Discourse analysis: A useful methodology for health-care system researches

AI Through Ethical Lenses: A Discourse Analysis of Guidelines for AI in Healthcare

While the technologies that enable Artificial Intelligence (AI) continue to advance rapidly, there are increasing promises regarding AI's beneficial outputs and concerns about the challenges of human-computer interaction in healthcare. To address these concerns, institutions have increasingly resorted to publishing AI guidelines for healthcare, aiming to align AI with ethical practices. However, guidelines as a form of written language can be analyzed to recognize the reciprocal links between its textual communication and underlying societal ideas. From this perspective, we conducted a discourse analysis to understand how these guidelines construct, articulate, and frame ethics for AI in healthcare. We included eight guidelines and identified three prevalent and interwoven discourses: (1) AI is unavoidable and desirable; (2) AI needs to be guided with (some forms of) principles (3) trust in AI is instrumental and primary. These discourses signal an over-spillage of technical ideals to AI ethics, such as over-optimism and resulting hyper-criticism. This research provides insights into the underlying ideas present in AI guidelines and how guidelines influence the practice and alignment of AI with ethical, legal, and societal values expected to shape AI in healthcare.

Exploring the Systemic Structures That Affect Access to Physical Therapist Services for Non-Indigenous Black People in Australia

OBJECTIVE

Physical therapy is generally considered to be a white profession in Western nations. Australia's increasingly diverse population, driven largely by growth in immigration, invites Australian health systems to be responsive to factors that may impact on non-white Australian population's access to health care. Here, the authors sought to explore non-Indigenous Black people's perspectives of physical therapy in Australia.

METHODS

Eligible participants (n = 12) took part in semistructured, in-depth interviews and were prompted to discuss their experiences and perceptions of physical therapy. Interview data were analyzed using critical discourse analysis, underpinned by critical race theory.

RESULTS

Participants were on average 29.4 years (SD = 12.9) from diverse cultural and linguistic backgrounds. Participants described mostly positive experiences with physical therapists, but they noted that it was not widely accessed by their communities, with 2 key discourses underpinning these discussions. Discourse 1, "physiotherapy is a solution for white people," established physical therapy as primarily accessed by and welcoming of white people. "Whiteness" and the perpetuation of Western norms in physical therapy resulted in little consideration of other cultural practices. Participants' discussions also pointed to the intersections of systemic racism and social inequities such as low income and language barriers, impacting Black people's engagement with physical therapy. Discourse 2, "physiotherapists are white," was mostly concerned with how the perceived "whiteness" of professionals and lack of Black physical therapists impacts cultural safety and comfort when accessing physical therapy.

CONCLUSION

Our results suggest that Westernization and whiteness persist among discourses surrounding physical therapy. Such discourses are likely to inform Black people's perceptions and experiences of physical therapy. Our analyses suggest avenues to enhance the cultural diversity of the profession and improve physical therapy accessibility for Black people in Australia by providing culturally appropriate material, including critical reflexivity, epistemic and cultural humility in the curricula, recruiting staff from diverse backgrounds, and providing outreach services to underserved populations.

IMPACT

These findings highlight the need for increased cultural safety and diversity within the physical therapy profession to improve equity.

Nursing Development should Now Become a Priority for Health Systems in Europe

The vast majority of European countries are struggling to embrace nursing as a profession and as a science. There are still not enough nurses with bachelor's degrees and advanced practical skills, and clinical specialisations for nurses are being developed at the master's level. Attention should be paid to recognising nurses as an equal healthcare workforce who need to be empowered to advance their profession and be provided with professional development opportunities. Changes needed include improving pay and working conditions, providing opportunities to improve skills and professional recognition, empowering nurses to deliver care, and harnessing the power of technology to better support nurses. The declining interest in nursing education and the often stereotypical and condescending view of the role and work of nurses on the healthcare team should be a warning signal to all who are working on healthcare reform.

