Background
Methods
Overall study design
Participants and setting
Interview process
Vignette development/procedure
Variables | Variables in each vignette () indicates number of vignettes which included the variable | |
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Controlled variables | Age | 50–60 yrs (3 vignettes); 60–75 yrs (3) |
Gender | Male (3) Female (3) | |
Chronic conditions | All vignette patients had at least 3 of the following conditions: musculoskeletal pain/arthritis (6); type 2 diabetes (4); diabetic sequelae (2); mental health (4); gut/bowel (3); cardiovascular (3); respiratory (2) | |
Environmental variables | Income source | Age pension (2); disability pension (1); unemployed (2); part-time work (1) |
Family situation | Living with spouse (3—all 60 + yr); spouse and children (1); single parent (1); alone (1) | |
Housing | Rental (3); own home (2); mobile home (1) | |
Narrative (capacity) variables | These factors were distributed across the vignettes | |
Physical | Diabetes complications, blood sugar control, multiple surgeries, functional or mobility impairments | |
Personal | Mental health issues, motivation, memory | |
Social | Family proximity, carer demands, quality of family relationships, family stressors (e.g. substance use), socially engaged or isolated | |
Employment | Job loss, manual work history, self-employment, voluntary work, carer demands |
Analysis
Normalisation Process Theory (NPT) | Patient capacity (BREWS) | ||
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Coherence (Sense-making) | Understanding the condition and treatments, planning care, setting goals | (B) Biography | Reframing to create a meaningful life that includes illness and treatment |
Cognitive participation (Relationship work) | Obtaining support from family, friends and HCPs; managing difficulties in relationships | (R) Resource mobilisation | Access to, and ability to mobilise physical (energy, physical function); cognitive (literacy, memory); personal (resilience, self-efficacy); financial; and instrumental (time, transport etc.) resources |
Collective action (Enacting work) | Carrying out work – adhering to treatments, making lifestyle and psychological adjustments, attending appointments | (E) Environment | Healthcare and social environments that fit with healthcare needs without interfering with other priorities |
Reflexive monitoring (Appraisal) | Monitoring symptoms, reflecting on work undertaken and adjusting as necessary | (W) Work realisation | The experience of, and ability to normalise treatment workload as well as other life roles |
(S) Social functioning | Ability to socialise; practical social support; social acceptance of the patients’ CD and limitations; relations with HCPs |
Results
Participant and interview characteristics
Location | Site 1: 7 participants, Site 2: 5 participants |
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Gender | All female |
Age | 24–56 years, mean 41 years |
Profession | 2 nurses; 4 diabetes educators (all nurses); 3 occupational therapists; 1 physiotherapist; 1 exercise physiologist; 1 podiatrist |
Years since graduation | 1–34 years, mean 13 years |
Years in CDSM | 1–18 years, mean 9 years |
Specific postgraduate training in CDSM | 7/12 reported formal training in CDSM |
Reported typical patient population | Low socioeconomic status: blue-collar workers or healthcare card holders Age group: over 50 Chronic health conditions: Diabetes, COPD, cardiovascular disease, chronic pain, arthritis, anxiety/depression, obesity and multimorbidity |
Vignette validity
”they are so typical… both of them” (B4) “it sounds like one of my clients…” (S3).
Ability of HCPs to identify burden and capacity factors in vignettes
Vignette no | Key capacity issues in vignette | Issues discussed by at least 3 HCPs (each vignette was reviewed by 4 HCPs) |
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1 ‘Pete’ | Complex multimorbidity and functional impairment, housing situation, limited family support | Likely high treatment demands, difficult housing situation, ability to access healthcare, reduced family support |
2 ‘Angela’ | Insulin dependent diabetic, some carer responsibilities, good social support | Low income, ability to prioritise health due to carer demands, good social support, needs good support for diabetes management |
3 ‘Lyn’ | Poor diabetes control, poverty, carer demands, lack of social support, family dysfunction, mental health | Inability to prioritise health due to life demands, mental health, social isolation, financial stress, needs significant support from healthcare system but access may be difficult |
4 ‘Steve’ | Work demands/stress related to business, long history of depression, poor diabetes management | Financial stress, depression, prioritising work over health leading to escalating health issues |
5 ‘Mark’ | Rural/isolated location, functional impairments, poverty | Functional limitations for day to day tasks, social isolation, ability to access healthcare, housing security, financial stress, health literacy |
6 ‘Irene’ | Caring responsibilities, social isolation, pain-related functional limitations, anxiety | Carer responsibilities affecting ability to prioritise health, social isolation, ability to access healthcare services |
HCPs’ understanding of burden and capacity, as described by the Theory of Patient Capacity (BREWS) and Normalisation Process Theory (NPT)
Analysis of capacity
“… they haven't prioritised their own health for quite a while and they've just been working and putting food on the table … so sometimes there's some resistance to change … “(S3, V4)
“…they just think they're getting older and this is just normal… we just put up with it…” (B5, V6).
