriptional level, the switch of the maternal-to-zygotic transition fails to be induced properly and LINE-1 retrotransposons are not properly silenced. We propose that KDM1A plays critical roles in establishing the correct epigenetic landscape of the zygote upon fertilization, in preserving genome integrity and in initiating new patterns of genome expression that drive early mouse development.

DOI:http://dx.doi.org/10.7554/eLife.08851.001

During fertilization, an egg cell and a sperm cell combine to make a cell called a zygote that then divides many times to form an embryo. Many of the characteristics of the embryo are determined by the genes it inherits from its parents. However, not all of these genes should be “expressed” to produce their products all of the time. One way of controlling gene expression is to add a chemical group called a methyl tag to the DNA near the gene, or to one of the histone proteins that DNA wraps around.

Soon after fertilization, a process called reprogramming occurs that begins with the rearrangement of most of the methyl tags a zygote inherited from the egg and sperm cells. This dynamic process is thought to help to activate a new pattern of gene expression. Reprogramming is assisted by “maternal factors” that are inherited from the egg cell.

KDM1A is a histone demethylase enzyme that can remove specific methyl tags from certain histone proteins, but how this affects the zygote is not well understood. Now, Ancelin et al. (and independently Wasson et al.) have investigated the role that KDM1A plays in mouse development.

Ancelin et al. genetically engineered mouse eggs to lack KDM1A and used them to create zygotes, which die before or shortly after they have divided for the first time. The zygotes display severe reprogramming faults (because methyl tags accumulate at particular histones) and improper gene expression patterns, preventing a correct maternal-to-zygotic transition. Further experiments then showed that KDM1A also regulates the expression level of specific mobile elements, which indicates its importance in maintaining the integrity of the genome.

These findings provide important insights on the crucial role of KDM1A in establishing the proper expression patterns in zygotes that are required for early mouse development. These findings might help us to understand how KDM1A enzymes, and histone demethylases more generally, perform similar roles in human development and diseases such as cancer.

DOI:http://dx.doi.org/10.7554/eLife.08851.002

Voluntary Organizations and Community Groups as New Partners in Diabetes Self-management and Education: A Critical Interpretative Synthesis

PURPOSE

The purpose of this study is to critically review the literature on the role and work of voluntary organizations and community groups and volunteers in diabetes self-management programs. It seeks to explain how these organizations are located and could be integrated further within a broader system of support.

METHODS

A critical interpretative synthesis of the literature was undertaken as part of the conceptual development of a European research project. Evidence (2000-November 2014) was searched in databases, with the use of key terms, and limited to the languages of the participating countries. This was supplemented by an additional hand search and snowballing technique. A total of 21 articles were included in the review.

RESULTS

Evidence regarding the involvement of voluntary organizations in diabetes self-management programs mainly related to: the nature and remit of their work, responsibilities, and attributes; key strategies of programs accounting for success; motivations/barriers for engaging in volunteering participation; relationships between volunteers and users; and connections/tensions with formal services.

CONCLUSIONS

This review has uncovered a range of facets of voluntary organizations and community groups relevant for supporting diabetes self-management such as the context within which they act and the nature of relationships developed with community and health services. The principles of "assistance, support, sharing, and link" seem essential for this voluntary initiative in self-management to establish effective reciprocal collaboration with health professionals.

Connecting local support: A qualitative study exploring the role of voluntary organisations in long-term condition management

OBJECTIVES

To examine the role of community groups to support people living with long-term conditions and the organisational factors that influence this role.

METHODS

Thirty-three semi-structured interviews were conducted with voluntary group organisers purposefully sampled in Greater Manchester from a local database of community groups. Interviews explored the organisations role in supporting people living with a long-term condition, their social networks and the origins of the groups.

RESULTS

Respondents' construed their role in supporting individual capacity for management either explicitly (e.g. providing exercise) or implicitly (e.g. emotional support). This role was influenced by a combination of group ideology, funding and social networks. Analysis highlights the role of the non-clinical setting, the social support provided within the group, as well as organisational processes that influenced their capacity to support people living with long-term conditions.

CONCLUSION

By examining the organisation of voluntary groups, this study highlights the way in which they may support or constrain access to an extended range of support for people with long-term conditions. This paper has implications for commissioning of services by the health service from the third sector because of the differing ideological perspectives and limited operational capacity.

Assessing the implementability of telehealth interventions for self-management support: a realist review

Background

There is a substantial and continually growing literature on the effectiveness and implementation of discrete telehealth interventions for health condition management. However, it is difficult to predict which technologies are likely to work and be used in practice. In this context, identifying the core mechanisms associated with successful telehealth implementation is relevant to consolidating the likely elements for ensuring a priori optimal design and deployment of telehealth interventions for supporting patients with long-term conditions (LTCs).