What's the low back pain problem represented to be? An analysis of discourse of the Australian policy directives

PURPOSE

Low back pain (LBP) directives provide information about how LBP should be managed, communicated and navigated in complex health systems, making them an important form of policy. This study aimed to examine how LBP is problematised (represented) in Australian directives.

MATERIALS AND METHODS

We employed an analysis of discourse of LBP directives drawing on Bacchi's "What's the problem represented to be?" policy problematisation approach.

RESULTS

Our analysis suggests that LBP is problematised as a symptom that tends to improve when individuals take responsibility for themselves, but may require care at times. The way in which LBP is represented in the directives excludes important aspects, such as the uncertainties of scientific knowledge, paradigms other than (post)positivist, multimorbidity, social and structural determinants of health.

CONCLUSION

LBP directives may benefit from problematisations of LBP that consider the ongoing nature of LBP and broader contextual factors that impact on both LBP outcomes and care, beyond individual responsibility. Consideration of a wider range of paradigms and expanded evidence base may also be beneficial, as these are likely to enable individuals, clinicians and the Australian healthcare system to address LBP while dealing with its complexities, enabling real-world changes to lessen the LBP burden.IMPLICATIONS FOR REHABILITATIONHealthcare professionals who work with people who experience low back pain (LBP) may benefit from critically reflecting about discourses embedded in policy directives.Healthcare professionals may consider engaging in policy changes processes to expand the discourses on which LBP policy directives rely.Healthcare professionals' ability to enact policy recommendations may be enhanced by consideration of the fluctuating nature of LBP, uncertainties, multimorbidity and determinants of health.

The global effect of digital health technologies on health workers' competencies and health workplace: an umbrella review of systematic reviews and lexical-based and sentence-based meta-analysis

Systematic reviews have quantified the effectiveness, feasibility, acceptability, and cost-effectiveness of digital health technologies (DHTs) used by health-care workers. We aimed to collate available evidence on technologies' effect on health-care workers' competencies and performance. We searched the Cochrane Database of Systematic Reviews, Embase, MEDLINE, Epistemonikos, and Scopus for reviews published from database inception to March 1, 2023. Studies assessing the effects of DHTs on the organisational, socioeconomic, clinical, and epidemiological levels within the workplace, and on health-care workers' performance parameters, were included. Data were extracted and clustered into 25 domains using vote counting based on the direction of effect. The relative frequency of occurrence (RFO) of each domain was estimated using R software. AMSTAR-2 tool was used to appraise the quality of reporting, and the Confidence in the Evidence from Reviews of Qualitative research approach developed by Grading of Recommendations Assessment, Development and Evaluation was used to analyse the certainty of evidence among included studies. The 12 794 screened reviews generated 132 eligible records for assessment. Top-ranked RFO identifiers showed associations of DHT with the enhancement of health-care workers' performance (10·9% [95% CI 5·3-22·5]), improvement of clinical practice and management (9·8% [3·9-24·2]), and improvement of care delivery and access to care (9·2% [4·1-20·9]). Our overview found that DHTs positively influence the daily practice of health-care workers in various medical specialties. However, poor reporting in crucial domains is widely prevalent in reviews of DHT, hindering our findings' generalisability and interpretation. Likewise, most of the included reviews reported substantially more data from high-income countries. Improving the reporting of future studies and focusing on low-income and middle-income countries might elucidate and answer current knowledge gaps.

Healthcare professionals discourses on men and masculinities in sexual healthcare: a focus group study