“…an acceptance of the situation and a hope for the future… understanding that you have this pain, the pain’s not going to go away but having hope that there [are] ways that you can manage it…” (S2, V5).
“…it's not just for 6 or 8 weeks but for a lifetime and that's a lot to take on board…” (S1, V3)
“…there's sort of no quick fix for them there's no we'll fix it with this …it’s you have a chronic disease it's going to be there for the rest of your life…” (B4)
Resource mobilisation
“…he is probably noticing his back pain more than his erratic sugar levels…for people that have chronic pain it is often hard to see past the pain…” (B2, V4)
“…I would imagine (the pain) would have an effect on all the other things that are happening… so that would probably be where I would imagine Mark would want to …is get to the bottom of the pain…” (S6, V5).
“…financially he is on Newstart and he is rurally isolated … there is going to be the fuel cost plus the financial cost of paying the gap payment to see any specialists…” (S1, V5)
“…they are on the age pension they may or may not have money difficulties… transport or services…” (S2, V6)
“…she has been on the pension for the past 10 years…she'll probably be under some financial stress…” (S7, V2)
“… for some people, there are some huge health issues that have kind of never been explained to them properly by any health professional…” (S1)
“…[to] have the confidence to ask the right questions that I need to ask for my health… for example why am I taking that medication how is it going to help… if that doesn't work what is next what's my next step so having that confidence…” (S4).
“…he's got a history of depression which is probably compounded now by all these other things…sometimes until that is dealt with they're not going to move forward with and they're not motivated to make the other changes…” (S3, V4).
“…when people have a lot of pain and then … that affects their mental health their ability to problem solve becomes quite impaired…” (S6, V5)
Environment
“… humans are about building relationships and that is in terms of your health relationships as well… you need to feel confident and comfortable with the healthcare professional that you are going to see…” (S5, V2).
“…trust and rapport… that really helps with self-management because they feel valued …that makes a big difference to the outcomes that the client has…” (S7)
“…I think a really big important one is the services that they have been engaged with in the past …if you've had a bad experience previously you are just likely to live with a bad health condition and not address it …” (S1, V5).
“…I think if she's got a lot going on in her life…it can be difficult to get people to worry about themselves when they are worrying about other people a lot…” (B1, V3)
“…he lives in a local caravan park which in my mind becomes relevant because of his living conditions… whether that is safe with his chronic back pain…” (B3, V1)
“…I would dare say that she probably puts other people's needs before her own and you know that will lead to a decline in her diabetes management …” (S5, V2)
“…he’s on Newstart…that system is just going to set him up to drive that pain even further because of the stress that will put him under…” (S6, V5)
Work Realisation
“…at the next session say how did you go with that … I'll say you did do well maybe we can build on that … that increases their capacity to do things because they can see the benefit of what they've done …” (S3).
Social Functioning
“…if we are talking about being socially isolated as well it's all that stuff drives people's mental health which will have an effect on his pain and vice versa…” (S6, V5)
“…how are those family connections and how does he feel about that… is he depressed or upset about that… is that going to affect his ability to look after his health…” (S5, V1)
Analysis of burden
Coherence
“…I’d guess number one is finding out if Mark has any idea about pain… you really can't manage that until you get a good understanding of what the condition is…” (S6, V5)
“…they don't have that knowledge so we have to provide that knowledge to them but then again it does become overwhelming the amount of knowledge that we are providing …” (S5)
“…a lot of people just give out brochures and things like that and expect people to read them but they don't they just go in the bin…” (B1)
“…it can be overwhelming for people to be told lots of different things by lots of different health professionals who are looking after lots of different things…” (S1)
Cognitive Participation
“…people who are seeing multiple specialists …sometimes people are just ticking a box they are going to an appointment at times they are not sure why they're there and they are too overburdened to actually take anything on board…” (S1, V4).
