Adherence and the Moral Construction of the Self: A Narrative Analysis of Anticoagulant Medication

Seeking help for atrial fibrillation: the role of the body in distributed decision making

We adopt Rapley's (2008) concept of distributed decision making to explore the role of the body in people's decisions to seek medical care. We conducted in-depth interviews with patients diagnosed with atrial fibrillation (AF) who were taking long-term anticoagulants to prevent stroke. We interviewed seventeen patients recruited from English anticoagulant clinics using the biographic-narrative-interpretive method, and conducted thematic, structural and metaphorical analyses. This pluralistic analysis focused on how distributed decision-making was enacted through a range of socio-material, relational and embodied practices. Participants told how they experienced AF-related sensations that fluctuated in intensity and form. Some had no symptoms at all; others experienced sudden incapacitation - these experiences shaped different journeys towards seeking medical help. We draw on work by Mol (2002) to show how the body was differently observed, experienced and done across contexts as the narratives unfolded. We show that as part of a relational assemblage, involving social, material and technological actors over time, a new body-in-need-of-help was enacted and medical help sought. This body-in-need-of-help was collectively discussed, interpreted and experienced through distribution of body parts, fluids and technological representations to shape decisions. RAPLEY T., 2008. Distributed decision making: the anatomy of decisions-in-action. Sociology of Health & Illness, 30, 429-444. MOL A., 2002. The body multiple: ontology in medical practice. Duke University Press: Durham.

Living with polypharmacy: a narrative interview study with older Pakistanis in East London

BACKGROUND

Polypharmacy is a growing and major public health issue. It can be burdensome and risky for patients and costly to healthcare systems. Older adults and those from ethnic minority backgrounds are disproportionately affected by polypharmacy. This study focuses on medication practices among Urdu-speaking Pakistani patients, a significant ethnic group in the UK. Most existing research on medication practices within South-Asian communities centres on adherence, leaving the social and moral dimensions of polypharmacy unpacked. Understanding how British Pakistani patients understand and manage polypharmacy in the context of their daily lives is crucial to avoiding harmful polypharmacy.

METHODS

In-depth narrative interviews were conducted with 15 first-generation Pakistani patients using the Biographical Narrative Interview Method. Participants were recruited from GP practices in East London. All participants were prescribed ten or more regular medications (a pragmatic marker of 'higher risk' polypharmacy) and were aged over 50. Interviews were conducted with a bilingual researcher at home and were designed to elicit narratives of patients' experiences of polypharmacy in the context of their biographies and daily lives.

RESULTS

Polypharmacy is enacted through networks of interpersonal and socio-material relationships. The doctor-patient relationship and the family network held particular significance to study participants. In addition, participants described emotional bonds between themselves and their medicines, identifying them as 'forces for good'-substances which allowed them to maintain their health through the intercession of God. Meanings attributed to medicines and enacted through these social, emotional, and spiritual relationships contributed to emerging and sustaining polypharmacy.

CONCLUSIONS

Patients make sense of and manage treatments in culturally specific ways. Developing an understanding of how medication practices in different communities are enacted is important for informing meaningful and effective conversations with patients about their medicines. Our findings contribute to enabling the integration of culturally sensitive approaches to prescribing.

Erasing inequality: Examining discrepancies between electronic health records and patient narratives to uncover perceived stigma and dismissal in clinical encounters

Current policy efforts to reduce health disparities focus on integrating patients' social determinants of health (SDHs) into their electronic health records (EHRs), with the goal of addressing both clinical and social risks through the health system. Yet clinicians' documentation of and engagement with patients' social characteristics may, in certain circumstances, actually contribute to health disparities. This paper compares accounts of clinical encounters from in-depth interviews with forty-six non-college-educated women against their EHR's codes and free-text notes, which document the clinician's perspective of the encounter. We identify how documentation of clinical encounters may exacerbate the very health disparities that health systems seek to intervene upon by 1) translating social suffering stemming from structural inequality into stigmatized risk factors, and 2) suppressing conflicts over diagnosis and treatment, sometimes by framing observations of women's social identities as evidence of their unreliability as patients. We demonstrate how perceived negative interactions lead some women to resist the health system, either by self-treating in ways that could adversely affect their health or by attempting to challenge the authority of clinicians, which is not documented as resistance in their medical charts.

Episodic Relatedness in Socioeconomically Disadvantaged Families Where a Parent has Multiple Diagnoses

There is a strong association between social relationships and health. In this article, we ask how a view of social relationships played out in time can help to nuance the role of patients' social networks in their healthcare-seeking behavior. We investigate this link by exploring the dynamics of relatedness in socioeconomically vulnerable young families with a multimorbid parent and their extended networks. Data were generated through repeated semi-structured and open-ended interviews and participant observation. The study found that, for much of their lives, participants experienced life as a series of events that happened to them and were out of their control. This way of being-in-the-world was linked to a consistent pattern of intense and then suddenly discontinued relationships. The relevance for health professionals is that there is a growing trend in healthcare systems worldwide to involve relatives and extended networks in a patient's treatment process. Our findings indicate challenges to this approach and recommend that health professionals are aware that for socioeconomically vulnerable patients with multimorbidity, important relationships can change dramatically, quickly, and repeatedly, over short periods of time.