Studies have reported that men's uptake of sexual health services is low, that these services make them feel vulnerable, and that they experience sexual healthcare (SHC) as stressful, heteronormative, potentially sexualised and "tailored for women". They also suggest that healthcare professionals (HCPs) working in SHC view masculinity as problematic, and situated in private relationships. This study aimed to explore how HCPs construct the gendered social location in SHC, specifically in terms of masculinity and a perception that masculinity is situated in relationships. Critical Discourse Analysis was used to analyse transcripts from seven focus group interviews with 35 HCPs working with men's sexual health in Sweden. The study found that gendered social locations were discursively constructed in four ways: (I) by problematising and opposing masculinity in society; (II) through discursive strategies where a professional discourse on men and masculinity is lacking; (III) by constructing SHC as a feminine arena where masculinity is a visible norm violation; (IV) by constructing men as reluctant patients and formulating a mission to change masculinity. The discourses of HCPs constructed the gendered social location of masculinity in society as incompatible with SHC, and saw masculinity in SHC as a violation of feminine norms. Men seeking SHC were constructed as reluctant patients, and HCPs were seen as agents of change with a mission to transform masculinity. The discourses of HCPs risk othering men in SHC, which could prevent care on equal terms. A shared professional discourse on masculinity could create a common foundation for a more consistent, knowledge-based approach to masculinity and men's sexual health in SHC.

What does the literature mean by social prescribing? A critical review using discourse analysis

Social prescribing (SP) seeks to enhance the role of the voluntary and community sector in addressing patients' complex needs in primary care. Using discourse analysis, this review investigates how SP is framed in the scientific literature and explores its consequences for service delivery. Theory driven searches identified 89 academic articles and grey literature that included both qualitative and quantitative evidence. Across the literature three main discourses were identified. The first one emphasised increasing social inequalities behind escalating health problems and presented SP as a response to the social determinants of health. The second one problematised people's increasing use of health services and depicted SP as a means of enhancing self-care. The third one stressed the dearth of human and relational dimensions in general practice and claimed that SP could restore personalised care. Discourses circulated unevenly in the scientific literature, conditioned by a wider political rationality which emphasised individual responsibility and framed SP as 'solution' to complex and contentious problems. Critically, this contributed to an oversimplification of the realities of the problems being addressed and the delivery of SP. We propose an alternative 'care-based' framing of SP which prioritises (and evaluates) holistic, sustained and accessible practices within strengthened primary care systems.

The weight of words: Discursive constructions of health in weight-neutral peer-reviewed journal articles

Weight-neutral approaches to health, like the Health at Every Size® (HAES®) approach arose in response to emerging evidence showing the negative health consequences of weight-focused approaches through the effects of stigma and marginalization in many settings, including healthcare. While the discourses of dominant 'weight-normative' approaches are well-researched and described, little is known about how language and discourse is creating certain 'truths' about weight-neutral approaches. The aim of this study was to explore how academic discourses create truths about weight-neutral approaches to health. A discourse analysis of 63 academic journal articles was conducted. We found that the language used in academic literature is creating confusing and contradictory messages about weight and weight-neutral approaches to health (like the HAES® approach) through: (i) the continued use of stigmatising and normative labels like 'overweight' and 'obese', (ii) paradoxical language like 'flexible restraint', and (iii) a focus on individual responsibility and blame for health and weight without acknowledgement of broader societal and systemic factors. More research is needed to characterize weight-neutral approaches and develop a clearer framework for researchers wishing to engage with the weight-neutral paradigm of health.

Lessons Learnt from the EU Response to NCDs: A Content Analysis on Building Resilient Post-COVID Health Systems

Non-communicable diseases (NCDs) impose a heavy burden on the healthcare system of countries in the European Union (EU). An estimated 91.3% of all deaths and 86.6% of DALYs in the EU-28 were attributable to NCDs. It is imperative that the EU act on mitigating this challenging health issue and help create trajectories for building resilient health systems. Using qualitative analysis, this study examines the question of how the European Commission 2019-2024 is planning to mitigate the impact of NCDs on health systems, while taking into account the COVID-19 pandemic. A content analysis of 44 documents communicating the European Commission's position on the issue was done. In vivo coding was performed using the software package ATLAS.ti 9. Unique codes were simplified and grouped into main themes. Five main themes were identified: 'health plan', 'COVID-19', 'future direction', 'collaboration and solidarity', and 'persuasion'. This study shows that the European Commission is emphasising the impact of the pandemic and the relevance of policies tackling NCDs. By calling for more cross- and multi-sectoral collaboration, the Commission hopes to create the right climate for a European framework for cooperation, which can help develop EU-wide resilient health systems.

