Overruling uncertainty about preventative medications: the social organisation of healthcare professionals' knowledge and practices

Communicating cardiovascular risk: Systematic review of qualitative evidence

INTRODUCTION

Cardiovascular risk prediction models are widely used to help individuals understand risk and make decisions.

METHODS

Systematic review of qualitative evidence. We searched MEDLINE, Embase, PsycINFO and CINAHL. We included English-language qualitative studies on the communication of cardiovascular risk. We assessed study quality using Hawker et al.'s tool and synthesised data thematically.

RESULTS

Thirty-seven studies were included. Many patients think that risk scores are of limited practical value. Other sources of information feed into informal estimates of risk, which may lead patients to reject the results of clinical risk assessment when the two conflict. Clinicians identify a number of barriers to risk communication, including patients' limited understanding of risk and excessive anxiety. They use a range of strategies for adapting risk communication. Both clinicians and individuals express specific preferences for risk communication formats.

DISCUSSION

Ways of communicating risk that provide some comparison or reference point seem more promising. The broader context of communication around risk may be more important than the risk scoring instrument. Risk communication interventions, in practice, may be more about appeals to emotion than a rationalistic model of decision-making.

Wider institutional research cultures and their influence on patient and public involvement and engagement in health research - An institutional ethnography

Focus on patient and public involvement and engagement (PPIE) is increasing in health policy and research governance. PPIE is considered by some to be a democratic right, and by others to be a way to improve health care and research outcomes and implementation. Most recently, policy makers, funders and (clinical) research institutions are making PPIE a strategic requirement for health research urging researchers to invite patients and relatives into their research activities. Our study is based in a Danish university hospital where PPIE has been introduced as one of five strategic research goals. We investigated how researchers experienced this new practice and how their research practices connect to the wider context of the Danish health care system. Ten cases were studied during a year using observations, interviews, and document analysis. As our method of inquiry, we used institutional ethnography to look at researchers' work from their perspective and to understand how PPIE practices are part of a larger institutional research culture reaching far beyond the individual. We found that current research culture has implications for the selection of patients and relatives and for what they are asked to do. Researchers who experienced that PPIE outcomes aided their existing research practices felt motivated. Researchers who engaged patients and relatives before it was a strategy, were ideologically driven and their approaches resulted in an increased diversity of inclusion and researcher assimilation. These findings add to the current knowledge on PPIE practices and help us understand that further development towards collaborative research practices require a change in key performance indicators and training and perhaps call for attention to our shared acceptance of knowledge generation in research.

Examining the Impact of Polygenic Risk Information in Primary Care

BACKGROUND

Polygenic risk testing examines variation across multiple genes to estimate a risk score for a particular disease, including risk scores for many common, chronic health conditions. Although polygenic risk information (PRI) may be a promising tool for enhancing preventive counseling and facilitating early identification of disease, its potential impact on primary-care encounters and disease prevention efforts has not been well characterized.

METHODS

We conducted in-depth, semi-structured interviews of patients to assess their understandings of PRI and their beliefs about its relevance to disease prevention.

RESULTS

We completed interviews with 19 participants. Participants described enthusiasm for the generation of PRI and recognized its utility for disease prevention. Participants also described the value of PRI as limited if not corroborated by non-genetic risk factors. Finally, participants noted that PRI, by itself, would be insufficient as a trigger for initiating many preventive interventions.

CONCLUSION

PRI has the potential to become an important tool in primary care. However, patient views about PRI as well as the complexities of disease prevention in the primary care context may limit the impact of PRI on disease prevention.

The ubiquity of uncertainty in low back pain care

Despite clinicians being important actors in the context of uncertainty, their experiences navigating uncertainty remain largely unexplored. Drawing on a theory-driven post-qualitative approach, we used Mol's logic of choice/care as a lens through which we made sense of interviews with 22 clinicians who work with patients who experience low back pain (LBP). Our analysis suggests that uncertainty is ubiquitous in LBP care and not limited to particular domains. Clinicians navigated uncertainty when considering patients' personal and social contexts; making therapeutic decisions; navigating emotions and mental health; communicating with, and educating, patients, among others. These uncertainties are intertwined with clinical aspects such as treatment choices and evidence-based education about LBP. At times, clinicians resolved these uncertainties by producing certainty at the cost of attending to human aspects of care. We argue that epistemic shifts, theorisation and practical engagement with theory in training, research and clinical practice may prompt clinicians to embrace uncertainty and enact the logic of care.