A phenomenological analysis of the experience of taking medication to prevent a further heart attack

Following an acute myocardial infarction, patients are prescribed a regime of cardio-protective medication to prevent recurrent cardiovascular events and mortality. Adherence to medication is poor in this patient group, and not fully understood. Current interventions have made limited improvements but are based upon presumed principles. To describe the phenomenon of medicine-taking for an individual taking medication for secondary prevention for an AMI, Interpretative Phenomenological Analysis was used to analyse transcripts of semi-structured interviews with participants. Themes were generated for each participant, then summarized across participants. Five key themes were produced; the participants needed to compare themselves to others, showed that knowledge of their medicines was important to them, discussed how the future was an unknown entity for them, had assimilated their medicines into their lives, and expressed how an upset to their routine reduced their ability to take medication. Participants described complex factors and personal adaptations to taking their medication. This suggests that a patient-centred approach is appropriate for adherence work, and these themes could inform clinical practice to better support patients in their medicine adherence.

Self-Management in Older Pakistanis Living With Multimorbidity in East London

In this article, we explore how older British Pakistani people experience multimorbidity (defined as the coexistence of two or more medical conditions) and engage with self-management within the context of their life histories and relationships. We conducted biographical narrative interviews in Urdu and/or English with 15 first-generation Pakistani migrants living with multimorbidity, at their homes in East London. Our analysis showed that the triadic construct of family, faith, and health was central to how participants made sense of their lives, constituting notions of "managing" in the context of multimorbidity. For Pakistani patients, the lived experience of health was inseparable from a situated context of family and faith. Our findings have implications for existing public health strategies of self-management, underpinned by neoliberal discourses that focus on individual responsibility and agency. Health care provision needs to better integrate the importance of relationships between family, faith, and health when developing services for these patients.

Organising polypharmacy: unpacking medicines, unpacking meanings-an ethnographic study

OBJECTIVES

We explore how older patients affected by polypharmacy manage the 'hidden work' of organising their medicines, how they make sense of this work and integrate it into their lives.

DESIGN AND SETTING

Ethnographic study observing patients over 18-24 months in patients' homes, general practice and community pharmacy, in England, UK.

PARTICIPANTS AND METHODS

Ethnographic case study including longitudinal follow-up of 24 patients aged 65 or older and prescribed ten or more items of medication. Our dataset includes: 562 hours of ethnographic observation across patients homes, community pharmacies and general practices; 47 audio-recorded interviews with patients about their lives and medicines practices; cultural probes (photographs, body maps, diaries and imagined 'wishful thinking' conversations); fieldnotes from regular home visits; telephone calls, and observation/video-recording of healthcare encounters. We apply a 'practice theory' lens to our analysis, illuminating what is being accomplished, why and by whom.

RESULTS

All patients had developed strategies and routines for organising medicines into their lives, negotiating medicine taking to enable acceptable adherence and make their medicines manageable. Strategies adopted by patients often involved the use of 'do-it-yourself' dosette boxes. This required careful 'organising' work similar to that done by pharmacy staff preparing multicompartment compliance aids (MCCAs). Patients incorporated a range of approaches to manage supplies and flex their regimens to align with personal values and priorities. Practices of organising medicines are effortful, creative and often highly collaborative. Patients strive for adherence, but their organisational efforts privilege 'living with medicines' over taking medicines strictly 'as prescribed'.

CONCLUSIONS

Polypharmacy demands careful organising. The burden of organising polypharmacy always falls somewhere, whether undertaken by pharmacists as they prepare MCCAs or by patients at home. Greater appreciation among prescribers of the nature and complexity of this work may provide a useful point of departure for tackling the key issue that sustains it: polypharmacy.

Why do patients struggle with their medicines?-A phenomenological hermeneutical study of how patients experience medicines in their everyday lives

Why do so many people struggle with their medicines despite decades of research on medicines taking? Research into how people experience medicines in their everyday life remains scarce with the majority of research in this area of focusing on whether or not people take their medicines as prescribed. Hence, this study used a phenomenological hermeneutical qualitative design to gain a deeper understanding of individuals’ perspectives on the lived experience of medicine-taking. Findings from this study highlight five main themes where participants experience medicines as: 1) life-saving and indispensable, 2) normal and a daily routine, 3) confusing and concerning, 4) unsuitable without adjustment, and 5) intrusive and unwelcome. These results can be the basis for mutually agreed prescribing through a co-creative approach that aims at enhancing open and honest dialogues between patients and healthcare professionals in partnership about medicines.