Power analysis in health policy and systems research: a guide to research conceptualisation

Power is a growing area of study for researchers and practitioners working in the field of health policy and systems research (HPSR). Theoretical development and empirical research on power are crucial for providing deeper, more nuanced understandings of the mechanisms and structures leading to social inequities and health disparities; placing contemporary policy concerns in a wider historical, political and social context; and for contributing to the (re)design or reform of health systems to drive progress towards improved health outcomes. Nonetheless, explicit analyses of power in HPSR remain relatively infrequent, and there are no comprehensive resources that serve as theoretical and methodological starting points. This paper aims to fill this gap by providing a consolidated guide to researchers wishing to consider, design and conduct power analyses of health policies or systems. This practice article presents a synthesis of theoretical and conceptual understandings of power; describes methodologies and approaches for conducting power analyses; discusses how they might be appropriately combined; and throughout reflects on the importance of engaging with positionality through reflexive praxis. Expanding research on power in health policy and systems will generate key insights needed to address underlying drivers of health disparities and strengthen health systems for all.

Investigating Public Discourses Around Gender and COVID-19: a Social Media Analysis of Twitter Data

We collected over 50 million tweets referencing COVID-19 to understand the public’s gendered discourses and concerns during the pandemic. We filtered the tweets based on English language and among three gender categories: men, women, and sexual and gender minorities. We used a mixed-method approach that included topic modelling, sentiment analysis, and text mining extraction procedures including words’ mapping, proximity plots, top hashtags and mentions, and most retweeted posts. Our findings show stark differences among the different genders. In relation to women, we found a salient discussion on the risks of domestic violence due to the lockdown especially towards women and girls, while emphasizing financial challenges. The public discourses around SGM mostly revolved around blood donation concerns, which is a reminder of the discrimination against some of these communities during the early days of the HIV/AIDS epidemic. Finally, the discourses around men were focused on the high death rates and the sentiment analysis results showed more negative tweets than among the other genders. The study concludes that Twitter influencers can drive major online discussions which can be useful in addressing communication needs during pandemics.

How Doctors Do Things with Empathy in Online Medical Consultations in China: A Discourse-analytic Approach

It is widely acknowledged that doctors' expressions of empathy are fundamental to a successful medical consultation. While extensive work has been done on empathic communication in face-to-face medical encounters, few studies explored expressions of empathy in online medical consultations. Such research is particularly scarce in Chinese contexts, even though China has recently seen substantial growth in e-healthcare activities. To gain a better understanding of clinical empathic communication in online environment, this study, using discourse-analytic tools, explores the pragmatic functions of doctors' empathic responses in text-based online medical consultations in China. The study finds that most empathic responses by doctors can be said to perform the function of facilitating the institutional task of problem-solving, and a few serve the function of self-promotion that is likely to be triggered by the e-commerce model for online medical services.

Competent to provide compassionate care? A critical discourse analysis of accreditation standards

BACKGROUND

Medical school accreditation is recognised internationally as an important quality control process for programmes that lead to the Medical Doctor (MD) degree. Accreditation standards govern the accreditation process which in turn drives educational objectives. Given the power of these standards to shape what becomes valued in the curricula, it is therefore imperative to ensure that core values and ideals of the profession are meaningfully incorporated. As the provision of compassionate care has long been a central medical value, this value should be clearly articulated in MD programme accreditation standards.

METHODS

We conducted a Critical Discourse Analysis of compassionate care within Undergraduate Medical Education (UME) Accreditation Standards governing North American medical schools since 1957. We explored how and to what extent the written language of the accreditation standards incorporated compassionate care.

