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Band R, Ewings S, Cheetham-Blake T, Ellis J, Breheny K, Vassilev I, Portillo MC, Yardley L, Blickem C, Kandiyali R, Culliford D, Rogers A. 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. BMJ Open 2019; 9:e028718. [PMID: 31427326 PMCID: PMC6701612 DOI: 10.1136/bmjopen-2018-028718] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Revised: 03/13/2019] [Accepted: 06/17/2019] [Indexed: 12/27/2022] Open
Abstract
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.
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Affiliation(s)
- Rebecca Band
- Psychology, University of Southampton, Southampton, UK
- Health Sciences, University of Southampton, Southampton, UK
- NIHR Collaboration for Leadership in Applied Health Research and Care Wessex, NIHR, Wessex, UK
| | - Sean Ewings
- Health Sciences, University of Southampton, Southampton, UK
| | - Tara Cheetham-Blake
- Health Sciences, University of Southampton, Southampton, UK
- NIHR Collaboration for Leadership in Applied Health Research and Care Wessex, NIHR, Wessex, UK
| | - Jaimie Ellis
- Health Sciences, University of Southampton, Southampton, UK
- NIHR Collaboration for Leadership in Applied Health Research and Care Wessex, NIHR, Wessex, UK
| | - Katie Breheny
- Population Health Sciences, University of Bristol, Bristol, UK
| | - Ivaylo Vassilev
- Health Sciences, University of Southampton, Southampton, UK
- NIHR Collaboration for Leadership in Applied Health Research and Care Wessex, NIHR, Wessex, UK
| | - Mari Carmen Portillo
- Health Sciences, University of Southampton, Southampton, UK
- NIHR Collaboration for Leadership in Applied Health Research and Care Wessex, NIHR, Wessex, UK
| | - Lucy Yardley
- Academic Unit of Psychology, University of Southampton, Southampton, UK
- School of Psychological Science, University of Bristol, Bristol, UK
| | | | - Rebecca Kandiyali
- Centre for Child and Adolescent Health, University of Bristol School of Social and Community Medicine, Bristol, UK
| | - David Culliford
- NIHR Collaboration for Leadership in Applied Health Research and Care Wessex, NIHR, Wessex, UK
- Faculty of Medicine, University of Southampton, Southampton, UK
| | - Anne Rogers
- Health Sciences, University of Southampton, Southampton, UK
- NIHR Collaboration for Leadership in Applied Health Research and Care Wessex, NIHR, Wessex, UK
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Madden H, Harris J, Blickem C, Harrison R, Timpson H. "Always paracetamol, they give them paracetamol for everything": a qualitative study examining Eastern European migrants' experiences of the UK health service. BMC Health Serv Res 2017; 17:604. [PMID: 28851364 PMCID: PMC5575835 DOI: 10.1186/s12913-017-2526-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2016] [Accepted: 08/08/2017] [Indexed: 01/02/2023] Open
Abstract
Background The enlargement of the European Union since 2004 has led to an increase in the number of Eastern European migrants living in the UK. The health of this group is under-researched though some mixed evidence shows they are at higher risk of certain physical health conditions such as heart attacks, strokes, HIV and alcohol use and have poorer mental health. This is compounded by poor or insecure housing, low pay, isolation and prejudice. We aimed to understand the health needs and health service experiences of the Eastern European population in a town in Northern England. Methods Five semi structured one-to-one and small group interviews and five focus groups were conducted with 42 Eastern European participants between June and September 2014. The majority of participants were Polish and other participants were from Belarus, Hungary, Latvia, Russia, Slovakia and Ukraine. The data were analysed using thematic framework analysis. Results Key findings included a good understanding the UK health service structure and high registration and use of general practice/primary care services. However, overall, there were high levels of dissatisfaction, frustration and distrust in General Practitioners (GP). The majority of participants viewed the GP as unhelpful and dismissive; a barrier to secondary/acute care; reluctant to prescribe antibiotics; and that GPs too often advised them to take paracetamol (acetaminophen) and rest. Conclusions Overwhelmingly participants had strong opinions about access to primary care and the role of the general practitioners. Although the design of the UK health service was well understood, participants were unhappy with the system of GP as gatekeeper and felt it inferior to the consumer-focused health systems in their country of origin. More work is needed to promote the importance of self-care, reduce antibiotic and medication use, and to increase trust in the GP.
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Affiliation(s)
- Hannah Madden
- Public Health Institute, Liverpool John Moores University, Liverpool, UK.
| | - Jane Harris
- Public Health Institute, Liverpool John Moores University, Liverpool, UK
| | - Christian Blickem
- Public Health Institute, Liverpool John Moores University, Liverpool, UK
| | - Rebecca Harrison
- Public Health Institute, Liverpool John Moores University, Liverpool, UK
| | - Hannah Timpson
- Public Health Institute, Liverpool John Moores University, Liverpool, UK
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Patel NR, Kennedy A, Blickem C, Reeves D, Chew-Graham C. "I'm Managing My Diabetes between Two Worlds": Beliefs and Experiences of Diabetes Management in British South Asians on Holiday in the East--A Qualitative Study. J Diabetes Res 2015; 2016:5436174. [PMID: 26697499 PMCID: PMC4677201 DOI: 10.1155/2016/5436174] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2015] [Accepted: 06/14/2015] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Diabetes is disproportionately high among British South Asians compared to the general UK population. Whilst the migrant British South Asians group has received most attention on research related to diabetes management, little consideration has been given to impact of travel back to the East. This study aimed to explore the role of social networks and beliefs about diabetes in British South Asians, to better understand their management behaviours whilst holidaying in the East. METHODS Semistructured interviews were conducted in Greater Manchester. Forty-four participants were recruited using random and purposive sampling techniques. Interviews were analysed thematically using a constant comparison approach. RESULTS Migrant British South Asians expressed a strong preference to be in a hot climate; they felt they had a healthier lifestyle in the East and often altered or abandoned their diabetes medication. Information acquisition on diabetes and availability of social networks in the East was valued. CONCLUSION Social networks in the East are a valued source of information and support for diabetes. The lack of adherence to medication whilst abroad suggests that some migrant British South Asians have a poor understanding of diabetes. Future research needs to explore whether patients are seeking professional advice on diabetes management prior to their extended holiday.
