Adjudications and tinkering with care for socially vulnerable patients with type 2 diabetes in general practice.

OBJECTIVE: To analyse the mechanisms at play in the adjudications made by professionals and socially vulnerable patients with type 2 diabetes about their eligibility for care. DESIGN, SETTING AND SUBJECTS: The study included 14 patients and 10 health professionals in seven general practice surgeries in deprived areas in Greater Copenhagen. The study data consist of 17 semi-structured interviews with patients and 22 with health professionals immediately after observation of 23 consultations. Our analytical approach was inspired by Systematic Text Condensation and the concept of 'candidacy' for access to health care. RESULTS: Adjudications of patients not being candidates for services were common, but we also found that both patients and health professionals worked to align the services to the needs of the patients. This could include using services differently than was intended by the providers or by changing routines to make it easier for patients to use the services. We discuss these processes as 'tinkering'. This usually implies that the best individual solution for the patient is aimed for, and in this study, the best solution sometimes meant not focusing on diabetes. CONCLUSION: The study adds to existing knowledge about access to services for socially vulnerable patients by demonstrating that both patients and professionals in general practice engage in tinkering processes to make services work.

Unequal use and benefits of health services play a significant role in relation to social inequality in healthFlexibility in services and alternatives to school-like rehabilitation are needed to reduce inequality in access to health carePatients were sometimes judged as unsuitable for available routine services, but professionals 'tinkered' with services to make them fitAdaptation of services by professionals in general practice implies a longer time frame for obtaining goals.

Pharmacokinetics and safety of prolonged paracetamol treatment in neonates: An interventional cohort study.

AIMS: To investigate the pharmacokinetics and safety of prolonged paracetamol use (>72 h) for neonatal pain. METHODS: Neonates were included if they received paracetamol orally or intravenously for pain treatment. A total of 126 samples were collected. Alanine aminotransferase and bilirubin were measured as surrogate liver safety markers. Paracetamol and metabolites were measured in plasma. Pharmacokinetic parameters for the parent compound were estimated with a nonlinear mixed-effects model. RESULTS: Forty-eight neonates were enrolled (38 received paracetamol for >72 h). Median gestational age was 38 weeks (range 25-42), and bodyweight at inclusion was 2954 g (range 713-4750). Neonates received 16 doses (range 4-55) over 4.1 days (range 1-13.8). The median (range) dose was 10.1 mg/kg (2.9-20.3). The median oxidative metabolite concentration was 14.6 µmol/L (range 0.12-113.5) and measurable >30 h after dose. There was no significant difference (P > .05) between alanine aminotransferase and bilirubin measures at <72 h or >72 h of paracetamol treatment or the start and end of the study. Volume of distribution and paracetamol clearance for a 2.81-kg neonate were 2.99 L (% residual standard error = 8, 95% confidence interval 2.44-3.55) and 0.497 L/h (% residual standard error = 7, 95% confidence interval 0.425-0.570), respectively. Median steady-state concentration from the parent model was 50.3 µmol/L (range 30.6-92.5), and the half-life was 3.55 h (range 2.41-5.65). CONCLUSION: Our study did not provide evidence of paracetamol-induced liver injury nor changes in metabolism in prolonged paracetamol administration in neonates.

Involving supermarkets in health promotion interventions in the Danish Project SoL. A practice-oriented qualitative study on the engagement of supermarket staff and managers.

BACKGROUND: Supermarkets have been suggested as relevant settings for environmental and educational initiatives encouraging healthier shopping and eating decisions, but in the literature, limited attention has been paid to the context, perspectives, and everyday practices of supermarket staff. The aim of this study was to examine the engagement of supermarket staff in a health promotion project from a practice-oriented perspective. METHODS: The study was based on qualitative data collected in the supermarket setting of Project SoL; a community-based health promotion project in Denmark. We conducted 26 in-depth interviews with store managers and other key staff members in seven participating supermarkets. In addition, we collected data on planning, implementation, and perceptions of supermarket staff of in-store interventions and other project-related activities. These field data included short telephone interviews, observational notes, photos, and audiotapes of meetings. Data were analysed from the perspective of practice theory. RESULTS: Although supermarket staff found community-based health promotion meaningful to engage in, the study observed that their engagement was challenged by a business mindset, practical routines and structural requirements favouring sales promotion over health promotion. Nevertheless, there were also examples of how health promotion activities and ways of thinking were successfully incorporated in everyday staff practices during and after Project SoL. CONCLUSIONS: Our findings point to both potentials and challenges for using supermarkets as settings for health promotion. The voluntary engagement of supermarket staff in community-based health projects cannot stand alone but should be supplemented by more long-lasting strategies and policies regulating this and other food environments. Context-sensitive and practice-oriented analyses in local food environments could inform such strategies and policies to make sure they target unwanted elements and practices and not just individual behavior.