Public health in the making: Dietary innovators and their on-the-job sociology

Diet is understood to be one of the most important influences on public health and chronic disease, and is particularly implicated in the so-called 'obesity epidemic'. Yet interventions aiming to improve the population's dietary habits have failed to translate into widespread health improvements. Simultaneously, the knowledge landscape has become increasingly contentious, with fat activism challenging dominant approaches to how obesity is framed and addressed. This paper is based on 24 ethnographic interviews, and explores the work of health practitioners promoting therapeutic carbohydrate restriction ('low-carb' diets) for people with metabolic health conditions. Drawing on Michel Callon's study of technological innovation, I show practitioners engaging in 'on-the-job sociology'-situated sociological work to justify, and forge a space for, innovative dietary intervention. These innovators employ physiological explanations of hormones, satiety (or hunger), and pleasure (or shame), supported with personal experience, to emphasise material connections between particular eating habits and the sustainability of dietary improvement in everyday life. They resist fat activist influence on healthcare practice (that has resulted in practitioners avoiding conversations about diet, fatness and health), as well as the more extensively critiqued practices of health promotion. Deflecting blame/shame from individuals, innovators spotlight the role of the food industry in undermining public understandings of food and physiology, and dietary improvement that is achievable and sustainable. Through on-the-job sociology, innovators forge a space to engage patients in collaborative dietary experimentation and improvement. This study highlights the importance of on-the-job sociology in the contemporary knowledge landscape, providing new insights about public health in the making.

Managerial thinking in neonatal care: a qualitative study of place of care decision-making for preterm babies born at 27-31 weeks gestation in England

OBJECTIVES

Preterm babies born between 27 and 31 weeks of gestation in England are usually born and cared for in either a neonatal intensive care unit or a local neonatal unit-with such units forming part of Operational Delivery Networks. As part of a national project seeking to optimise service delivery for this group of babies (OPTI-PREM), we undertook qualitative research to better understand how decisions about place of birth and care are made and operationalised.

DESIGN

Qualitative analysis of ethnographic observation data in neonatal units and semi-structured interviews with neonatal staff.

SETTING

Six neonatal units across two neonatal networks in England. Two were neonatal intensive care units and four were local neonatal units.

PARTICIPANTS

Clinical staff (n=15) working in neonatal units, and people present in neonatal units during periods of observation.

RESULTS

In the context of real-world neonatal practice, with multiple (and rapidly-evolving) uncertainties relating to mothers, babies and unit/network capacity, 'best place of care' protocols were only one element of much more complex decision-making processes. Staff often made judgements from a less-than-ideal starting point, and were forced to respond to evolving clinical and organisational factors. In particular, we report that managerial considerations relating to demand and capacity organised decision-making; demand and capacity management was time-consuming and generated various pressures on families, and tensions between staff.

CONCLUSIONS

Researchers and policymakers should take account of the organisational context within which place of care decisions are made. The dominance of demand and capacity management considerations is likely to limit the impact of other improvement interventions, such as initiatives to integrate families into the neonatal care provision. Demand and capacity management is an important element of neonatal care that may be overlooked, but significantly organises how care is delivered.

Not 'putting a name to it': Managing uncertainty in the diagnosis of childhood obesity

Childhood obesity is a challenging diagnosis. Children's body mass index (BMI) is an imprecise diagnostic of health, leading clinicians' interactions with patients and families to focus on the potential of future harm rather than the presence of infirmity or disease. This is complicated by emphasis on certainty in medical care; clinical diagnoses like childhood obesity are intended to help delineate good and bad health among patients. However, healthiness and wellbeing take on many meanings among individual children and families, especially in relation to weight. To better understand different forms of uncertainty and challenges in providing care, this study draws on 28 semi-structured interviews with U.S. health practitioners working with pediatric patients to examine strategies for communicating risk and defining success in the diagnosis and treatment of childhood obesity. Rather than focusing on patients' current BMIs or making the explicit diagnosis of obesity, clinicians turn to more optimistic prognoses emphasizing the gradual development of beliefs and behaviors that promote long-term physical, mental, and social health. This prognostic framework privileges the doctor-patient relationship over medical guidelines and protocols dictated by diagnoses, encouraging greater consideration of non-clinical factors shaping patients' health and weight. Clinicians expand their diagnostic framework and criteria to include information on the totality of patients' present and future lives, allowing for cognitively, emotionally, and socially attuned understanding of health and weight that is not focused on BMI. Critically, clinicians' awareness of the social etiology childhood obesity heightens their sense of futility about addressing it through clinical interventions, demonstrating the need for a diagnostic and treatment model that empowers doctors to look beyond the more proximate, biophysiological determinants of health.