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Affiliation(s)
- Neesha R. Patel
- Centre for Endocrinology and Diabetes and Manchester Centre for Health Psychology, Institute of Human Development, The University of Manchester, Room S42, Second Floor, Zochonis Building, Brunswick Street, Manchester M13 9PT, UK
| | - Anne Kennedy
- NIHR Collaboration for Leadership in Applied Health Research and Care (CLAHRC) Wessex, Faculty of Health Sciences, University of Southampton, Highfield Campus, Building 67, Southampton SO17 1BJ, UK
| | - Christian Blickem
- NIHR Collaboration for Leadership in Applied Health Research and Care (CLAHRC) Greater Manchester, Centre for Primary Care, 5th Floor, Williamson Building, Oxford Road, Manchester M13 9PL, UK
| | - David Reeves
- Centre for Primary Care, 5th Floor, Williamson Building, Oxford Road, Manchester M13 9PL, UK
| | - Carolyn Chew-Graham
- Research Institute, Primary Care and Health Sciences and NIHR Collaboration for Leadership in Applied Health Research and Care (CLAHRC) West Midlands, Keele University, Keele, Staffordshire ST5 5BG, UK
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Mossabir R, Morris R, Kennedy A, Blickem C, Rogers A. A scoping review to understand the effectiveness of linking schemes from healthcare providers to community resources to improve the health and well-being of people with long-term conditions. Health Soc Care Community 2015; 23:467-84. [PMID: 25494621 DOI: 10.1111/hsc.12176] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 10/14/2014] [Indexed: 05/12/2023]
Abstract
The prevalence of people living with long-term conditions is increasing, accompanied by an increased expectation that patients will become more involved in self-management. Long-term conditions are associated with increased social isolation and poor physical and mental health. But there remains a gap in health provision between providing medical treatment and effectively addressing psychosocial well-being. One potential way of addressing this gap is by utilising social interventions which link patients from health services to community-based sources of support. However, the mechanisms involved in the delivery of interventions providing that link and their effectiveness remain unclear. This review adopted the methodological framework for conducting scoping studies, searching for both academic and grey literature on social interventions which link people from healthcare settings to a range of community and voluntary sector organisations. A literature search between May and June 2013, involving five electronic databases, hand searching of two journals and the use of Google search engine, identified seven studies relevant to the review question. In terms of key characteristics and mechanisms of the interventions, mental health conditions and social isolation were the most common reasons for referral to the interventions, and referrals were usually made through general practices. Almost all the interventions were facilitator-led, whereby the facilitator worked to identify and link participants to appropriate community-based resources. In regard to health and social outcomes and their cost-effectiveness, studies reported improvement to participants' psychological and social well-being as well as their decreased use of health services, although there were limited measures of participants' physical health outcomes. Interventions for linking patients from healthcare setting to community-based resources target and address psychosocial needs of participants. The review identified involvement of health professionals in aiding the referral of patients to the intervention and the role of the intervention facilitators as key components of the interventions.
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Affiliation(s)
- Rahena Mossabir
- Centre for Primary Care, Institute of Population Health, University of Manchester, Manchester, UK
| | - Rebecca Morris
- Centre for Primary Care, Institute of Population Health, University of Manchester, Manchester, UK
| | - Anne Kennedy
- NIHR CLAHRC Wessex, Health Sciences, University of Southampton, Southampton, UK
| | - Christian Blickem
- NIHR CLAHRC Greater Manchester, Centre for Primary Care, Institute of Population Health, University of Manchester, Manchester, UK
| | - Anne Rogers
- NIHR CLAHRC Wessex, Health Sciences, University of Southampton, Southampton, UK
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Galdas P, Darwin Z, Fell J, Kidd L, Bower P, Blickem C, McPherson K, Hunt K, Gilbody S, Richardson G. A systematic review and metaethnography to identify how effective, cost-effective, accessible and acceptable self-management support interventions are for men with long-term conditions (SELF-MAN). Health Serv Deliv Res 2015. [DOI: 10.3310/hsdr03340] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BackgroundSelf-management support interventions can improve health outcomes, but their impact is limited by the numbers of patients able or willing to access them. Men’s attendance at, and engagement with, self-management support appears suboptimal despite their increased risk of developing serious and disabling long-term conditions (LTCs).ObjectivesTo assess the effectiveness, cost-effectiveness, accessibility and acceptability of self-management support interventions in men with LTCs.MethodsA quantitative systematic review with meta-analysis and a qualitative review using a metaethnography approach. The findings of the two reviews were integrated in parallel synthesis.Data sourcesIn the quantitative review, the Cochrane Database of Systematic Reviews was searched to identify published reviews of self-management support interventions. Relevant reviews were screened to identify randomised controlled trials (RCTs) of self-management support interventions conducted in men alone, or which analysed the effects of interventions by gender. In the qualitative review, the databases Cumulative Index to Nursing and Allied Health Literature, EMBASE, Medical Literature Analysis and Retrieval System Online, PsycINFO and Social Science Citation Index (July 2013) were searched from inception to July 2013.Review methodsIn the quantitative review, data on relevant outcomes, patient populations, intervention type and study quality were extracted. Quality appraisal was conducted independently by two reviewers using the Cochrane risk of bias tool. Meta-analysis was conducted to compare the effects of interventions in male, female and mixed-sex groups. In the metaethnography, study details, participant quotes (first-order constructs) and study authors’ themes/concepts (second-order constructs) were extracted. Quality appraisal was conducted independently by two reviewers using the Critical Appraisal Skills Programme tool. Data were synthesised according to a metaethnography approach. Third-order interpretations/constructs were derived from the extracted data and integrated to generate a ‘line-of-argument’ synthesis.ResultsForty RCTs of self-management support interventions in male-only samples, and 20 RCTs where an analysis by gender was reported, were included in the quantitative review. Meta-analysis suggested that interventions including physical activity, education and peer support have a positive impact on quality of life in men, and that men may derive more benefit than women from them, but there is currently insufficient evidence to draw definitive conclusions. Thirty-eight qualitative studies relevant to men’s experiences of, and perceptions of, self-management support were included in the qualitative review. The metaethnography identified four concepts: (1) need for purpose; (2) trusted environments; (3) value of peers; and (4) becoming an expert. Findings indicated that men may feel less comfortable engaging in support if it is perceived to be incongruous with valued aspects of masculine identities. Men may find support interventions more attractive when they have a clear purpose, are action-oriented and offer practical strategies that can be integrated into daily life. Support delivered in an environment that offers a sense of shared understanding can be particularly appealing to some men.ConclusionsHealth professionals and those involved in designing interventions may wish to consider whether or not certain components (e.g. physical activity, education, peer support) are particularly effective in men, although more research is needed to fully determine and explore this. Interventions are most likely to be accessible and acceptable to men when working with, not against, valued aspects of masculine identities.Study registrationThis study is registered as PROSPERO CRD42013005394.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Paul Galdas
- Department of Health Sciences, University of York, York, UK
| | - Zoe Darwin
- School of Healthcare, Faculty of Medicine, University of Leeds, Leeds, UK
| | - Jennifer Fell
- Department of Health Sciences, University of York, York, UK
| | - Lisa Kidd
- School of Health and Life Sciences/Institute for Applied Health Research, Glasgow Caledonian University, Glasgow, UK
| | - Peter Bower
- National Institute for Health Research School for Primary Care Research, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
| | - Christian Blickem
- National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care (CLAHRC) Greater Manchester, Centre for Primary Care, Institute of Population Health, University of Manchester, Manchester, UK
| | - Kerri McPherson
- School of Health and Life Sciences/Institute for Applied Health Research, Glasgow Caledonian University, Glasgow, UK
| | - Kate Hunt
- Medical Research Council/Chief Scientist Office Social and Public Health Sciences Unit, University of Glasgow, Glasgow, UK
| | - Simon Gilbody
- Department of Health Sciences, University of York, York, UK
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Morris R, Kirk S, Kennedy A, Vassilev I, Mathieson A, Jeffries M, Blickem C, Brooks H, Sanders C, Rogers A. Connecting local support: A qualitative study exploring the role of voluntary organisations in long-term condition management. Chronic Illn 2015; 11:140-55. [PMID: 25199957 DOI: 10.1177/1742395314551098] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2014] [Accepted: 08/08/2014] [Indexed: 11/15/2022]
Abstract
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.