Integrated Mental Healthcare and Vocational Rehabilitation for People on Sick Leave with Anxiety or Depression: 24-Month Follow-up of the Randomized IBBIS Trial.

Integration of vocational rehabilitation and mental healthcare has shown some effect on work participation at 1-year follow-up after sick leave with depression and anxiety. We aimed to study the effect on work and health outcomes at 2-year follow-up, why we performed a randomized trial was conducted to study the effectiveness of integrated intervention (INT) compared to service as usual (SAU) and best practice mental healthcare (MHC). We included 631 participants, and at 24-month follow-up, we detected no differences in effect between INT and SAU. Compared to MHC, INT showed faster return-to-work (RTW) rates (p = 0.044) and a higher number of weeks in work (p = 0.024). No symptom differences were observed between the groups at 24 months. In conclusion, compared to SAU, INT was associated with a slightly higher work rate reaching borderline statistical significance at 12-month follow-up and lower stress levels at 6-month follow-up. The disappearance of relative effect between 12 and 24 months may be explained by the fact that the intervention lasted less than 12 months or by delayed spontaneous remission in the SAU group after 12 months. Despite the lack of effect at long-term follow-up, INT still performed slightly better than SAU overall. Moderate implementation difficulties, may partly explain the absence of the hypothesized effect. Integrated intervention, as implemented in this trial, showed some positive effects on mid-term vocational status and short-term stress symptom levels. However, these effects were not sustained beyond the duration of the intervention.

Coupling S-adenosylmethionine-dependent methylation to growth: Design and uses.

We present a selection design that couples S-adenosylmethionine-dependent methylation to growth. We demonstrate its use in improving the enzyme activities of not only N-type and O-type methyltransferases by 2-fold but also an acetyltransferase of another enzyme category when linked to a methylation pathway in Escherichia coli using adaptive laboratory evolution. We also demonstrate its application for drug discovery using a catechol O-methyltransferase and its inhibitors entacapone and tolcapone. Implementation of this design in Saccharomyces cerevisiae is also demonstrated.

Challenges and lessons learnt from conducting a health survey in an ethnically diverse population.

Aim: To document the challenges of developing and executing an interviewer-driven survey questionnaire in an ethnically diverse and deprived social housing area undergoing reconstruction in Denmark. Methods: The survey was initially planned to be conducted in three waves (before, during and after reconstruction of the housing area), based on a questionnaire covering health, wellbeing and social relations. The first two waves took place in 2018 and 2019 (invited n=~600 per wave) and the third wave will be conducted once the reconstruction is finalised. The approach to the third wave is under revision by the research team. The questionnaire was translated from Danish into the seven most common languages in the housing area. A bilingual interview team went door to door interviewing residents. Field notes were collected systematically during each wave to document the process. Results: The response rates were 35% (n=209) and 22% (n=132) for waves 1 and 2, respectively. There was an overall decrease in response rates between waves 1 and 2 for all language groups, but particularly for Arabic and Turkish-speaking men. The most frequently stated reasons for non-participation included illness and language barriers. The key lessons learnt were that overcoming linguistic and cultural barriers to conducting research among residents in this social housing area requires time and resources. Conclusions: Several challenges are associated with conducting a survey in ethnically diverse and deprived social housing areas. Documenting the challenges and learning from experience are both important, in order to include this hard-to-reach population in health research.

Social relations and contact with general practitioner in a middle-aged Danish population: a prospective register- and survey-based cohort study.

BACKGROUND: Findings about the relationship between individuals' social relations and general practitioner (GP) contact are ambiguous as to whether weak social relations are associated with an increased or decreased consultation pattern. Furthermore, social relations may affect GP contact differently for men compared to women, between socioeconomic groups and according to perceived need. The overall aim of the study is to examine the association between functional aspects of social relations, perceived emotional and instrumental social support, the tendency to consult a GP and the frequency of GP contact. METHODS: The study comprised 6911 individuals aged 49-61 at baseline from the Copenhagen Aging and Midlife Biobank (CAMB). We conducted a two-part regression to explore the association between perceived emotional and instrumental social support and GP contact (tendency and frequency), controlling for age, sex, occupational social class, cohabitation status and number of morbidities. RESULTS: Results show no overall effect of the perceived social support aspects of social relations on GP contact independent of health-related needs. CONCLUSIONS: Our results do not support that perceived social support, reflecting functional aspects of social relations, are associated with general practitioner contact among middle-aged people. TRIAL REGISTRATION: The study has been registered and approved by the Danish Data Protection Agency and the local ethical committee (approval No.H-A-2008-126 and No. 2013-41-1814).