RESULTS

References to compassionate care in the UME Accreditation Standards were few and far between. Historically, a statement of 'The Objectives of Undergraduate Medical Education' published by the Association of American Medical Colleges (AAMC) was referenced for the first and only time in the 1957 standards, describing the development of attributes such as the provision of compassionate care as a basic objective of UME. Thereafter, there was infrequent mention of this value. Terms that could potentially incorporate aspects of compassionate care were identified, yet these were explicated in ways that limited connection to compassion. Instead, the term 'care' has increasingly been used instrumentally (ie acute care, chronic care).

CONCLUSION

The relative absence of language pertaining to compassionate care in accreditation standards is troubling as compassion is integral to good medical care. This absence is particularly important to attend to in the current era of competency-based training where we must be explicit about all important curricular objectives lest essential values and practices be unintentionally lost.

Making the case for clinical mental health nurses to break their silence on the healing they create: A critical discussion

This discursive paper aims to clarify what roles mental health nurses identify as being within their scope of practice in clinical settings. It also aims to highlight any consumer benefits arising from these roles. Role theory and its relationship with identity are critically discussed as a framework to explain how contemporary mental health nursing roles are poorly understood and undervalued within mental health services. In order to meet the aims of the paper literature written in the last five years by clinical mental health nurses reporting their roles, and outcomes of those roles were searched. This literature was then considered through the lens of social constructionism that premises truths are accessed and then constructed though relationship based language. Six core mental health nursing roles were identified across international settings. The MHN is a psychotherapist. The MHN is a consumer advocate. The MHN is a physical health therapist. The MHN is a psycho-pharmacological therapist. The MHN is a relationship focussed therapist and finally the MHN is an aggression management therapist. While European and American nurses reported consumer benefit emerging from these roles those from Australia and the United Kingdom did not. The roles reported on were largely instrumental ones that offered little clarity towards the identity of our profession, nor its worth to consumers or funders of services. Mental health nurses will only have their true breadth of clinical capabilities recognized where there is a consistent construction emerging from clinicians in clinical settings on the efficacy of their clinical work.

Stroke follow-up in primary care: a discourse study on the discharge summary as a tool for knowledge transfer and collaboration

Background

The acute treatment for stroke takes place in hospitals and in Norway follow-up of stroke survivors residing in the communities largely takes place in general practice. In order to provide continuous post stroke care, these two levels of care must collaborate, and information and knowledge must be transferred between them. The discharge summary, a written report from the hospital, is central to this communication. Norwegian national guidelines for treatment of stroke, issued in 2010, therefore give recommendations on the content of the discharge summaries. One ambition is to achieve collaboration and knowledge transfer, contributing to integration of the health care services. However, studies suggest that adherence to guidelines in general practice is weak, that collaboration within the health care services does not work the way the authorities intend, and that health care services are fragmented.

This study aims to assess to what degree the discharge summaries adhere to the guideline recommendations on content and to what degree they are used as tools for knowledge transfer and collaboration between secondary and primary care.

Methods

The study was an analysis of 54 discharge summaries for home-dwelling stroke patients. The patients had been discharged from two Norwegian local hospitals in 2011 and 2012 and followed up in primary care. We examined whether content was according to guidelines’ recommendations and performed a descriptive and interpretative discourse analysis, using tools adapted from an established integrated approach to discourse analysis. 

Results

We found a varying degree of adherence to the different advice for the contents of the discharge summaries. One tendency was clear: topics relevant here and now, i.e. at the hospital, were included, while topics most relevant for the later follow-up in primary care were to a larger degree omitted. In most discharge summaries, we did not find anything indicating that the doctors at the hospital made themselves available for collaboration with primary care after dischargeof the patient.

Conclusions

The discharge summaries did not fulfill their potential to serve as tools for collaboration, knowledge transfer, and guideline implementation. Instead, they may contribute to sustain the gap between hospital medicine and general practice.