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Affiliation(s)
- Rebecca Morris
- Centre for Primary Care, Institute of Population Health, University of Manchester, Manchester, UK
| | - Susan Kirk
- School of Nursing, Midwifery and Social Work, University of Manchester, Jean McFarlane Building, Manchester, UK
| | - Anne Kennedy
- Health Sciences, University of Southampton, Southampton, UK
| | | | - Amy Mathieson
- Centre for Primary Care, Institute of Population Health, University of Manchester, Manchester, UK
| | - Mark Jeffries
- Centre for Primary Care, Institute of Population Health, University of Manchester, Manchester, UK
| | - Christian Blickem
- Centre for Primary Care, Institute of Population Health, University of Manchester, Manchester, UK
| | - Helen Brooks
- School of Nursing, Midwifery and Social Work, University of Manchester, Jean McFarlane Building, Manchester, UK
| | - Caroline Sanders
- Centre for Primary Care, Institute of Population Health, University of Manchester, Manchester, UK
| | - Anne Rogers
- Health Sciences, University of Southampton, Southampton, UK
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Patel NR, Chew-Graham C, Bundy C, Kennedy A, Blickem C, Reeves D. Illness beliefs and the sociocultural context of diabetes self-management in British South Asians: a mixed methods study. BMC Fam Pract 2015; 16:58. [PMID: 25958196 PMCID: PMC4438635 DOI: 10.1186/s12875-015-0269-y] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/29/2014] [Accepted: 04/27/2015] [Indexed: 12/30/2022]
Abstract
Background British South Asians have a higher incidence of diabetes and poorer health outcomes compared to the general UK population. Beliefs about diabetes are known to play an important role in self-management, yet little is known about the sociocultural context in shaping beliefs. This study aimed to explore the influence of sociocultural context on illness beliefs and diabetes self-management in British South Asians. Methods A mixed methods approach was used. 67 participants recruited using random and purposive sampling, completed a questionnaire measuring illness beliefs, fatalism, health outcomes and demographics; 37 participants completed a social network survey interview and semi-structured interviews. Results were analysed using SPSS and thematic analysis. Results Quantitative data found certain social network characteristics (emotional and illness work) were related to perceived concern, emotional distress and health outcomes (p < 0.05). After multivariate analysis, emotional work remained a significant predictor of perceived concern and emotional distress related to diabetes (p < 0.05). Analysis of the qualitative data suggest that fatalistic attitudes and beliefs influences self-management practices and alternative food ‘therapies’ are used which are often recommended by social networks. Conclusions Diabetes-related illness beliefs and self-management appear to be shaped by the sociocultural context. Better understanding of the contextual determinants of behaviour could facilitate the development of culturally appropriate interventions to modify beliefs and support self-management in this population. Electronic supplementary material The online version of this article (doi:10.1186/s12875-015-0269-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Neesha R Patel
- Centre for Endocrinology and Diabetes and Manchester Centre for Health Psychology, Institute of Human Development, The University of Manchester, Room S42, Second Floor, Zochonis Building, Brunswick Street, Manchester, M13 9PT, UK.
| | - Carolyn Chew-Graham
- Primary Care and Health Sciences, and NIHR Collaboration for Leadership in Applied Health Research and Care (CLAHRC) West Midlands, Research Institute, Keele University, Keele, Staffordshire, ST5 5BG, UK.
| | - Christine Bundy
- Institute for Inflammation and Repair, The University of Manchester, 1.530 Stopford Building, Oxford Road, Manchester, M13 9PL, UK.
| | - Anne Kennedy
- NIHR CLAHRC Wessex, Faculty of Health Sciences, Building 67, University of Southampton, Highfield Campus, Southampton, SO17 1BJ, UK.
| | - Christian Blickem
- NIHR CLAHRC Greater Manchester, The University of Manchester, Centre for Primary Care, 5th Floor Williamson Building, Oxford Road, Manchester, M13 9PL, UK.
| | - David Reeves
- Centre for Primary Care, The University of Manchester, 5th Floor Williamson Building, Oxford Road, Manchester, M13 9PL, UK.
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Jeffries M, Mathieson A, Kennedy A, Kirk S, Morris R, Blickem C, Vassilev I, Rogers A. Participation in voluntary and community organisations in the United Kingdom and the influences on the self-management of long-term conditions. Health Soc Care Community 2015; 23:252-261. [PMID: 25175423 DOI: 10.1111/hsc.12138] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 06/20/2014] [Indexed: 06/03/2023]
Abstract
Voluntary and community organisations (VCOs) have health benefits for those who attend and are viewed as having the potential to support long-term condition management. However, existing community-level understandings of participation do not explain the involvement with VCOs at an individual level, or the nature of support, which may elicit health benefits. Framing active participation as 'doing and experiencing', the aim of this qualitative study was to explore why people with long-term vascular conditions join VCOs, maintain their membership and what prevents participation. Twenty participants, self-diagnosed as having diabetes, chronic heart disease or chronic kidney disease, were purposefully sampled and recruited from a range of VCOs in the North West of England identified from a mapping of local organisations. In semi-structured interviews, we explored the nature of their participation. Analysis was thematic and iterative involving a continual reflection on the data. People gave various reasons for joining groups. These included health and well-being, the need for social contact and pursuing a particular hobby. Barriers to participation included temporal and spatial barriers and those associated with group dynamics. Members maintained their membership on the basis of an identity and sense of belonging to the group, developing close relationships within it and the availability of support and trust. Participants joined community groups often in response to a health-related event. Our findings demonstrate the ways in which the social contact associated with continued participation in VCOs is seen as helping with long-term condition management. Interventions designed at improving chronic illness management might usefully consider the role of VCOs.
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Affiliation(s)
- Mark Jeffries
- Centre for Primary Care, Institute of Population Health, University of Manchester, Manchester, UK
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Galdas P, Fell J, Bower P, Kidd L, Blickem C, McPherson K, Hunt K, Gilbody S, Richardson G. The effectiveness of self-management support interventions for men with long-term conditions: a systematic review and meta-analysis. BMJ Open 2015; 5:e006620. [PMID: 25795688 PMCID: PMC4368927 DOI: 10.1136/bmjopen-2014-006620] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
OBJECTIVES To assess the effectiveness of self-management support interventions in men with long-term conditions. METHODS A quantitative systematic review with meta-analysis. DATA SOURCES The Cochrane Database of Systematic Reviews was searched to identify published reviews of self-management support interventions. Relevant reviews were screened to identify randomised controlled trials (RCTs) of self-management support interventions conducted in men alone, or which analysed the effects of interventions by sex. REVIEW METHODS Data on relevant outcomes, patient populations, intervention type and study quality were extracted. Quality appraisal was conducted using the Cochrane Risk of Bias Tool. Meta-analysis was conducted to compare the effects of interventions in men, women, and mixed-sex sub-groups. RESULTS 40 RCTs of self-management support interventions in men, and 20 eligible RCTs where an analysis by sex was reported, were included in the review. Meta-analysis suggested that physical activity, education, and peer support-based interventions have a positive impact on quality of life in men. However, there is currently insufficient evidence to make strong statements about whether self-management support interventions show larger, similar or smaller effects in men compared with women and mixed-sex groups. CONCLUSIONS Clinicians may wish to consider whether certain types of self-management support (eg, physical activity, education, peer support) are particularly effective in men, although more research is needed to fully determine and explore this.