Physical and psychosocial work factors as explanations for social inequalities in self-rated health.

OBJECTIVE: We investigated the contribution of physical and psychosocial work factors to social inequalities in self-rated health (SRH) in a sample of Danish 40 and 50 years old occupationally active women and men. METHODS: In this longitudinal study, the study population consisted of 3338 Danish women and men. Data were collected by postal questionnaires in 2000 (baseline) and 2006 (follow-up). The independent variable, socioeconomic position (SEP), was assessed by the highest achieved educational level at baseline. We conducted gender-stratified parallel multiple mediation analyses. In the mediation analyses, SEP was categorised as SEP I, II, III, VI and V among men. Among women, SEP was dichotomised into SEP I-IV and V. The outcome, SRH, was assessed at baseline and follow-up. A wide range of physical and psychosocial work factors were included as potential mediators. RESULTS: We found a social gradient in SRH across all levels of SEP among men. Among women, we only found a poorer SRH among those with the lowest SEP. Mediation analyses showed that work factors together accounted for 56% of the social inequalities in SRH among men and 44% among women. In both genders, ergonomic exposures and job insecurity seemed to play the major role for social inequalities in SRH. For women only, we also found noise to contribute to the social inequalities in SRH. CONCLUSION: Physical and psychosocial work factors partially explained social inequalities in SRH among both genders. Improvement of the working environment can potentially contribute to the reduction of social inequalities in health.

Disability pension among persons with chronic disease: Differential impact of a Danish policy reform.

BACKGROUND: In 2013, Denmark implemented a reform that tightened the criteria for disability pension, expanded a subsidized job scheme ('flexi-job') and introduced a new vocational rehabilitation scheme. The overall aim of the reform was to keep more persons attached to the labour market. This study investigates the impact of the reform among persons with chronic disease and whether this impact differed across groups defined by labour market affiliation and chronic disease type. METHODS: The study was conducted as a register-based, nationwide cohort study. The study population included 480 809 persons between 40 and 64 years of age, who suffered from at least one of six chronic diseases. Hazard ratios (HR) and 95% confidence intervals (CI) of being awarded disability pension or flexi-job in the 5 years after vs. the 5 years prior to the reform were estimated. RESULTS: Overall, the probability of being awarded disability pension was halved after the reform (HR = 0.49, CI: 0.47-0.50). The impact was largest for persons receiving sickness absence benefits (HR = 0.31, CI: 0.24-0.39) and for persons with functional disorders (HR = 0.38, CI: 0.32-0.44). Also, the impact was larger for persons working in manual jobs than for persons working in non-manual jobs. The probability of being awarded a flexi-job was decreased by one-fourth (HR = 0.76, CI: 0.74-0.79) with the largest impact for high-skilled persons working in non-manual jobs. CONCLUSION: Access to disability pension and flexi-job decreased after the reform. This impact varied according to labour market affiliation and chronic disease type.

Adjusting health care: practicing care for socially vulnerable type 2 diabetes patients.

