Fiona Brooks

The Expert Patients Programme: a paradox of patient empowerment and medical dominance

Self-care is seen as a key element in managing resource demand in chronic disease and is also perceived as an empowering right for patients. The Chronic Disease Self-Management Programme developed in the USA has been adopted in a number of countries and in the UK has been as adapted as the Expert Patients Programme. However, despite its potential as a lay-led empowering initiative, the Expert Patients Programme has been criticised as perpetuating the medical model and failing to reach those in most need. This paper revisits a critique of the Expert Patients Programme, and drawing upon a qualitative study seeks to explore whether the Expert Patients Programme enables empowerment or replicates traditional patterns of the patient–professional relationship. A grounded-theory approach was adopted utilising focus groups, in-depth interviews and participant observation. Data were analysed through the constant comparative method and the development of codes and categories. Conducted in the relatively affluent area of the south-east of England, this paper draws on data from 66 individuals with a chronic illness who were knowledgeable, active and informed. The study revealed a number of characteristics common to expert patients that were linked to a systematic, proactive and organised approach to self-management, a clear communication style and the ability to compartmentalise emotion. The study included participant observation of an Expert Patients Programme and a professional-led self-management course. The paradoxical nature of the Expert Patients Programme was revealed, for whilst there was evidence that it reinforced the medical paradigm, there was a concurrent acknowledgement and support for the subjective experience of living with a long-term condition. Furthermore, whilst the policy emphasis has been on individual empowerment within the Expert Patients Programme, there is some evidence that it may be triggering a health consumer movement.

Adolescent multiple risk behaviour: an asset approach to the role of family, school and community

BACKGROUND Engagement in risk behaviours may pose a significant threat to health if involvement spans multiple behaviours. The asset model suggests that contextual aspects of young peoples lives, such as factors related to family, school and community, serve as a protective function against health risk behaviours. METHODS A risk-taking index was created from the English health behaviour in school-aged children study on 15 years olds, substance use and sexual activity. Using a multinomial regression, potential asset variables relating to school, family, peers, community and family affluence were tested for their association with levels of risk behaviours. RESULTS Sense of neighbourhood belonging, strong school belonging and parental involvement in decision-making about leisure time were related to lower engagement in health risk behaviours. A weaker sense of family belonging was associated with increased risk behaviours if connectedness with teachers was also low. Factors related to school and community played a greater role in adolescent participation in health-related risk behaviours than family-related factors, including family affluence. CONCLUSIONS Feelings of safety and belonging in the out-of-home settings of adolescents were positively associated with reduced risk behaviours, and indicate the importance of the wider community alongside parents and school as protective assets for health.

Sustaining a positive body image in adolescence: an assets-based analysis

The increasing impetus to provide an effective response to childhood obesity has generated a corresponding concern that weight management interventions may lead to emotional problems among young people, notably in relation to the development of a negative body image. However, currently the processes and factors that contribute to the acquisition of body image among young people is poorly understood. Drawing on salutogenic theory, this paper employs an assets-based approach that focuses on health promoting and protective factors to identify how young people may create or sustain positive body images. Secondary data analysis was undertaken from the WHO Health Behaviour in School Aged Children Study. During the spring term of 2002, information was collected from 6425 English adolescents aged 11-15 using a self-administered questionnaire. The data were analysed using stepwise multinomial logistic regression to determine which factors were associated with positive body image; a total of 2898 students were included in the final analysis. Adolescents who self-identified as having a positive body image were more likely to report ease of talking with a father figure, feeling intelligent, perceiving that their family were well off and a belief that their teachers were interested in them as people. Body Mass Index, age, gender and living within a household containing a father were also significant predictors of body image. The discussion provides an exploration of how the construction of young peoples emotional health is in part linked with the attainment of a secure and positive body image. The implications for health promotion and educational programmes are then examined. By considering the assets, which support or sustain a positive body image during adolescence, obesity prevention programmes could be better tailored to meet the needs of young people. In the future, a salutogenic curriculum might provide an alternative to unsustainable levels of deficit led, targeted programmes.