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Affiliation(s)
- Paul Galdas
- Department of Health Sciences, University of York, York, UK
| | - Jennifer Fell
- Department of Health Sciences, University of York, York, UK
| | - Peter Bower
- NIHR School for Primary Care Research, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
| | - Lisa Kidd
- School of Health and Life Sciences/Institute for Applied Health Research, Glasgow Caledonian University, Glasgow, UK
| | - Christian Blickem
- NIHR Collaboration for Leadership in Applied Health Research and Care (CLAHRC) Greater Manchester, Centre for Primary Care, Institute of Population Health, University of Manchester, Manchester, UK
| | - Kerri McPherson
- School of Health and Life Sciences/Institute for Applied Health Research, Glasgow Caledonian University, Glasgow, UK
| | - Kate Hunt
- MRC/CSO Social and Public Health Sciences Unit, University of Glasgow, Glasgow, UK
| | - Simon Gilbody
- Department of Health Sciences, University of York, York, UK
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Vassilev I, Rogers A, Sanders C, Cheraghi-Sohi S, Blickem C, Brooks H, Kapadia D, Reeves D, Doran T, Kennedy A. Social status and living with a chronic illness: an exploration of assessment and meaning attributed to work and employment. Chronic Illn 2014; 10:273-90. [PMID: 24486894 DOI: 10.1177/1742395314521641] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
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.
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Affiliation(s)
- Ivaylo Vassilev
- Greater Manchester Collaboration for Leadership in Applied Health Research and Care, University of Manchester, Manchester, UK Faculty of Health Sciences, University of Southampton, Southampton, UK
| | - Anne Rogers
- Faculty of Health Sciences, University of Southampton, Southampton, UK
| | - Caroline Sanders
- Greater Manchester Collaboration for Leadership in Applied Health Research and Care, University of Manchester, Manchester, UK Centre for Primary Care, Institute of Population Health, University of Manchester, Manchester, UK
| | - Sudeh Cheraghi-Sohi
- Greater Manchester Collaboration for Leadership in Applied Health Research and Care, University of Manchester, Manchester, UK Centre for Primary Care, Institute of Population Health, University of Manchester, Manchester, UK
| | - Christian Blickem
- Greater Manchester Collaboration for Leadership in Applied Health Research and Care, University of Manchester, Manchester, UK Centre for Primary Care, Institute of Population Health, University of Manchester, Manchester, UK
| | - Helen Brooks
- Greater Manchester Collaboration for Leadership in Applied Health Research and Care, University of Manchester, Manchester, UK School of Nursing, Midwifery & Social Work, University of Manchester, Manchester, UK
| | - Dharmi Kapadia
- Greater Manchester Collaboration for Leadership in Applied Health Research and Care, University of Manchester, Manchester, UK
| | - David Reeves
- Greater Manchester Collaboration for Leadership in Applied Health Research and Care, University of Manchester, Manchester, UK Centre for Primary Care, Institute of Population Health, University of Manchester, Manchester, UK
| | - Tim Doran
- Department of Health Sciences, University of York, York, UK
| | - Anne Kennedy
- Greater Manchester Collaboration for Leadership in Applied Health Research and Care, University of Manchester, Manchester, UK Faculty of Health Sciences, University of Southampton, Southampton, UK
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Gaffney H, Blakeman T, Blickem C, Kennedy A, Reeves D, Dawson S, Mossabir R, Bower P, Gardner C, Lee V, Rogers A. Predictors of patient self-report of chronic kidney disease: baseline analysis of a randomised controlled trial. BMC Fam Pract 2014; 15:196. [PMID: 25433525 PMCID: PMC4260196 DOI: 10.1186/s12875-014-0196-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/29/2013] [Accepted: 11/14/2014] [Indexed: 01/30/2023]
Abstract
Background Improving the quality of care for patients with vascular disease is a priority. Clinical guidance has emphasised the importance of early identification and active management of chronic kidney disease (CKD) in primary care in order to maintain vascular health. However, awareness of stage 3 CKD amongst patients remains limited. We aimed to identify predictors of patient self-report of CKD to inform tailoring of conversations around CKD in primary care for diverse patient populations. Methods We conducted a cross-sectional analysis of baseline data from 436 patients with stage 3 CKD from 24 GP practices taking part in a randomised controlled trial (RCT) evaluating a complex self-management intervention, which aimed to support the maintenance of vascular health in patients with stage 3 CKD. Potential predictors of patient self-report of CKD included demographics, stage of CKD, cardiovascular risk, self-reported co-morbidities, health status, self-management ability, and health service utilisation. Results Around half (52%, n = 227) of patients did not self-report CKD. Self-report rates did not appreciably differ by practice. Multivariate analysis revealed that female patients (p = 0.004), and patients with stage 3b CKD (p < 0.001), and with higher anxiety levels (p < 0.001), were more likely to self-report CKD. Conclusions Self-report of kidney problems by patients on CKD registers was variable and patterned by sociodemographic factors. Although it cannot be assumed that failure to self-report indicates a lack of awareness of CKD, our data do suggest the need for greater consistency in discussions around kidney health, with meaningful and relevant clinical dialogue that is aligned with existing clinical encounters to enable shared decision making and minimise anxiety. Electronic supplementary material The online version of this article (doi:10.1186/s12875-014-0196-3) contains supplementary material, which is available to authorized users.
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Galdas P, Darwin Z, Kidd L, Blickem C, McPherson K, Hunt K, Bower P, Gilbody S, Richardson G. The accessibility and acceptability of self-management support interventions for men with long term conditions: a systematic review and meta-synthesis of qualitative studies. BMC Public Health 2014; 14:1230. [PMID: 25428230 PMCID: PMC4295235 DOI: 10.1186/1471-2458-14-1230] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2014] [Accepted: 11/18/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Self-management support interventions can improve health outcomes, but their impact is limited by the numbers of people able or willing to access them. Men's attendance at existing self-management support services appears suboptimal despite their increased risk of developing many of the most serious long term conditions. The aim of this review was to determine whether current self-management support interventions are acceptable and accessible to men with long term conditions, and explore what may act as facilitators and barriers to access of interventions and support activities. METHODS A systematic search for qualitative research was undertaken on CINAHL, EMBASE, MEDLINE, PsycINFO and Social Science Citation Index, in July 2013. Reference lists of relevant articles were also examined. Studies that used a qualitative design to explore men's experiences of, or perceptions towards, self-management support for one or more long term condition were included. Studies which focused on experiences of living with a long term condition without consideration of self-management support were excluded. Thirty-eight studies met the inclusion criteria. A meta-ethnography approach was employed to synthesise the findings. RESULTS Four constructs associated with men's experience of, and perceptions towards, self-management support were identified: 1) need for purpose; 2) trusted environments; 3) value of peers; and 4) becoming an expert. The synthesis showed that men may feel less comfortable participating in self-management support if it is viewed as incongruous with valued aspects of their identity, particularly when activities are perceived to challenge masculine ideals associated with independence, stoicism, and control. Men may find self-management support more attractive when it is perceived as action-oriented, having a clear purpose, and offering personally meaningful information and practical strategies that can be integrated into daily life. CONCLUSIONS Self-management support is most likely to be successful in engaging men when it is congruent with key aspects of their masculine identity. In order to overcome barriers to access and fully engage with interventions, some men may need self-management support interventions to be delivered in an environment that offers a sense of shared understanding, connectedness, and normality, and involves and/or is facilitated by men with a shared illness experience.
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Affiliation(s)
- Paul Galdas
- Department of Health Sciences, University of York, York YO10 5DD, UK.