BACKGROUND: Type 2 diabetes cluster in lower social groups and people with type 2 diabetes from lower social groups experience more complications, benefit less from health services and live shorter lives than people with type 2 diabetes from higher social groups. Different logics govern diabetes care and potentially influence the possibility of socially vulnerable type 2 diabetes patients to access and benefit from health services. In order to understand which practice and underlying logic enable socially vulnerable type 2 diabetes patients to access and benefit from diabetes care we aim to describe what professionals at a specialized diabetes clinic do to adjust services to patient's needs and make the tasks involved in diabetes care doable for socially vulnerable patients and how this work is embedded in an organizational and moral context. METHODS: Ethnographic fieldwork combining participant observation and interviews was carried out between February 2017 and March 2018 in a specialized diabetes clinic located in a socially deprived area in the capital region of Denmark. Sixteen patients (9 male, 7 female, aged 35-73 years) and 12 professionals (7 doctors, 4 nurses, 1 secretary) participated in the study. We used Annemarie Mol's concept of "the logic of care" to guide our analysis. RESULTS: Our analysis shows that the logic of care and the care practices in this clinic are characterized by a needs-based approach to treatment involving adjustment of services (permeability, timing, and content) and seeing the patient as a person with many needs. Throughout our description of selected care practices, we both characterize how health professionals practice this particular logic of care and the organizational and normative conditions that this logic is entangled with. CONCLUSIONS: Practicing diabetes care based on patients' needs involves individualization, something often described as an element of patient centred care. Our study shows that this ideal of individualization and adjustment of treatment is possible in practice. Organizational flexibility and an organizational culture that values patient needs enable needs-based care. In order for socially vulnerable type 2 diabetes patients to benefit from health services it is necessary to create conditions under which professionals can attend to these patients' multiple and complex needs. Adjusting care to these needs demand a variety of professional efforts some of which are hardly predictable or standardisable.

Conflicting Logics in a Changing Action Space: Challenges Related to Type 1 Diabetes in Work Life.

Well-being at work is important to quality of life. However, reconciling work and diabetes management is often challenging; failing to do so threatens the well-being of people with type 1 diabetes (T1D). We explored the mechanisms underlying diabetes-specific challenges at work using theories of logics, involvement, and action space. Thematic analyses of two data sets, consisting of interviews with adults with T1D (n = 22) showed that people with T1D experience a conflict between two logics linked to diabetes and work, owing to the contradictory demands of work life and diabetes management. Individuals' ability to lower the priority of work tasks-shifting them from their main to a side involvement so as to properly manage T1D-helps resolve the conflict, as does being able to create an enabling action space for diabetes management at work. These insights can inform interventions targeting the well-being of workers with T1D.

"It Is a Full-time Job to Be Ill": Patient Work Involved in Attending Formal Diabetes Care Among Socially Vulnerable Danish Type 2 Diabetes Patients.

Previous research has shown social inequality in type 2 diabetes prevalence and that socially vulnerable type 2 diabetes patients benefit less than average from health services. Based on ethnographic fieldwork carried out between February 2017 and March 2018 in a Danish specialized outpatient clinic, this article focuses on patient work among socially vulnerable type 2 diabetes patients. Through attending to the border zone between formal health care and self-care, we show that patients do a lot of work requiring skills, resources, and initiative, to access and benefit from formal care. This work is complex and implicit in the organization of care. Patients' social situations, especially their employment situation, complicate getting patient work done. Attending to patient work and implicit tasks in care organization may help us to see how social inequality in type 2 diabetes outcomes develops, and may be combated.

Addressing ethnic disparity in antenatal care: a qualitative evaluation of midwives' experiences with the MAMAACT intervention.

BACKGROUND: In Denmark, 13% of all children are born by non-Western immigrant women. The public antenatal care has not adapted to this increased diversity of women. Compared to women coming from Western countries, non-Western immigrant women have an increased prevalence of severe maternal morbidity and higher risks of maternal death, stillbirth and infant death. Suboptimal care is a contributing factor to these ethnic disparities, and thus the provision of appropriate antenatal care services is pivotal to reducing these disparities and challenges to public health. Yet, little is known about the targeted interventions which have been developed to reduce these inequities in reproductive health. The MAMAACT intervention, which included a training course for midwives, a leaflet and a mobile application, as well as additional visit time, was developed and tested at a maternity ward to increase responses to pregnancy warning signs among midwives and non-Western immigrant women. AIM: To explore the feasibility and acceptability of the MAMAACT intervention among midwives and identify factors affecting midwives' delivery of the intervention. METHODS: Eight mini-group interviews with midwives (n = 18) were undertaken. Systematic text condensation was used to analyse data. RESULTS: Three main categories were identified, which were 'Challenges of working with non-Western immigrant women', 'Attitudes towards and use of the leaflet and mobile application', and 'Organisational factors affecting the use of the MAMAACT intervention'. CONCLUSIONS: The MAMAACT intervention was found to be feasible as well as acceptable among midwives. Women turning to relatives for pregnancy-related advice, time constraints during midwifery visits, incomplete clinical records and lack of professional interpreter assistance impacted midwives' delivery of the MAMAACT intervention. Midwives displayed a readiness for the MAMAACT intervention; however, there is a need to further examine how contextual factors may impact the use of the intervention in antenatal care. TRIAL REGISTRATION: ClinicalTrials.gov, Retrospective Registration (07/2/2020), registration number NCT04261400.