Methods

We adopted a two-stage realist synthesis approach to identify the core mechanisms underpinning telehealth interventions. In the second stage of the review, we tested inductively and refined our understanding of the mechanisms. We reviewed qualitative papers focused on COPD, heart failure, diabetes, and behaviours and complications associated with these conditions. The review included 15 papers published 2009 to 2014.

Results

Three concepts were identified, which suggested how telehealth worked to engage and support health-related work. Whether or not and how a telehealth intervention enables or limits the possibility for relationships with professionals and/or peers. Telehealth has the potential to reshape and extend existing relationships, acting as a partial substitute for the role of health professionals. The second concept is fit: successful telehealth interventions are those that can be well integrated into everyday life and health care routines and the need to be easy to use, compatible with patients’ existing environment, skills, and capacity, and that do not significantly disrupt patients’ lives and routines. The third concept is visibility: visualisation of symptoms and feedback has the capacity to improve knowledge, motivation, and a sense of empowerment; engage network members; and reinforce positive behaviour change, prompts for action and surveillance.

Conclusions

Upfront consideration should be given to the mechanisms that are most likely to ensure the successful development and implementation of telehealth interventions. These include considerations about whether and how the telehealth intervention enables or limits the possibility for relationships with professionals and peers, how it fits with existing environment and capacities to self-manage, and visibility-enabling-enhanced awareness to self and others.

Social status and living with a chronic illness: an exploration of assessment and meaning attributed to work and employment

BACKGROUND

Traditional measures of social status are predicated on position in the labour market. There has been less attention directed to the meanings of social position for people with a long-term condition whose relationship to employment is precarious. Previous research has demonstrated that the MacArthur scale is capable of capturing contextualised aspects of social status, which makes it a useful tool for exploring changes in meaning.

AIMS

The paper explores the meanings and experiences of social status of people living with a long-term condition with particular reference to employment status.

METHODS

A sample of 300 participants was drawn from diabetes and chronic heart disease registers of General Practices in North West England. A cross-sectional survey with nested qualitative interviews was used in collecting and analysing the data.

FINDINGS

Having financial independence and participating in valued activities are more important for people with chronic illness than power and status mediated through the labour market. Income and the lack and loss of employment were given a central role in respondents' narratives reflecting the absence of acceptable alternative routes through which social status for those with a long-term condition can realistically be rebuilt outside of participation in the labour market.

CONCLUSION

Social participation, where people with chronic illness feel valued and of tangible utility to other people, might offer some opportunities for rebuilding social status outside the labour market. Chronic illness management interventions need to focus on improving people's engagement with such activities.

Dynamics and nature of support in the personal networks of people with type 2 diabetes living in Europe: qualitative analysis of network properties

BACKGROUND

Living with and self-managing a long-term condition implicates a diversity of networked relationships. This qualitative study examines the personal communities of support of people with type 2 diabetes.

METHODS

We conducted 170 biographical interviews in six European countries (Bulgaria, Greece, the Netherlands, Norway, Spain and UK) to explore social support and networks. Analysis was framed with reference to three predetermined social support mechanisms: the negotiation of support enabling engagement with healthy practices, navigation to sources of support and collective efficacy. Each interview was summarized to describe navigation and negotiation of participants' networks and the degree of collective efficacy.

RESULTS

Analysis highlighted the similarities and differences between countries and provided insights into capacities of networks to support self-management. The network support mechanisms were identified in all interviews, and losses and gains in networks impacted on diabetes management. There were contextual differences between countries, most notably the impact of financial austerity on network dynamics. Four types of network are suggested: generative, diverse and beneficial to individuals; proxy, network members undertook diabetes management work; avoidant, support not engaged with; and struggling, diabetes management a struggle or not prioritized.

CONCLUSIONS

It is possible to differentiate types of network input to living with and managing diabetes. Recognizing the nature of active, generative aspects of networks support is likely to have relevance for self-management support interventions either through encouraging continuing development and maintenance of these contacts or intervening to address struggling networks through introducing the means to connect people to additional sources of support.

Effect of information and telephone-guided access to community support for people with chronic kidney disease: randomised controlled trial

BACKGROUND

Implementation of self-management support in traditional primary care settings has proved difficult, encouraging the development of alternative models which actively link to community resources. Chronic kidney disease (CKD) is a common condition usually diagnosed in the presence of other co-morbidities. This trial aimed to determine the effectiveness of an intervention to provide information and telephone-guided access to community support versus usual care for patients with stage 3 CKD.