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13
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Blakeman T, Blickem C, Kennedy A, Reeves D, Bower P, Gaffney H, Gardner C, Lee V, Jariwala P, Dawson S, Mossabir R, Brooks H, Richardson G, Spackman E, Vassilev I, Chew-Graham C, Rogers A. Effect of information and telephone-guided access to community support for people with chronic kidney disease: randomised controlled trial. PLoS One 2014; 9:e109135. [PMID: 25330169 PMCID: PMC4199782 DOI: 10.1371/journal.pone.0109135] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2014] [Accepted: 09/02/2014] [Indexed: 12/20/2022] Open
Abstract
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.
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Affiliation(s)
- Tom Blakeman
- NIHR Collaboration for Leadership in Applied Health Research (CLAHRC) Greater Manchester, Centre for Primary Care, Institute of Population Health, University of Manchester, Manchester, United Kingdom
| | - Christian Blickem
- NIHR Collaboration for Leadership in Applied Health Research (CLAHRC) Greater Manchester, Centre for Primary Care, Institute of Population Health, University of Manchester, Manchester, United Kingdom
| | - Anne Kennedy
- NIHR CLAHRC Wessex, Health Sciences, University of Southampton, Highfield Campus, Southampton, United Kingdom
| | - David Reeves
- NIHR Collaboration for Leadership in Applied Health Research (CLAHRC) Greater Manchester, Centre for Primary Care, Institute of Population Health, University of Manchester, Manchester, United Kingdom
| | - Peter Bower
- NIHR School for Primary Care Research, Centre for Primary Care, Institute of Population Health, University of Manchester, Manchester, United Kingdom
| | - Hannah Gaffney
- NIHR Collaboration for Leadership in Applied Health Research (CLAHRC) Greater Manchester, Centre for Primary Care, Institute of Population Health, University of Manchester, Manchester, United Kingdom
| | - Caroline Gardner
- NIHR School for Primary Care Research, Centre for Primary Care, Institute of Population Health, University of Manchester, Manchester, United Kingdom
| | - Victoria Lee
- NIHR School for Primary Care Research, Centre for Primary Care, Institute of Population Health, University of Manchester, Manchester, United Kingdom
| | - Praksha Jariwala
- NIHR Collaboration for Leadership in Applied Health Research (CLAHRC) Greater Manchester, Centre for Primary Care, Institute of Population Health, University of Manchester, Manchester, United Kingdom
| | - Shoba Dawson
- NIHR Collaboration for Leadership in Applied Health Research (CLAHRC) Greater Manchester, Centre for Primary Care, Institute of Population Health, University of Manchester, Manchester, United Kingdom
| | - Rahena Mossabir
- NIHR Collaboration for Leadership in Applied Health Research (CLAHRC) Greater Manchester, Centre for Primary Care, Institute of Population Health, University of Manchester, Manchester, United Kingdom
| | - Helen Brooks
- NIHR Collaboration for Leadership in Applied Health Research (CLAHRC) Greater Manchester, Centre for Primary Care, Institute of Population Health, University of Manchester, Manchester, United Kingdom
| | - Gerry Richardson
- Centre for Health Economics, University of York, Heslington, York, United Kingdom
| | - Eldon Spackman
- Centre for Health Economics, University of York, Heslington, York, United Kingdom
| | - Ivaylo Vassilev
- NIHR CLAHRC Wessex, Health Sciences, University of Southampton, Highfield Campus, Southampton, United Kingdom
| | - Carolyn Chew-Graham
- Primary Care & Health Services, University of Keele, Staffordshire, United Kingdom
| | - Anne Rogers
- NIHR CLAHRC Wessex, Health Sciences, University of Southampton, Highfield Campus, Southampton, United Kingdom
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14
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Blickem C, Kennedy A, Jariwala P, Morris R, Bowen R, Vassilev I, Brooks H, Blakeman T, Rogers A. 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. BMC Health Serv Res 2014; 14:262. [PMID: 24938492 PMCID: PMC4071856 DOI: 10.1186/1472-6963-14-262] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2013] [Accepted: 06/10/2014] [Indexed: 11/10/2022] Open
Abstract
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.
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Affiliation(s)
- Christian Blickem
- NIHR Collaboration for Leadership in Applied Health Research and Care (CLAHRC) Greater Manchester, Centre for Primary Care, Institute of Population Health, University of Manchester, Oxford Road, Manchester M13 9PL, UK.
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15
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Reeves D, Blickem C, Vassilev I, Brooks H, Kennedy A, Richardson G, Rogers A. The contribution of social networks to the health and self-management of patients with long-term conditions: a longitudinal study. PLoS One 2014; 9:e98340. [PMID: 24887107 PMCID: PMC4041782 DOI: 10.1371/journal.pone.0098340] [Citation(s) in RCA: 134] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2013] [Accepted: 05/01/2014] [Indexed: 11/29/2022] Open
Abstract
UNLABELLED 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.
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Affiliation(s)
- David Reeves
- National Institute for Health Research Collaboration for Leadership in Applied Health Research (NIHR CLAHRC) Greater Manchester, Centre for Primary Care, Institute of Population Health, University of Manchester, Manchester, United Kingdom
| | - Christian Blickem
- National Institute for Health Research Collaboration for Leadership in Applied Health Research (NIHR CLAHRC) Greater Manchester, Centre for Primary Care, Institute of Population Health, University of Manchester, Manchester, United Kingdom
| | - Ivaylo Vassilev
- National Institute for Health Research Collaboration for Leadership in Applied Health Research (NIHR CLAHRC) Wessex, Faculty of Health Sciences, University of Southampton, Southampton, United Kingdom
| | - Helen Brooks
- School of Nursing, Midwifery and Social Work, University of Manchester, Manchester, United Kingdom
| | - Anne Kennedy
- National Institute for Health Research Collaboration for Leadership in Applied Health Research (NIHR CLAHRC) Wessex, Faculty of Health Sciences, University of Southampton, Southampton, United Kingdom
| | - Gerry Richardson
- Centre for Health Economics and NIHR Research Design Service for Yorkshire and the Humber, University of York, York, United Kingdom
| | - Anne Rogers
- National Institute for Health Research Collaboration for Leadership in Applied Health Research (NIHR CLAHRC) Wessex, Faculty of Health Sciences, University of Southampton, Southampton, United Kingdom
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Rogers A, Brooks H, Vassilev I, Kennedy A, Blickem C, Reeves D. Why less may be more: a mixed methods study of the work and relatedness of 'weak ties' in supporting long-term condition self-management. Implement Sci 2014; 9:19. [PMID: 24524253 PMCID: PMC3932842 DOI: 10.1186/1748-5908-9-19] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2013] [Accepted: 02/10/2014] [Indexed: 11/18/2022] Open
Abstract
Background The distribution of the roles and responsibilities of long-term condition management (LTCM) outside of formal health services implicates a wide set of relationships and activities of involvement. Yet, compared to studies of professional implementation, patient systems of implementation remain under-investigated. The aim of this paper is to explore the work, meaning and function attributed to ‘weaker’ ties relative to other more bonding relationships in order to identify the place of these within a context of systems of support for long-term conditions. Methods This is a mixed methods survey with nested qualitative study. A total of 300 people from deprived areas in the North West of England with chronic illnesses took part in a survey conducted in 2010 to 2011. A concentric circles diagram was used as a research tool with which participants identified 2,544 network members who contributed to illness management. Notions of ‘work’ were used to describe activities associated with chronic illness and to identify how weaker ties are included and perceived to be involved through social network members (SNM) contributions. Results The results provide an articulation of how SNMs are substantially involved in weak tie illness management. Weaker ties constituted 16.1% of network membership involved in illness work. The amount of work undertaken was similar but less than that of stronger ties. Weaker ties appeared more durable and less liable to loss over time than stronger ties. The qualitative accounts suggested that weak ties enabled the moral positioning of the self-managing ‘self’ and acted on the basis of a strong sense of reciprocity. Conclusions Weak ties act as an acceptable bridge between a sense of personal agency and control and the need for external support because it is possible to construct a sense of moral acceptability through reciprocal exchange. Access to weak tie resources needs to be taken into account when considering the ways in which systems of health implementation for chronic illness are designed and delivered.