Intra-familial health polarisation: how diverse health concerns become barriers to health behaviour change in families with preschool children and emerging obesity.

In a disadvantaged rural area in Denmark, severe challenges have been identified concerning overweight and obesity in families with preschool-age children. The present paper examines how families with young children and emerging obesity issues perceive 'healthy living' and barriers to practising it. Using data from qualitative workshops with families and professionals working with them, we reveal health perceptions and related family dynamics. Drawing on P. Bourdieu's theory of habitus and 'tastes of necessity', K.L. Frohlich et al.'s notion of 'collective lifestyles' and E. Lindbladh and C. H. Lyttken's theory of preconditions for health behaviour change and reactions to risk-related information, we analyse how risk perceptions and related health practices within the families are influenced by the local contexts in the disadvantaged area under study. Despite shared perceptions of 'healthy living', we found that diverse health-risk perceptions created family dynamics in which parents performed opposed health behaviours, which became a huge barrier to becoming a healthier family. Based on our theoretical approach, we propose that risk perceptions and reactions are highly context dependent, as illustrated in both micro-contexts (family dynamics) and the macro-context (the disadvantaged area).

The joint effect of unemployment and cynical hostility on all-cause mortality: results from a prospective cohort study.

BACKGROUND: It is hypothesised that hostility accentuates the association between stressful conditions and health. This study aims to test this hypothesis by analysing the joint effect of unemployment and hostility on all-cause mortality among men and women. METHODS: The population was 3677 men and 4138 women from the Danish workforce who participated in a survey in 2000. The joint exposure variable was defined as 1) employed, not hostile, 2) unemployed, not hostile, 3) hostile and employed, 4) unemployed and hostile. Outcome was defined as all-cause mortality between 2000 and 2014. Data was analysed with Cox proportional hazards models with age as the underlying time scale. The interaction between unemployment and hostility was studied using the synergy index. RESULTS: Compared to employed non-hostile men, men who were both hostile and unemployed were at markedly higher risk of premature death with a hazard ratio (HR) of 3.19 (95% CI 2.22-4.69). A similar picture was found for hostile and unemployed women, with a HR of 1.97 (95% CI 1.24-3.12). However, the mortality in men and women exposed to both did not exceed what was expected from the combination of their individual effects. Hence, we did not find that hostility enhances the association between unemployment and all-cause mortality. CONCLUSION: Men and women exposed to both unemployment and hostility were at markedly high risk of premature mortality. However, this study did not support the hypothesis that the deleterious health effect of the combination of unemployment and hostility exceeds their individual effects.

Home care as reablement or enabling arrangements? An exploration of the precarious dependencies in living with functional decline.

The threat to welfare societies posed by population ageing has urged high-income countries to rethink the provision of social and healthcare services for the ageing population. One widely implemented policy solution is 'reablement': short-term home-based training programmes focusing on re-enabling older people to carry out activities of daily living independently. Drawing on empirical material from multisited ethnographic fieldwork of reablement practices in a Danish municipality we explore how the assumptions about independence embedded in the concept's linguistic parts - 're', 'able' and 'ment' - map onto lives characterised by functional decline. We find that home care applicants: (i) are often too deeply dependent on the capacities of others in order to have their independence restored; (ii) negotiate individual meanings of independence to maintain their identity as able human beings; and (iii) might possibly gain new capacities through reablement, yet these are not individual and stable achievements, but rather temporary effects of the care relations with eldercare professionals. Rather than reablement we, therefore, suggest the term 'enabling arrangements' as more appropriate for capturing independence as a distributed, negotiated and continuous accomplishment. Finally, we discuss the practical and ethical implications of this term.

Diversity in cancer care: exploring social categories in encounters between healthcare professionals and breast cancer patients.

BACKGROUND: The burden of breast cancer is a key challenge for women's health globally. Rehabilitation needs and strategies for living with long-term consequences of breast cancer and its treatment cannot be isolated from the social contexts of patients, including relationships with relatives and healthcare professionals. AIM: This study explores how healthcare professionals' categorisations engage with breast cancer patients' social identities in encounters about rehabilitation before hospital discharge. METHOD: We conducted a multiperspective case-based qualitative study at a Danish department of breast surgery, including participant observations and interviews with twelve patients and eight nurses. Data were analysed thematically using theories of categorisation and clinical encounters. Ethical considerations: The Danish Data Protection Agency approved the study (journal number 2012-41-0701). RESULTS: Interactions in clinical encounters are shaped by categorisations of patients' social identities in terms of social resources and ethnicity, and by the resource-constrained organisational context, with impact on the assessments of the patient's rehabilitation needs. CONCLUSIONS: There is a need for a greater focus on improving encounters between breast cancer patients and healthcare professionals to ensure that rehabilitation needs are accommodated for among diverse patient groups.