The Disparate Approaches of General Practitioners to the Pharmaceuticalisation of Cardiovascular Disease Prevention

In the context of current clinical practice guidance, this paper will analyse the role of GPs in decision-making about the primary prevention of cardiovascular disease (CVD) using the concept of pharmaceuticalisation. Drawing on thematic analysis of semi-structured interviews with 20 GPs, the paper argues that the way GPs approach CVD pharmaceuticalisation is shaped by their understandings of and use of guidelines (and the knowledge they embody), existing treatment perspectives and the moral qualities of preventative treatment, and professional evaluations of 'relevant' information. The analysis indicates that there exist disparate and distinct approaches to and understandings of CVD pharmaceuticalisation amongst GPs. Depending on how knowledge, treatment perspectives and values variously combine, GPs sit somewhere on a spectrum of how pharmaceuticalised they are in terms of the approaches to and understandings of the prevention of CVD.

Supporting people to implement a reduced carbohydrate diet: a qualitative study in family practice

INTRODUCTION

Much of the science behind dietary guidelines for risk reduction and chronic disease management is equivocal, and there are well-accepted uncertainties and complexities relating to diet in everyday life, as well as physiological processes. Guidelines have therefore stopped short of aligning with one particular approach, instead highlighting several evidence-based options. However, reduced carbohydrate, or 'low-carb', diets have increasing traction in the media and with patients, practitioners and the general public. This qualitative study examines healthcare practitioner (HCP) experiences of implementing a reduced carbohydrate diet.

METHODS

Semistructured, qualitative interviews were conducted with 19 HCPs in the UK family practice (including general practitioners, practice nurses and non-medical practitioners), recruited through a special interest forum, and social media. Data analysis employed social science theory and methods to produce key themes.

RESULTS

All participants self-identified as 'low-carb practitioners' who, over time, had introduced a specific focus around carbohydrate reduction into their work. They reported transformations in patients' metabolic markers, patient enthusiasm for the approach and renewed job satisfaction. Key themes highlight experiences of: (1) discovering low-carb as a new 'tool-in-the-box'; (2) promoting and supporting incremental low-carb experimentation; and (3) diverging from established dietary guidelines.

CONCLUSIONS

This study provides important experience-based evidence on a topical dietary intervention. Participants strongly advocated for the use of low-carb diets. The successes described draw attention to the need for pragmatic, formative evaluation of low-carb advice and support as a 'complex intervention' (alongside physiological research), to justify, challenge and/or shape low-carb intervention in clinical practice. The findings raise important questions about the contribution of particular care practices to the apparent success of low-carb. Social science analyses can elucidate how dietary intervention is carried out across different healthcare settings (eg, dietetics, endocrinology) and patient groups, how healthcare practices intersect with people's everyday self-management and how different forms of evidence are invoked and prioritised.

Taking sides with patients using institutional ethnography

Purpose

The main purpose of this paper is to document the first author's experience of using institutional ethnography (IE) to “take sides” in healthcare research. The authors illustrate the points with data and key findings from a study of cardiovascular disease prevention.

Design/methodology/approach

The authors use Dorothy E Smith's IE approach, and particularly the theoretical tool of “standpoint”.

Findings

Starting with the development of the study, the authors trouble the researcher's positionality, highlighting tensions between institutional knowledge of “prevention” and other locations where knowledge about patients' health needs materialises. The authors outline how IE's theoretically and methodologically integrated toolkit became a framework for “taking sides” with patients. They describe how the researcher used IE to take a standpoint and map institutional relations from that standpoint. They argue that IE enabled an innovative analysis but also reflect on the challenges of conducting an IE – the conceptual unpicking and (re)thinking, and demarcating boundaries of investigation within an expansive dataset.

Originality/value

This paper illustrates IE's relevance for organisational ethnographers wishing to find a theoretically robust approach to taking sides, and suggests ways in which the IE approach might contribute to improving services, particularly healthcare. It provides an illustration of how taking a patient standpoint was accomplished in practice, and reflects on the challenges involved.

Overdiagnosis and overtreatment: a sociological perspective on tackling a contemporary healthcare issue

Overdiagnosis and overtreatment are increasingly discussed as a significant problem in contemporary healthcare but are yet to receive any significant sociological attention, over and above that which is arguably transferable from the medicalisation literature. Overdiagnosis and overtreatment are often constructed as problems best addressed by educating patients and clinicians, and improving the relationships between them. The emergence of tools seeking to support decision-making and to facilitate patients' asking questions about whether interventions are really necessary supports this conceptualisation. This article questions whether significant traction on overdiagnosis and overtreatment is possible through these means alone, arguing that even when professionals and patients may wish to do less rather than more, the system within which care is delivered and received can make this challenging to achieve. Drawing on Scott's (Sociology, 2018, 52, 3) 'sociology of nothing', the article demonstrates that a sociological perspective on overdiagnosis and overtreatment recasts them as issues that must be understood as a consequence of the organisational, financial and cultural attributes of the system, not just individual interactions, and advances a research agenda for the area.