METHODS AND FINDINGS

In a pragmatic, two-arm, patient level randomised controlled trial 436 patients with a diagnosis of stage 3 CKD were recruited from 24 general practices in Greater Manchester. Patients were randomised to intervention (215) or usual care (221). Primary outcome measures were health related quality of life (EQ-5D health questionnaire), blood pressure control, and positive and active engagement in life (heiQ) at 6 months. At 6 months, mean health related quality of life was significantly higher for the intervention group (adjusted mean difference = 0.05; 95% CI = 0.01, 0.08) and blood pressure was controlled for a significantly greater proportion of patients in the intervention group (adjusted odds-ratio = 1.85; 95% CI = 1.25, 2.72). Patients did not differ significantly in positive and active engagement in life. The intervention group reported a reduction in costs compared with control.

CONCLUSIONS

An intervention to provide tailored information and telephone-guided access to community resources was associated with modest but significant improvements in health related quality of life and better maintenance of blood pressure control for patients with stage 3 CKD compared with usual care. However, further research is required to identify the mechanisms of action of the intervention.

TRIAL REGISTRATION

Controlled-Trials.com ISRCTN45433299.

Diabetes self-management arrangements in Europe: a realist review to facilitate a project implemented in six countries

Background

Self-management of long term conditions can promote quality of life whilst delivering benefits to the financing of health care systems. However, rarely are the meso-level influences, likely to be of direct relevance to these desired outcomes, systematically explored. No specific international guidelines exist suggesting the features of the most appropriate structure and organisation of health care systems within which to situate self-management approaches and practices. This review aimed to identify the quantitative literature with regard to diabetes self-management arrangements currently in place within the health care systems of six countries (The United Kingdom, The Netherlands, Norway, Spain, Bulgaria, and Greece) and explore how these are integrated into the broader health care and welfare systems in each country.

Methods

The methodology for a realist review was followed. Publications of interest dating from 2000 to 2013 were identified through appropriate MeSH terms by a systematic search in six bibliographic databases. A search diary was maintained and the studies were assessed for their quality and risk of bias.

Results

Following the multi-step search strategy, 56 studies were included in the final review (the majority from the UK) reporting design methods and findings on 21 interventions and programmes for diabetes and chronic disease self-management. Most (11/21, 52%) of the interventions were designed to fit within the context of primary care. The majority (11/21, 52%) highlighted behavioural change as an important goal. Finally, some (5/21, 24%) referred explicitly to Internet-based tools.

Conclusions

This review is based on results which are derived from a total of at least 5,500 individuals residing in the six participating countries. It indicates a policy shift towards patient-centred self-management of diabetes in a primary care context. The professional role of diabetes specialist nurses, the need for multidisciplinary approaches and a focus on patient education emerge as fundamental principles in the design of relevant programmes. Socio-economic circumstances are relevant to the capacity to self-manage and suggest that any gains and progress will be hard to maintain during economic austerity. This realist review should be interpreted within the wider context of a whole systems approach regarding self-care support and chronic illness management.

Electronic supplementary material

The online version of this article (doi:10.1186/1472-6963-14-453) contains supplementary material, which is available to authorized users.

The influence of social networks on self-management support: a metasynthesis

Background

There is increasing recognition that chronic illness management (CIM) is not just an individual but a collective process where social networks can potentially make a considerable contribution to improving health outcomes for people with chronic illness. However, the mechanisms (processes, activities) taking place within social networks are insufficiently understood. The aim of this review was to focus on identifying the mechanisms linking social networks with CIM. Here we consider network mechanisms as located within a broader social context that shapes practices, behaviours, and the multiplicity of functions and roles that network members fulfil.

Methods

A systematic search of qualitative studies was undertaken on Medline, Embase, and Web for papers published between 1^st January 2002 and 1^st December 2013. Eligible for inclusion were studies dealing with diabetes, and with conditions or health behaviours relevant for diabetes management; and studies exploring the relationship between social networks, self-management, and deprivation. 25 papers met the inclusion criteria. A qualitative metasynthesis was undertaken and the review followed a line of argument synthesis.

Results

The main themes identified were: 1) sharing knowledge and experiences in a personal community; 2) accessing and mediation of resources; 3) self-management support requires awareness of and ability to deal with network relationships. These translated into line of argument synthesis in which three network mechanisms were identified. These were network navigation (identifying and connecting with relevant existing resources in a network), negotiation within networks (re-shaping relationships, roles, expectations, means of engagement and communication between network members), and collective efficacy (developing a shared perception and capacity to successfully perform behaviour through shared effort, beliefs, influence, perseverance, and objectives). These network mechanisms bring to the fore the close interdependence between social and psychological processes in CIM, and the intertwining of practical and moral dilemmas in identifying, offering, accepting, and rejecting support.

Conclusions

CIM policy and interventions could be extended towards: raising awareness about the structure and organisation of personal communities; building individual and network capacity for navigating and negotiating relationships and CIM environments; maximising the possibilities for social engagement as a way of increasing the effectiveness of individual and network efforts for CIM.