An expression tag toolbox for microbial production of membrane bound plant cytochromes P450.

Membrane-associated Cytochromes P450 (P450s) are one of the most important enzyme families for biosynthesis of plant-derived medicinal compounds. However, the hydrophobic nature of P450s makes their use in robust cell factories a challenge. Here, we explore a small library of N-terminal expression tag chimeras of the model plant P450 CYP79A1 in different Escherichia coli strains. Using a high-throughput screening platform based on C-terminal GFP fusions, we identify several highly expressing and robustly performing chimeric designs. Analysis of long-term cultures by flow cytometry showed homogeneous populations for some of the conditions. Three chimeric designs were chosen for a more complex combinatorial assembly of a multigene pathway consisting of two P450s and a redox partner. Cells expressing these recombinant enzymes catalyzed the conversion of the substrate to highly different ratios of the intermediate and the final product of the pathway. Finally, the effect of a robustly performing expression tag was explored with a library of 49 different P450s from medicinal plants and nearly half of these were improved in expression by more than twofold. The developed toolbox serves as a platform to tune P450 performance in microbial cells, thereby facilitating recombinant production of complex plant P450-derived biochemicals. Biotechnol. Bioeng. 2017;114: 751-760. © 2016 Wiley Periodicals, Inc.

De-bugging and maximizing plant cytochrome P450 production in Escherichia coli with C-terminal GFP fusions.

Cytochromes P450 (CYP) are attractive enzyme targets in biotechnology as they catalyze stereospecific C-hydroxylations of complex core skeletons at positions that typically are difficult to access by chemical synthesis. Membrane bound CYPs are involved in nearly all plant pathways leading to the formation of high-value compounds. In the present study, we systematically maximize the heterologous expression of six different plant-derived CYP genes in Escherichia coli, using a workflow based on C-terminal fusions to the green fluorescent protein. The six genes can be over-expressed in both K- and B-type E. coli strains using standard growth media. Furthermore, sequences encoding a small synthetic peptide and a small bacterial membrane anchor markedly enhance the expression of all six genes. For one of the CYPs, the length of the linker region between the predicted N-terminal transmembrane segment and the soluble domain is modified, in order to verify the importance of this region for enzymatic activity. The work describes how membrane bound CYPs are optimally produced in E. coli and thus adds this plant multi-membered key enzyme family to the toolbox for bacterial cell factory design.

Patients' perception of disease and experience with type 2 diabetes patient education in Denmark.

BACKGROUND: Patient education programmes for a range of chronic conditions are widely implemented, but studies have shown that not all participants benefit equally from the patient education programmes. AIM: To explore differences in how persons with diabetes experience diabetes-related patient education programmes. METHODS: Qualitative in-depth interviews were conducted with eleven participants 6 months after participation in patient education. Using thematic analysis, we identified three themes: programme elements, interactions between participants and the role of facilitators. We used Alonzo's theory of Everyday Illness Behaviour and reported restrictions in daily activities to categorise seven participants as 'healthy' and four as 'ill' and compare their experiences of patient education. RESULTS: Although all participants identified information on diet and exercise as the most beneficial programme element, healthy participants found this information easy to understand and apply to make healthy changes in their daily lives. Ill participants found the information difficult to understand and were much less likely to implement related changes. Healthy participants valued social interactions occurring during interactive programme components such as weigh-in sessions, physical exercise and cooking classes. In contrast, ill participants did not value these social interactions. Healthy participants also tended to view programme facilitators more positively. Regardless of disease status, participants found it motivating to compare their health status to that of participants they perceived as more ill than themselves. CONCLUSION: Patient education experiences differ according to self-perceived disease status. Programme facilitators should be sensitive to the possibility that participants who are more ill may be less likely to perceive patient education as beneficial and implement new behaviours. Knowledge about factors leading to differences in patient experiences of chronic disease self-management education programmes is essential for the development of programmes that benefit all patients. Future research should explore the value of programmes differentiated for participants with different levels of health.