Trends and socioeconomic correlates of adolescent physical fighting in 30 countries

BACKGROUND AND OBJECTIVES: No recent international studies provide evidence about its prevalence, trends, or social determinants of physical fighting in adolescents. We studied cross-national epidemiologic trends over time in the occurrence of frequent physical fighting, demographic variations in reported trends, and national wealth and income inequality as correlates. METHODS: Cross-sectional surveys were administered in school settings in 2002, 2006, and 2010. Participants (N = 493874) included eligible and consenting students aged 11, 13, and 15 years in sampled schools from 30 mainly European and North American countries. Individual measures included engagement in frequent physical fighting, age, gender, participation in multiple risk behaviors, victimization by bullying, and family affluence. Contextual measures included national income inequality, absolute wealth and homicide rates. Temporal measure was survey cycle (year). RESULTS: Frequent physical fighting declined over time in 19 (63%) of 30 countries (from descriptive then multiple Poisson regression analyses). Contextual measures of absolute wealth (relative risk 0.96, 95% confidence interval 0.93–0.99 per 1 SD increase in gross domestic product per capita) but not income inequality (relative risk 1.01, 95% confidence interval 0.98–1.05 per 1 SD increase) related to lower levels of engagement in fighting. Other risk factors identified were male gender, younger age (11 years), multiple risk behaviors, victimization by bullying, and national homicide rates. CONCLUSIONS: Between 2002 and 2010, adolescent physical fighting declined in most countries. Specific groups of adolescents require targeted violence reduction programs. Possible determinants responsible for the observed declines are discussed.

Physical activity as leisure: the meaning of physical activity for the health and well-being of adolescent women.

Globally, low participation in physical activity by adolescent young women is a major health concern. While the barriers to activity for this group are well documented, little is known about the views and experiences of nonathlete, but active, young women. In order to gain an understanding of young womens lived experiences of the relationship between physical activity as leisure and health, data were collected through focus groups. Active nonathlete young women in the United Kingdom attached significant meaning to physical activity as a space for leisure, and used it to enhance their health and well-being.

Women in general practice: responding to the sexual division of labour?

This paper provides an exploration of the gendered nature of the working experience of women within a high status and predominantly male dominated medical specialty, that of general practice or primary care physician. Women currently represent just over a third of all general practitioners in the U.K. and their numbers have been increasing. Women now account for 60% of new recruits into general practice. Despite this increase, consideration of the experience and role of women within medicine has largely focused on hospital medicine. The findings presented are derived from a three year project, that aimed to develop an understanding of the role women health workers play in the U.K. in the construction and provision of primary health care services for women. The methods employed consisted of a series of postal surveys and qualitative interviews conducted with GPs, female nurses and women service users. The first section of the discussion provides an exploration of the nature and impact of the sexual division of labour within general practice and the resulting occupational marginalisation of women GPs. Attention is given to identifying the key processes whereby the sexual division of labour is maintained and reproduced, particularly through the normative expectations of colleagues, patients and women GPs themselves. The final section presents a typology of the differing strategies the sampled women GPs adopted for managing their working roles in response to the existence of a sexual division of labour. The conclusion highlights the possible impact of the differing strategies upon the functioning of women within general practice and their relationship with women users of the service.

Success and failure in integrated models of nursing for long term conditions: Multiple case studies of whole systems