“…the issue is what we all like to do is send people off to 7 different Professionals and then that can be …that's where we lose them sometimes isn't it so that's an issue” (S6)
“…it's not so much the number of clients that we are seeing in a day it's the level of…like there's an awful lot of emotional energy that goes into our work…” (B4)
Collective action
“…things you can no longer do… you can no longer eat your time is not your own anymore because you have appointment after appointment after appointment at all different places … trying to keep up and manage your life around your health…” (B5).
“…lots of medications to take at home… things like exercise programs that people have to do at home …not being able to live the rest of your life because you’re always having to do things for your health…” (B1).
“…if you do a referral that's one thing but getting into that appointment or accessing the dietitian or the physio it's sometimes restricted and then they think oh what's the point I haven't got in so I won't bother…” (S3, V3).
“…some people just cannot afford the gap payments for psychologists…if you ask them to find $80 a fortnight some people just cannot afford that…” (B4)
“…not all services are in the same place and some services can change quickly depending on government funding…” (S4)
Reflexive monitoring
“…for Mark it's a case of … getting him to prioritise what would he like to achieve in life and then what would it take to get where he wants to be so what steps could we put in place…” (S1, V5).
“…you're not trying to solve all of their health issues …just if you can make one thing easier for them today sometimes that's a really important thing… and I think that is often missed… there [are] constant demands that the patient achieves everything all of the time and it is unrealistic … that if they can achieve something they should be really proud of that…” (B3).
Strategies to reduce burden and increase capacity, and barriers identified.
Building capacity
“…the psychosocial stuff in the background that makes it complex …the finance, the family situation, the culture, the language… all those additional things that are outside of the biomedical situation …” (S7).
“…they have numerous health conditions or a range of health conditions… their home situation they might have a complex family or socioeconomic status whether there is a range of barriers…” (B2)
“…a lot of it does come down to relationships with our clients and linking them into services that can help… link them in and sticking to what's important to a person…” (S2)
“…finances, finances, finances and finances… I think the vast majority of people that we see are surviving very few are thriving…” (S1)
“…oh god we just need more money… people with complex care needs need to be able to access things without having to pay a gap…” (B3)
“…one of the biggest challenges when their mental health is a long-standing mental health issue that has never been adequately addressed … sometimes we are seeing people and it has been 40 years…when that's been something that has driven a lot of their health concerns the whole time and trying to unpack that 40 years later is challenging…” (S6).
“…I think someone's mental health is going to be one of the most important things… if they're mentally not in a space that they feel that they can change or where they feel they are not in control then I think you're fighting a battle that is out of your control…” (S7).
Reducing Burden
Reducing burden | • Assistance with system navigation • Knowledge of available resources and greater access (waitlists, funding for equipment and social services) • Improved access to specialists and mental health services (telehealth, transport support, no gap payments, address waitlists and workforce). • Technology to improve service co-ordination (shared healthcare information plus time to read it) • Supportive HCPs who are patient-centred • Sustainable (long-term) service funding |
Increasing capacity | • Available income • Understanding their condition and the point of treatment, being confident in management • Acceptance of condition and recognition of the need to address it • Ability to prioritise health • Living in a healthy environment • Availability of services (home help, respite) • Having goals and a purpose • Early provision of services (before people become too disabled) • Good mental health • Good social relationships |
Both | • Established routine/integrating treatment into life, able to troubleshoot and prioritise • Manageable life demands (e.g. caring role) |
“…where there are multiple services if they are all in one place it helps to co-ordinate your care…” (S4)
“…there is a lot of jumping to and fro between various organisations as well…” (B5)
“…we have some clients who aren't eligible with home care packages but it really would be beneficial for them…so I think funding has a lot to do with it…” (B2)
“…it would be really nice if we had multiple access to multiple providers in one location that they could get into at one time…that would be nice… it's a bit pie in the sky…” (B3)
“…it's lovely that we have so many services but that just adds to the [feeling of] being overwhelmed really doesn't it…” (S6)
“…when I have had someone who has come in and they are complex it's not often that the general practitioner is all over it…I think that the GP can become overwhelmed in that scenario…” (S5)