Sarah Francesca Maria Bigi

Analyzing the Pragmatic Structure of Dialogues

In this article, we describe the notion of dialogue move intended as the minimal unit for the analysis of dialogues. We propose an approach to discourse analysis based on the pragmatic idea that the joint dialogical intentions are also co-constructed through the individual moves and the higher-order communicative intentions that the interlocutors pursue. In this view, our goal is to bring to light the pragmatic structure of a dialogue as a complex net of dialogical goals (such as persuasion, deliberation, information-sharing, etc.), which represent the communicative purposes that the interlocutors intend to achieve through their utterances. Dialogue moves are shown to represent the necessary interpretive link between the general description of the dialogical context or type and the syntactical analysis of the sentences expressed by the individual utterances. In the concluding part of this article, we show how this method can be used and further developed for analyzing various types of real-life dialogues, outlining possible uses and lines of empirical research based thereon.

Understanding Misunderstandings. Presuppositions and Presumptions in Doctor-Patient Chronic Care Consultations

Abstract Pragmatic presupposition is analyzed as grounded on an implicit reasoning process based on a set of presumptions, which can define cultural differences. The basic condition for presupposing a proposition is represented as a reasoning criterion, namely reasonableness. Presuppositions, on this view, need to be reasonable, namely they need to be the reasonable conclusions of an underlying presumptive reasoning, which does not or may not contain contradictions with other presumptions. Presumptions are in turn analyzed considering their nature and their hierarchy, namely their subject matter and their possible contextual backing, which eliminates some of their possible defaults. This analysis of presupposition brings to light the relationship between misunderstandings deriving from presuppositional failures and the underlying system of presumptions. This approach is applied to the investigation of communicative issues within the medical context, and more precisely doctor-patient communication in diabetes cases.

Fertilizing a patient engagement ecosystem to innovate healthcare: Toward the first Italian Consensus conference on patient engagement

Currently we observe a gap between theory and practices of patient engagement. If both scholars and health practitioners do agree on the urgency to realize patient engagement, no shared guidelines exist so far to orient clinical practice. Despite a supportive policy context, progress to achieve greater patient engagement is patchy and slow and often concentrated at the level of policy regulation without dialoguing with practitioners from the clinical field as well as patients and families. Though individual clinicians, care teams and health organizations may be interested and deeply committed to engage patients and family members in the medical course, they may lack clarity about how to achieve this goal. This contributes to a wide “system” inertia—really difficult to be overcome—and put at risk any form of innovation in this filed. As a result, patient engagement risk today to be a buzz words, rather than a real guidance for practice. To make the field clearer, we promoted an Italian Consensus Conference on Patient Engagement (ICCPE) in order to set the ground for drafting recommendations for the provision of effective patient engagement interventions. The ICCPE will conclude in June 2017. This document reports on the preliminary phases of this process. In the paper, we advise the importance of “fertilizing a patient engagement ecosystem”: an oversimplifying approach to patient engagement promotion appears the result of a common illusion. Patient “disengagement” is a symptom that needs a more holistic and complex approach to solve its underlined causes. Preliminary principles to promote a patient engagement ecosystem are provided in the paper.

Healthy Reasoning: The Role of Effective Argumentation for Enhancing Elderly Patients' Self-management Abilities in Chronic Care

One of the biggest challenges for doctors working in chronic care is the correct management of the argumentation phases during the encounters with their patients. During these phases doctors should provide patients with acceptable reasons for being adherent to treatment and for changing certain unhealthy behaviors and lifestyles, something which is particularly difficult for elderly patients, for whom changing life long habits can be extremely hard. However, the medical literature on the subject of communication in the chronic care encounter shows lack of theoretical models and methodological approaches that can highlight which specific linguistic structures or elements in different communication styles favor or impede patient commitment, trust in the relationship and adherence to treatment. The contribution describes ongoing research on argumentative strategies in the encounter with diabetes patients. I describe one recently concluded research project on the argumentation phases of medical encounters in diabetes care, which highlighted critical areas in need of improvement. I also describe the design and aims of a new research project, aimed at testing the effectiveness and usability of certain argumentation schemes in the medical encounter.

Weak Educational Components in mHealth Devices for Diabetes Support Available on the Italian Market