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Affiliation(s)
- Anne Rogers
- NIHR CLAHRC Wessex, Faculty of Health Sciences, University of Southampton Building 67, Highfield Campus, University Road, S017 1BJ Hampshire, UK.
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Kennedy A, Rogers A, Blickem C, Daker-White G, Bowen R. Developing cartoons for long-term condition self-management information. BMC Health Serv Res 2014; 14:60. [PMID: 24507692 PMCID: PMC3945740 DOI: 10.1186/1472-6963-14-60] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2013] [Accepted: 02/05/2014] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Advocating the need to adopt more self-management policies has brought with it an increasing demand for information about living with and making decisions about long-term conditions, with a significant potential for using cartoons. However, the purposeful use of cartoons is notably absent in many areas of health care as is evidence of their acceptability to patients and lay others. This paper outlines the process used to develop and evaluate cartoons and their acceptability for a series of self-management guidebooks for people with inflammatory bowel disease, irritable bowel syndrome, diabetes, chronic obstructive pulmonary disease and chronic kidney disease (CKD). METHODS Principles for a process to develop information and cartoons were developed. Cartoon topics were created using qualitative research methods to obtain lay views and experiences. The CKD guidebook was used to provide a detailed exemplar of the process. Focus group and trial participants were recruited from primary care CKD registers. The book was part of a trial intervention; selected participants evaluated the cartoons during in-depth interviews which incorporated think-aloud methods. RESULTS In general, the cartoons developed by this process depict patient experiences, common situations, daily management dilemmas, making decisions and choices and the uncertainties associated with conditions. CKD cartoons were developed following two focus groups around the themes of getting a diagnosis; understanding the problem; feeling that facts were being withheld; and setting priorities. Think-aloud interviews with 27 trial participants found the CKD cartoons invoked amusement, recognition and reflection but were sometimes difficult to interpret. CONCLUSION Humour is frequently utilised by people with long-term conditions to help adjustment and coping. Cartoons can help provide clarity and understanding and could address concerns related to health literacy. Using cartoons to engage and motivate people is a consideration untapped by conventional theories with the potential to improve information to support self-management.
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Affiliation(s)
- Anne Kennedy
- Faculty of Health Sciences, NIHR CLAHRC Wessex, University of Southampton, Southampton, UK
| | - Anne Rogers
- Faculty of Health Sciences, NIHR CLAHRC Wessex, University of Southampton, Southampton, UK
| | - Christian Blickem
- Centre for Primary Care, Institute of Population Health, University of Manchester, Manchester, UK
| | - Gavin Daker-White
- NIHR Greater Manchester Primary Care Patient Safety Translational Research Centre, University of Manchester, Manchester, UK
| | - Robert Bowen
- Centre for Primary Care, Institute of Population Health, University of Manchester, Manchester, UK
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Patel NR, Kennedy A, Blickem C, Rogers A, Reeves D, Chew-Graham C. Having diabetes and having to fast: a qualitative study of British Muslims with diabetes. Health Expect 2014; 18:1698-708. [PMID: 24438123 DOI: 10.1111/hex.12163] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/13/2013] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND There are approximately 2.7 million Muslims in the UK, constituting 4.8% of the population. It is estimated that 325,000 UK Muslims have diabetes. Whilst dietary practices of Muslims with diabetes have been explored, little work has described the beliefs and decisions to fast during Ramadan, whereby Muslims with diabetes refrain from eating, drinking and taking medication between sunrise and sunset. OBJECTIVE To explore beliefs and experiences of fasting during Ramadan of Muslim respondents with diabetes and their perceptions of the role played by their general practitioner (GP) and/or practice nurse (PN) in supporting them. DESIGN Qualitative study. SETTING General practices and community groups located in Greater Manchester. PARTICIPANTS 23 South Asian Muslims. METHODS Semi-structured interviews were conducted as part of the Collaboration of Applied Health Research and Care (CLAHRC) programme, Greater Manchester. Respondents were recruited using random and purposive sampling techniques. Interviews were analysed thematically using a constant comparison approach. RESULTS Thirteen respondents reported they fasted and altered diabetes medication and diet during Ramadan. The decision to fast was influenced by pressures from the family and the collective social aspect of fasting, and respondents made limited contact with primary care during fasting. CONCLUSION Tensions exist between the respondent's personal desire to fast or not fast and their family's opinion on the matter, with a strong reluctance to disclose fasting to GP and/or PN. Future research needs to explore whether GPs or PNs feel competent enough to support patients who wish to fast.
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Affiliation(s)
- Neesha R Patel
- Centre for Primary Care, Institute of Population Health, University of Manchester, Manchester, UK
| | - Anne Kennedy
- Health Services Research, Faculty of Health Sciences, University of Southampton, Southampton, UK
| | - Christian Blickem
- Centre for Primary Care, Institute of Population Health, University of Manchester, Manchester, UK
| | - Anne Rogers
- Health Systems Implementation, Health Services Research, Faculty of Health Sciences, University of Southampton, Southampton, UK
| | - David Reeves
- Centre for Primary Care, Institute of Population Health, University of Manchester, Manchester, UK
| | - Carolyn Chew-Graham
- General Practice Research, Primary Care Sciences, Research Institute: Primary Care and Health Sciences, Keele University, Keele, Staffordshire, UK
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Small N, Blickem C, Blakeman T, Panagioti M, Chew-Graham CA, Bower P. Telephone based self-management support by 'lay health workers' and 'peer support workers' to prevent and manage vascular diseases: a systematic review and meta-analysis. BMC Health Serv Res 2013; 13:533. [PMID: 24370214 PMCID: PMC3880982 DOI: 10.1186/1472-6963-13-533] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2013] [Accepted: 12/10/2013] [Indexed: 11/13/2022] Open
Abstract
Background Improved prevention and management of vascular disease is a global priority. Non-health care professionals (such as, ‘lay health workers’ and ‘peer support workers’) are increasingly being used to offer telephone support alongside that offered by conventional services, to reach disadvantaged populations and to provide more efficient delivery of care. However, questions remain over the impact of such interventions, particularly on a wider range of vascular related conditions (such as, chronic kidney disease), and it is unclear how different types of telephone support impact on outcome. This study assessed the evidence on the effectiveness and cost-effectiveness of telephone self-management interventions led by ‘lay health workers’ and ‘peer support workers’ for patients with vascular disease and long-term conditions associated with vascular disease. Methods Systematic review of randomised controlled trials. Three electronic databases were searched. Two authors independently extracted data according to the Cochrane risk of bias tool. Random effects meta-analysis was used to pool outcome measures. Results Ten studies were included, primarily based in community settings in the United States; with participants who had diabetes; and used ‘peer support workers’ that shared characteristics with patients. The included studies were generally rated at risk of bias, as many methodological criteria were rated as ‘unclear’ because of a lack of information. Overall, peer telephone support was associated with small but significant improvements in self-management behaviour (SMD = 0.19, 95% CI 0.05 to 0.33, I2 = 20.4%) and significant reductions in HbA1c level (SMD = -0.26, 95% CI −0.41 to −0.11, I2 = 47.6%). There was no significant effect on mental health quality of life (SMD = 0.03, 95% CI −0.12 to 0.18, I2 = 0%). Data on health care utilisation were very limited and no studies reported cost effectiveness analyses. Conclusions Positive effects were found for telephone self-management interventions via ‘lay workers’ and ‘peer support workers’ for patients on diabetes control and self-management outcomes, but the overall evidence base was limited in scope and quality. Well designed trials assessing non-healthcare professional delivered telephone support for the prevention and management of vascular disease are needed to identify the content of effective components on health outcomes, and to assess cost effectiveness, to determine if such interventions are potentially useful alternatives to professionally delivered care.