Predicting the readability of physicians' secure messages to improve health communication using novel linguistic features: Findings from the ECLIPPSE study

Background

Low literacy skills impact important aspects of communication, including health-related information exchanges. Unsuccessful communication on the part of physician or patient contributes to lower quality of care, is associated with poorer chronic disease control, jeopardizes patient safety and can lead to unfavorable healthcare utilization patterns. To date, very little research has focused on digital communication between physicians and patients, such as secure messages sent via electronic patient portals.

Method

The purpose of the current study is to develop an automated readability formula to better understand what elements of physicians' digital messages make them more or less difficult to understand. The formula is developed using advanced natural language processing (NLP) to predict human ratings of physician text difficulty.

Results

The results indicate that NLP indices that capture a diverse set of linguistic features predict the difficulty of physician messages better than classic readability tools such as Flesch Kincaid Grade Level. Our results also provide information about the textual features that best explain text readability.

Conclusion

Implications for how the readability formula could provide feedback to physicians to improve digital health communication by promoting linguistic concordance between physician and patient are discussed.

Strategies for increasing impact, engagement, and accessibility in HIV prevention programs: suggestions from women in urban high HIV burden counties in the Eastern United States (HPTN 064)

BACKGROUND

Merely having the tools to end HIV is insufficient. Effectively ending the epidemic necessitates addressing barriers that impede engagement in biomedical and behavioral prevention and wide scale implementation and utilization of existing interventions. This qualitative study identifies suggestions for increasing access to, engagement in, and impact of HIV prevention among women living in cities in high HIV burden counties in the eastern US.

METHODS

Data analyzed for the current study were collected via a qualitative sub-study within the HIV Prevention Trials Network Study 064 (HPTN 064), a multisite observational cohort study designed to estimate HIV incidence among women residing in communities with elevated HIV prevalence who also reported personal or partner characteristics associated with increased risk of HIV acquisition. Focus group and interview participants in the qualitative sub-study (N = 288) were from four cities in the eastern US.

RESULTS

Thematic analyses revealed four themes describing women's most frequently stated ideas for improving prevention efforts: 1) Promote Multilevel Empowerment, 2) Create Engaging Program Content, 3) Build "Market Demand", and 4) Ensure Accessibility. We conducted additional analyses to identify contradictory patterns in the data, which revealed an additional three themes: 1) Address Structural Risk Factors, 2) Increase Engagement via Pleasure Promotion, 3) Expand Awareness of and Access to Prevention Resources.

CONCLUSIONS

Findings may be useful for enhancing women's engagement in and uptake of behavioral and biomedical HIV prevention resources, improving policy, and addressing multilevel risk factors.

TRIAL REGISTRATION

Clinicaltrials.gov: NCT00995176 , prospectively registered.

Institutional Engagement Practices as Barriers to Public Health Capacity in Climate Change Policy Discourse: Lessons from the Canadian Province of Ontario

Public health engagement in the communication, discussion, and development of climate change policies is essential for climate change policy decisions and discourse. This study examines how the existing governance approaches impact, enable, or constrain the inclusion, participation, and deliberation of public health stakeholders in the climate change policy discourse. Using the case study of the Canadian Province of Ontario, we conducted semi-structured, key informant interviews of public health (11) and non-public health (13) participants engaged in climate change policies in the province. The study results reveal that engagement and partnerships on climate change policies occurred within and across public health and non-public health organizations in Ontario. These engagements impacted public health's roles, decisions, mandate, and capacities beyond the climate change discourse; enabled access to funds, expertise, and new stakeholders; built relationships for future engagements; supported knowledge sharing, generation, and creation; and advanced public health interests in political platforms and decision making. However, public health's participation and deliberation were constrained by a fragmented sectoral approach, a lack of holistic inter-organizational structures and process, political and bureaucratic influences, irregular and unestablished communication channels for public health integration, and identities and culture focused on functions, mandates, biased ideologies, and a lack of clear commitment to engage public health. We conclude by providing practical approaches for integrating public health into climate change discourse and policymaking processes and advancing public health partnerships and collaborative opportunities.