On the frontier between technology, psychology, and the behavioral sciences, the research field of positive technology studies the kinds of technological devices that can impact individuals’ well-being and the way they do so. In a way, mHealth can be considered as a subset of positive technology in that it aims at supporting “individuals in reaching engaging and self-actualizing experiences.” In spite of this potential, there remain a few open questions as to the effectiveness of the mHealth devices currently on offer. We report the results of a review of apps for diabetes patients on offer for the Italian-speaking public. Apps were identified by conducting a search in the Google Play Store (for the Android mobile operating system) and Apple App Store (for the IOS mobile operating system) during October 2015. We have considered 140 apps on the Google Play Store (GPS) and 73 apps on the Apple App Store (AAS). The smaller number of apps considered for IOS users probably depends on different inclusion criteria adopted by the 2 stores. Of the 180 rejected apps, 53.5% do not have an Italian-language user interface (67% for Android category and 25% for IOS category), 21.7% are paid apps (15% for Android category and 35% for IOS category), and 13.9% are not apps designed for the task of diabetes self-management (12.5% for Android category and 16.7% for IOS category). The total number of eligible apps is 20 for the GPS and 13 for the AAS, of which 16 are duplicate apps and have thus been left out. Overall, the final selection is of 17 apps (of which just 3 apps are available on both stores). The 17 selected apps resulting from our selection have been analyzed by looking at how they are structured as regards the educational level. International reviews have already underlined the lack of educational contents in the majority of mobile applications worldwide. Our review confirms this result also for Italy. In considering which of the apps’ functionalities to include in the category “educational,” we have decided to include those functions designated to offer information aimed at improving self-awareness and autonomy of patients regarding their disease. In particular, we have regarded education as a composite category and we have analyzed apps with reference to 6 subcategories: decision support (8 apps feature this function; 47%), messages (8 apps feature this function; 47%), contents (2 apps feature this function; 11.8%), visual aids (16 apps feature this function; 94.1%), goal setting (3 apps feature this function; 17.6%), social sharing (3 apps feature this function; 17.6%). Our analysis of the educational functionalities reveals an underlying idea of education that is mostly limited to the transmission of information. For example, when we paid attention to the linguistic structure of the messages used by the apps we observed that all messages evaluated are used to provide alerts or reminders. We never found messages used as instruments for critical thinking to foster self-awareness and autonomy. This exemplification suggests that the educational functionalities included in the reviewed apps did not take into account more comprehensive conceptions of education, which include the ability to process and interpret information, allowing users to then act on it. Based on these observations, we are planning to design and test a new mobile app for diabetes support for the Italian market. By working in particular on the visual aids, goal setting functions and messages functions included in the app, we are designing messages encouraging critical thinking that are based on the theoretical assumptions derived from the use of a cognitive-argumentative model of verbal communication. To verify the efficacy of our assumptions regarding the effectiveness of the messages featured in this application, we will test a prototype with type 2 diabetes patients in 2 hospitals in Italy. Further interventions devoted to assessing the role of different educational functions to improve diabetes self-management are necessary.

Communication Skills for Patient Engagement: Argumentation Competencies As Means to Prevent or Limit Reactance Arousal, with an Example from the Italian Healthcare System

The paper discusses the role of argumentative competencies for the achievement of patient engagement through communication in doctor-patient consultations. The achievement of patient engagement is being proposed by recent studies as a condition that can facilitate in particular patient adherence, which involves behavior change. One obstacle to behavior change that has been observed is reactance, i.e., resistance to persuasive messages when a threat to freedom is perceived. In the medical field, reactance theory has been mostly applied in the field of mental health, less frequently to understand non-adherence in general. However, a few studies have revealed that reactance can actually explain in part the motives behind non-adherence. These studies propose that the arousal of reactance could be limited or prevented by adopting relational measures aimed at giving patients the feeling that they still hold some control over the process of care and that the “impositions” on their freedoms are acceptable because they have had the opportunity to decide about them. However, they do not discuss how these strategies should be operationalized at the dialogical level. A debated issue in the study of reactance is the role played by knowledge. It seems that pure information regarding an issue is likely to represent a threat in itself. Complementary to this is the finding that quality of argument does not impact on the degree of reactance. These findings pose a problem in view of the goal of patient education, itself considered as a necessary premise for any process of patient engagement and adherence. It seems necessary to move away from a conception of education as mere transmission of information and look for more effective ways of transferring knowledge to patients. With regard to this issue, the paper argues that useful insights can be found in studies on science education, in which it is shown experimentally that argumentative processes favor learning and understanding. Drawing on previous studies and taking an interdisciplinary perspective on the issue, the paper brings into the discussion on engagement concepts developed in the field of argumentation theory, showing how the suggestions for avoiding reactance could be realized dialogically.

Types of Dialogue and Pragmatic Ambiguity

The purpose of this chapter is twofold. On the one hand, our goal is theoretical, as we aim at providing an instrument for detecting, analyzing, and solving ambiguities based on the reasoning mechanism underlying interpretation. To this purpose, combining the insights from pragmatics and argumentation theory, we represent the background assumptions driving an interpretation as presumptions. Presumptions are then investigated as the backbone of the argumentative reasoning that is used to assess and solve ambiguities and drive (theoretically) interpretive mechanisms. On the other hand, our goal is practical. By analyzing ambiguities as stemming from different presumptions concerning language or, more importantly, expected communicative roles and goals, we can use communicative misunderstandings as the signal of deeper disagreements concerning mutual expectations or cultural differences. This argumentation-based interpretive mechanism will be applied to the analysis of medical interviews in the area of diabetes care, and will be used to bring to light the sources of misunderstanding and the different presumptions that define distinct cultures. We will consequently illustrate the analytical tools by identifying and distinguishing the various types of ambiguity underlying misunderstandings, and we will address them by describing the communicative intentions ascribed to the ambiguous utterances.

The ActiveAgeing Mobile App for Diabetes Self-management: First Adherence Data and Analysis of Patients’ in-App Notes

The up-to-date treatment of diabetes often includes the adoption of technology (eHealth) to support patients’ self-management. This contribution features first data on patients’ usage of ActiveAgeing, a mobile app supporting daily self-management. Over 6 months, 15 elderly patients with type 2 diabetes (T2D) and 11 young women with gestational diabetes mellitus (GDM) received daily reminders to perform treatment activities, registered capillary glucose within the app, and added personal notes to explain abnormal values. While no differences emerged between the groups’ glucose registrations, T2D patients were more likely to add notes. Sentiment analysis with the software Watson on T2D patients’ notes and some selected notes are reported. Discussion highlights that notes may be used not only to explain abnormal data, but also to express emotions and confide personal information. eHealth presents opportunities not only for self-management, but also to empower and enrich trust between patients and health providers.