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Affiliation(s)
- Nicola Small
- Greater Manchester Collaboration for Leadership in Applied Health Research and Care, Centre for Primary Care, and Manchester Academic Health Science Centre, University of Manchester, Manchester, UK.
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Blickem C, Kennedy A, Vassilev I, Morris R, Brooks H, Jariwala P, Blakeman T, Rogers A. Linking people with long-term health conditions to healthy community activities: development of Patient-Led Assessment for Network Support (PLANS). Health Expect 2013; 16:e48-59. [PMID: 23731452 PMCID: PMC3908360 DOI: 10.1111/hex.12088] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/01/2013] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE To combine insights from service users with long-term conditions (LTCs) to assist the development of a community referral intervention designed to promote engagement and improve access to health-relevant resources. BACKGROUND Social deprivation and reduced access to resources have been causally linked with social isolation and the ability to manage LTCs. Participation in meaningful activity has been associated with positive health benefits, and strategies to promote access to community activities have shown some potential to improve outcomes for people with LTCs. This suggests the need to develop an engagement and referral intervention in partnership with service users and community groups as part of mainstream self-care support. METHOD A series of focus groups and interviews with members of community groups in Greater Manchester designed as an iterative and collaborative approach to elicit the role of personal and community networks that support long-term condition management (LTCM) to develop a community referral tool. RESULTS Participants reported a broad range of resources relevant to LTCM that often went beyond the usual concerns associated with self-care. This helped to inform a tool (PLANS) to tailor access to types of community-based resources which can support LTCM. CONCLUSIONS Understanding the everyday challenges of living with a LTC highlighted the importance of connecting and engaging with localized support for people. In response to this, we developed an intervention (PLANS) which tailors access to local resources based on personal preferences, needs and acceptability to encourage service users to engage with sustainable health choices.
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Affiliation(s)
- Christian Blickem
- Centre for Primary Care, Institute of Population Health, University of Manchester, Manchester, UK.
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Vassilev I, Rogers A, Blickem C, Brooks H, Kapadia D, Kennedy A, Sanders C, Kirk S, Reeves D. Social networks, the 'work' and work force of chronic illness self-management: a survey analysis of personal communities. PLoS One 2013; 8:e59723. [PMID: 23565162 PMCID: PMC3615067 DOI: 10.1371/journal.pone.0059723] [Citation(s) in RCA: 121] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2012] [Accepted: 02/17/2013] [Indexed: 11/18/2022] Open
Abstract
Self-management support forms a central aspect of chronic Illness management nationally and globally. Evidence for the success of self-management support has mainly focussed on individually-centred outcomes of behavioural change. While it is recognised that social network members play an important role there is currently a gap in knowledge regarding who provides what type of support and under what circumstances. This is relevant for understanding the division of labour and the meeting of needs for those living with a long-term condition. We therefore took a network approach to explore self-management support conceptualising it as types of illness ‘work’ undertaken within peoples’ social networks. 300 people from deprived areas and with chronic illnesses took part in a survey conducted in 2010 in the North West of England. A concentric circles diagram was used as a research tool with which participants identified 2,544 network members who contributed to illness management. The results provide an articulation of how social network members are substantially involved in illness management. Whilst partners and close family make the highest contributions there is evidence of inputs from a wide range of relationships. Network member characteristics (type of relationship, proximity, frequency of contact) impact on the amount of illness work undertaken in peoples’ networks. In networks with ‘no partner’ other people tend to contribute more in the way of illness related work than in networks with a partner. This indicates a degree of substitutability between differently constituted networks, and that the level and type of input by different members of a network might change according to circumstances. A network perspective offers an opportunity to redress the balance of an exclusively individual focus on self-management because it addresses the broader set of contributions and resources available to people in need of chronic illness management and support.
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Affiliation(s)
- Ivaylo Vassilev
- Centre for Primary Care, Institute of Population Health, Collaboration for Leadership in Applied Health Research (CLAHRC), The University of Manchester, Manchester, United Kingdom.
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Blickem C, Blakeman T, Kennedy A, Bower P, Reeves D, Gardner C, Lee V, Chew-Graham C, Richardson G, Brooks H, Dawson S, Mossabir R, Jariwala P, Swallow A, Kontopantelis E, Gaffney H, Small N, Spackman E, Rogers A. The clinical and cost-effectiveness of the BRinging Information and Guided Help Together (BRIGHT) intervention for the self-management support of people with stage 3 chronic kidney disease in primary care: study protocol for a randomized controlled trial. Trials 2013; 14:28. [PMID: 23356861 PMCID: PMC3599273 DOI: 10.1186/1745-6215-14-28] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2012] [Accepted: 01/11/2013] [Indexed: 12/31/2022] Open
Abstract
Background Improving the quality of care for people with vascular disease is a key priority. Chronic kidney disease (CKD) has recently been included as a target condition for general practices to add to registers of chronic conditions as part of the Quality and Outcome Framework. This paper outlines the implementation and evaluation of a self-management intervention involving an information guidebook, tailored access to local resources and telephone support for people with stage 3 chronic kidney disease. Methods/Design The study involves a multi-site, longitudinal patient-level randomized controlled trial. The study will evaluate the clinical use and cost-effectiveness of a complex self-management intervention for people with stage 3 chronic kidney disease in terms of self-management capacity, health-related quality of life and blood pressure control compared to care as usual. We describe the methods of the patient-level randomized controlled trial. Discussion The management of chronic kidney disease is a developing area of research. The BRinging Information and Guided Help Together (BRIGHT) trial aims to provide evidence that a complementary package of support for people with vascular disease that targets both clinical and social need broadens the opportunities of self-management support by addressing problems related to social disadvantage. Trial registration Trial registration reference: ISRCTN45433299
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Affiliation(s)
- Christian Blickem
- Centre for Primary Care, Institute of Population Health, University of Manchester, Oxford Road, Manchester M13 9PL, UK.