Aligning everyday life priorities with people's self-management support networks: an exploration of the work and implementation of a needs-led telephone support system

BACKGROUND

Recent initiatives to target the personal, social and clinical needs of people with long-term health conditions have had limited impact within primary care. Evidence of the importance of social networks to support people with long-term conditions points to the need for self-management approaches which align personal circumstances with valued activities. The Patient-Led Assessment for Network Support (PLANS) intervention is a needs-led assessment for patients to prioritise their health and social needs and provide access to local community services and activities. Exploring the work and practices of patients and telephone workers are important for understanding and evaluating the workability and implementation of new interventions.

METHODS

Qualitative methods (interviews, focus group, observations) were used to explore the experience of PLANS from the perspectives of participants and the telephone support workers who delivered it (as part of an RCT) and the reasons why the intervention worked or not. Normalisation Process Theory (NPT) was used as a sensitising tool to evaluate: the relevance of PLANS to patients (coherence); the processes of engagement (cognitive participation); the work done for PLANS to happen (collective action); the perceived benefits and costs of PLANS (reflexive monitoring). 20 patients in the intervention arm of a clinical trial were interviewed and their telephone support calls were recorded and a focus group with 3 telephone support workers was conducted.

RESULTS

Analysis of the interviews, support calls and focus group identified three themes in relation to the delivery and experience of PLANS. These are: formulation of 'health' in the context of everyday life; trajectories and tipping points: disrupting everyday routines; precarious trust in networks. The relevance of these themes are considered using NPT constructs in terms of the work that is entailed in engaging with PLANS, taking action, and who is implicated this process.

CONCLUSIONS

PLANS gives scope to align long-term condition management to everyday life priorities and valued aspects of life. This approach can improve engagement with health-relevant practices by situating them within everyday contexts. This has potential to increase utilisation of local resources with potential cost-saving benefits for the NHS.

TRIAL REGISTRATION

ISRCTN45433299.

The contribution of social networks to the health and self-management of patients with long-term conditions: a longitudinal study

Evidence for the effectiveness of patient education programmes in changing individual self-management behaviour is equivocal. More distal elements of personal social relationships and the availability of social capital at the community level may be key to the mobilisation of resources needed for long-term condition self-management to be effective.

AIM

To determine how the social networks of people with long-term conditions (diabetes and heart disease) are associated with health-related outcomes and changes in outcomes over time.

METHODS

Patients with chronic heart disease (CHD) or diabetes (n = 300) randomly selected from the disease registers of 19 GP practices in the North West of England. Data on personal social networks collected using a postal questionnaire, alongside face-to-face interviewing. Follow-up at 12 months via postal questionnaire using a self-report grid for network members identified at baseline.

ANALYSIS

Multiple regression analysis of relationships between health status, self-management and health-economics outcomes, and characteristics of patients' social networks.

RESULTS

Findings indicated that: (1) social involvement with a wider variety of people and groups supports personal self-management and physical and mental well-being; (2) support work undertaken by personal networks expands in accordance with health needs helping people to cope with their condition; (3) network support substitutes for formal care and can produce substantial saving in traditional health service utilisation costs. Health service costs were significantly (p<0.01) reduced for patients receiving greater levels of illness work through their networks.

CONCLUSIONS

Support for self-management which achieves desirable policy outcomes should be construed less as an individualised set of actions and behaviour and more as a social network phenomenon. This study shows the need for a greater focus on harnessing and sustaining the capacity of networks and the importance of social involvement with community groups and resources for producing a more desirable and cost-effective way of supporting long term illness management.

Social support systems as determinants of self-management and quality of life of people with diabetes across Europe: study protocol for an observational study

BACKGROUND

Long-term conditions pose major challenges for healthcare systems. Optimizing self-management of people with long-term conditions is an important strategy to improve quality of life, health outcomes, patient experiences in healthcare, and the sustainability of healthcare systems. Much research on self-management focuses on individual competencies, while the social systems of support that facilitate self-management are underexplored. The presented study aims to explore the role of social systems of support for self-management and quality of life, focusing on the social networks of people with diabetes and community organisations that serve them.

METHODS

The protocol concerns a cross-sectional study in 18 geographic areas in six European countries, involving a total of 1800 individuals with diabetes and 900 representatives of community organisations. In each country, we include a deprived rural area, a deprived urban area, and an affluent urban area. Individuals are recruited through healthcare practices in the targeted areas. A patient questionnaire comprises measures for quality of life, self-management behaviours, social network and social support, as well as individual characteristics. A community organisations' survey maps out interconnections between community and voluntary organisations that support patients with chronic illness and documents the scope of work of the different types of organisations. We first explore the structure of social networks of individuals and of community organisations. Then linkages between these social networks, self-management and quality of life will be examined, taking deprivation and other factors into account.

DISCUSSION

This study will provide insight into determinants of self-management and quality of life in individuals with diabetes, focusing on the role of social networks and community organisations.