BACKGROUND Current projections indicate that the UK faces a 252% increase in people aged over 65 with one or more long term conditions (LTC) by 2050. Nurses, managing their own caseloads and clinics, working across sectors and organisational boundaries and as part of a wider multi-disciplinary team, are frequently seen as key to managing this growing demand. However, the evidence base informing the nursing role in managing LTC, the most effective configuration of the multi-disciplinary team and the policy evidence relating to the infrastructure required to support cross organisational working, remains weak. OBJECTIVES To explore, identify and characterise the origins, processes and outcomes of effective chronic disease management models and the nursing contributions to such models. DESIGN Case study whole systems analysis using qualitative interview methods. SETTINGS Two community matron services, two primary care (GP) practice nursing services, two hospital based specialist nursing services were purposefully sampled from across England and Wales. PARTICIPANTS Selection criteria were derived using a consensus conference. The nurses in the service, all patients and carers on the caseload, members of the multi-disciplinary team and stakeholders were invited to participate. METHODS Semi-structured interviews with all participants, thematic analysis within a whole system framework. RESULTS The study found high levels of clinical nursing expertise which in the case of the community matrons was meeting the aim of reducing hospital admissions. Both the primary care and hospital nurse specialist indicate similar levels of clinical expertise which was highly valued by medical colleagues and patients. Patients continued to experience fragmented care determined by diagnostic categories rather than patient need and by the specific remit of the clinic or service the patient was using. Patient data systems are still organised around the impact on services and prevalence of disease at an individual level and not around the patient experience of disease. CONCLUSION Nurses are making a major contribution to meeting the policy objectives for long term conditions. Primary care nurses and hospital nurse specialists do broadly similar roles. The scope of the nursing roles and services studied were idiosyncratic, opportunistic and reactive, rather than planned and commissioned on an analysis of local population need.

Making sense of assets: what can an assets based approach offer public health?

Editorial. The concept for this special section of the journal arose from the Second International Symposium on Health Assets in a Global Context: Theory Methods Action, London (2011), a two day event designed to consider the translation of the asset model into policy, research and practise. The purpose of this special section is to further explore what we know and what needs to be done to develop an assets evidence base for public health.

Subjective well-being in adolescence and teacher connectedness: A health asset analysis

Objectives: Teacher connectedness is an important factor for young people’s well-being. The aim of this paper was to examine teacher connectedness in detail and its potential association with emotional well-being. More specifically, we set out to analyse whether teacher connectedness acted as a universal asset for boys and girls of different ages and countries as well as across adolescents with differing perceptions of their performance at school. Methods: The study sample consisted of 9,444 young people aged 11, 13 and 15 years who had taken part in the World Health Organization (WHO) collaborative survey Health Behaviour in School-aged Children in Spain and England. After examining differences in teacher connectedness associated with demographic factors, we used general linear models to analyse the relationship between teacher connectedness and emotional well-being (including interaction teacher connectedness by country) across different age and performance-derived groups. Results: Results indicated some significant differences in teacher connectedness associated with age, country and perceived performance, but a consistent positive association between teacher connectedness and emotional well-being regardless of demographic factors, country and perceptions of school performance. Older adolescents and low achievers reported lower level of connectedness to their teachers, but the association between teacher connectedness and emotional well-being operated irrespective of adolescents’ age and perceived performance at school. Conclusion: Results support the perspective that teacher connectedness can act as a significant health asset that operates irrespective of key demographic factors, while they point to some inequalities in teacher connectedness associated with age and performance at school. These findings have significant implications for health promotion interventions.

Trends in adolescents' perceived parental communication across 32 countries in Europe and North America from 2002 to 2010

BACKGROUND The quality of communication with parents is a determinant of health and well-being during adolescence, being predictive of self-esteem, self-rated health and the ability to navigate health risk behaviours. METHODS This article describes trends in adolescents (aged 11, 13 and 15 years) perception of communication with mothers and fathers by gender across 32 European and North American countries from 2002 to 2010. Analyses were performed on 425 699 records employing a General Linear Model (MANOVA). RESULTS In most countries, significant increases in the prevalence of ease of communication with both mothers and fathers were observed, with the greatest positive changes over time in Estonia, Denmark and Wales. In some countries, the opposite trend was found with the greatest negative changes occurring in France, Slovenia and Poland. Across the pooled dataset, a significant positive trend was observed for ease of communication with father, for both boys and girls and for ease of communication with mother for boys only. CONCLUSION The temporal trends demonstrated an increase in a positive health asset for many young people, that of family communication. Positive trends may be a feature of the economic boom over the past decade coupled with cultural changes in attitudes to parenting, especially fathering.