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Blickem C, Bower P, Protheroe J, Kennedy A, Vassilev I, Sanders C, Kirk S, Chew-Graham C, Rogers A. The role of information in supporting self-care in vascular conditions: a conceptual and empirical review. Health Soc Care Community 2011; 19:449-459. [PMID: 21158998 DOI: 10.1111/j.1365-2524.2010.00975.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Self-care has the potential to make a significant contribution to vascular conditions, but engagement with self-care support has been limited. Lack of relevant information is highlighted by patients and policy-makers as an important barrier to effective self-care, and information provides a potentially efficient platform for changing behaviour. However, work within the social sciences has generally seen information as a necessary but insufficient driver of health behaviours. Furthermore, some groups (such as the socially disadvantaged) are expected to be less amenable to information interventions. We conducted an integrated conceptual and empirical review on information-based interventions for people with vascular disease (diabetes, heart disease and kidney disease). We reviewed conceptual and empirical work concerning the role and impact of information in self-care support to generate an explanatory framework to determine why information was effective or ineffective in encouraging self-care in patients with vascular conditions. This involved mapping relevant theories and models linking information and self-care. We also explored published systematic reviews of educational interventions in diabetes, coronary heart disease and chronic kidney disease to examine the role of information and evidence concerning its effectiveness and impact in different patient populations. The conceptual review identified variation among information interventions in terms of type, function, and their relationship to behaviour change techniques and psychological mediators of behaviour change. Key moderators of the effect of information included types of disorder, and patient capacity and resources. A wealth of educational interventions exists for diabetes and heart conditions, but the precise components of these interventions that are effective are difficult to identify. There is little evidence concerning optimal ways of tailoring interventions for socially disadvantaged groups other than ethnic minorities. A focus on printed information may not provide access to effective methods of information delivery (e.g. tailored information, use of narratives and user generated content). Developing a framework for the effective use of information needs to take account the full range of the factors identified.
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Affiliation(s)
- Christian Blickem
- NIHR Collaboration for Leadership in Applied Health Research (CLARHC) for Greater Manchester, Health Sciences Research Group, The University of Manchester, Manchester, UK.
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Rogers A, Vassilev I, Sanders C, Kirk S, Chew-Graham C, Kennedy A, Protheroe J, Bower P, Blickem C, Reeves D, Kapadia D, Brooks H, Fullwood C, Richardson G. Social networks, work and network-based resources for the management of long-term conditions: a framework and study protocol for developing self-care support. Implement Sci 2011; 6:56. [PMID: 21619695 PMCID: PMC3120720 DOI: 10.1186/1748-5908-6-56] [Citation(s) in RCA: 96] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2011] [Accepted: 05/29/2011] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Increasing the effective targeting and promotion of self-care support for long-term conditions requires more of a focus on patient contexts and networks. The aim of this paper is to describe how within a programme of research and implementation, social networks are viewed as being centrally involved in the mobilisation and deployment of resources in the management of a chronic condition. This forms the basis of a novel approach to understanding, designing, and implementing new forms of self-management support. METHODS Drawing on evidence syntheses about social networks and capital and the role of information in self-management, we build on four conceptual approaches to inform the design of our research on the implementation of self-care support for people with long-term conditions. Our approach takes into consideration the form and content of social networks, notions of chronic illness work, normalisation process theory (NPT), and the whole systems informing self-management engagement (WISE) approach to self-care support. DISCUSSION The translation and implementation of a self-care agenda in contemporary health and social context needs to acknowledge and incorporate the resources and networks operating in patients' domestic and social environments and everyday lives. The latter compliments the focus on healthcare settings for developing and delivering self-care support by viewing communities and networks, as well as people suffering from long-term conditions, as a key means of support for managing long-term conditions. By focusing on patient work and social-network provision, our aim is to open up a second frontier in implementation research, to translate knowledge into better chronic illness management, and to shift the emphasis towards support that takes place outside formal health services.
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Affiliation(s)
- Anne Rogers
- Health Sciences Research Group, and Collaboration for Leadership in Applied Health Research and Care (CLAHRC) for Greater Manchester, School for Community Based Medicine, University of Manchester, Manchester, UK
| | - Ivaylo Vassilev
- Health Sciences Research Group, and Collaboration for Leadership in Applied Health Research and Care (CLAHRC) for Greater Manchester, School for Community Based Medicine, University of Manchester, Manchester, UK
| | - Caroline Sanders
- Health Sciences Research Group, and Collaboration for Leadership in Applied Health Research and Care (CLAHRC) for Greater Manchester, School for Community Based Medicine, University of Manchester, Manchester, UK
| | - Susan Kirk
- Health Sciences Research Group, and Collaboration for Leadership in Applied Health Research and Care (CLAHRC) for Greater Manchester, School for Community Based Medicine, University of Manchester, Manchester, UK
| | - Carolyn Chew-Graham
- Health Sciences Research Group, and Collaboration for Leadership in Applied Health Research and Care (CLAHRC) for Greater Manchester, School for Community Based Medicine, University of Manchester, Manchester, UK
| | - Anne Kennedy
- Health Sciences Research Group, and Collaboration for Leadership in Applied Health Research and Care (CLAHRC) for Greater Manchester, School for Community Based Medicine, University of Manchester, Manchester, UK
| | - Joanne Protheroe
- Health Sciences Research Group, and Collaboration for Leadership in Applied Health Research and Care (CLAHRC) for Greater Manchester, School for Community Based Medicine, University of Manchester, Manchester, UK
| | - Peter Bower
- Health Sciences Research Group, and Collaboration for Leadership in Applied Health Research and Care (CLAHRC) for Greater Manchester, School for Community Based Medicine, University of Manchester, Manchester, UK
| | - Christian Blickem
- Health Sciences Research Group, and Collaboration for Leadership in Applied Health Research and Care (CLAHRC) for Greater Manchester, School for Community Based Medicine, University of Manchester, Manchester, UK
| | - David Reeves
- Health Sciences Research Group, and Collaboration for Leadership in Applied Health Research and Care (CLAHRC) for Greater Manchester, School for Community Based Medicine, University of Manchester, Manchester, UK
| | - Dharmi Kapadia
- Health Sciences Research Group, and Collaboration for Leadership in Applied Health Research and Care (CLAHRC) for Greater Manchester, School for Community Based Medicine, University of Manchester, Manchester, UK
| | - Helen Brooks
- Health Sciences Research Group, and Collaboration for Leadership in Applied Health Research and Care (CLAHRC) for Greater Manchester, School for Community Based Medicine, University of Manchester, Manchester, UK
| | - Catherine Fullwood
- Health Sciences Research Group, and Collaboration for Leadership in Applied Health Research and Care (CLAHRC) for Greater Manchester, School for Community Based Medicine, University of Manchester, Manchester, UK
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Vassilev I, Rogers A, Sanders C, Kennedy A, Blickem C, Protheroe J, Bower P, Kirk S, Chew-Graham C, Morris R. Social networks, social capital and chronic illness self-management: a realist review. Chronic Illn 2011; 7:60-86. [PMID: 20921033 DOI: 10.1177/1742395310383338] [Citation(s) in RCA: 150] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
BACKGROUND Existing literature on the design of interventions and health policy about self-management have tended to focus on individual-centred definitions of self-care and there is growing recognition of the need to extend consideration beyond individual factors, which determine self-care, to examine wider influences such as the health service, the family and the wider social context. AIMS To explore the theoretical and empirical links between social networks, social capital and the self-care practices associated with chronic illness work and management in the context of people's everyday lives. METHOD A realist review method was used to search and appraise relevant quantitative and qualitative literature. FINDINGS The review findings indicate that social networks play an important part in the management of long-term conditions. We found that social networks tend to be defined narrowly and are primarily used as a way of acknowledging the significance of context. There is insufficient discussion in the literature of the specific types of networks that support or undermine self-care as well as an understanding of the processes involved. This necessitates shifting the emphasis of self-care towards community and network-centred approaches, which may also prove more appropriate for engaging people in socially and economically deprived contexts.
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Affiliation(s)
- Ivaylo Vassilev
- Health Sciences Research Group-Primary Care, School of Community Based Medicine, University of Manchester, UK.
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