Conflicting experiences of health and habitus in a poor urban neighbourhood: A Bourdieusian ethnography.

An ethnographic study of health and wellbeing was undertaken in a deprived urban neighbourhood in the UK Midlands. Drawing on Bourdieu's concepts of habitus, capital and field, we discerned three different, even conflicting, ways of understanding and acting on health: (i) older adults discussed their wellbeing in relation to the local context or field, walking the dog, helping at the community centre and visiting the off licence, (ii) young professionals and students who lived in the neighbourhood were oriented towards leisure facilities, career opportunities and supermarkets outside of the neighbourhood, disdaining local facilities and (iii) community activists and carers discussed health in terms of providing for others but not themselves. Bourdieu is frequently used in medical sociology to highlight how poor people's lifestyle is constrained by their habitus; we suggest paying more attention to its both enabling and differentiating contradictions as well as the constraints it entails. Empirically and in terms of health promotion findings suggest that supposedly healthy activities, such as going to the gym, may also be a means of rejecting the local community; similarly, older people's pottering about in the neighbourhood, which is not usually recognised as a healthy activity, may enhance wellbeing in this context.

Digital health - a new medical cosmology? The case of 23andMe online genetic testing platform.

This article argues that commercial digital health platforms and devices commodify participatory features of the digital creating a new medical cosmology. Drawing on sociology on medical cosmologies, research on digital media and marketing and an analysis of the 23andMe online genetic testing platform, I identify three features of this cosmology. First, digital health seeks to foment 'flow' or enjoyable, continuous immersion in health. Second, digital health configures its consumers as 'co-creators' of health data and knowledge together with companies and other consumers. Third, digital health frames medical knowledge as tentative, up for revision and scepticism by expert and lay science. The way in which digital health configures consumers as immersed, creative and sceptical gives it an open-ended and participatory air. However, the conceptual discussion and the analysis of the 23andMe platform highlight that these features represent commercial capture of the lifeworld, even if they appear radical against classical medical cosmologies.

Effect of adding systematic family history enquiry to cardiovascular disease risk assessment in primary care: a matched-pair, cluster randomized trial.

BACKGROUND: Evidence of the value of systematically collecting family history in primary care is limited. OBJECTIVE: To evaluate the feasibility of systematically collecting family history of coronary heart disease in primary care and the effect of incorporating these data into cardiovascular risk assessment. DESIGN: Pragmatic, matched-pair, cluster randomized, controlled trial. (International Standardized Randomized Controlled Trial Number Register: ISRCTN 17943542). SETTING: 24 family practices in the United Kingdom. PARTICIPANTS: 748 persons aged 30 to 65 years with no previously diagnosed cardiovascular risk, seen between July 2007 and March 2009. INTERVENTION: Participants in control practices had the usual Framingham-based cardiovascular risk assessment with and without use of existing family history information in their medical records. Participants in intervention practices also completed a questionnaire to systematically collect their family history. All participants were informed of their risk status. Participants with high cardiovascular risk were invited for a consultation. MEASUREMENTS: The primary outcome was the proportion of participants with high cardiovascular risk (10-year risk ≥ 20%). Other measures included questionnaire completion rate and anxiety score. RESULTS: 98% of participants completed the family history questionnaire. The mean increase in proportion of participants classified as having high cardiovascular risk was 4.8 percentage points in the intervention practices, compared with 0.3 percentage point in control practices when family history from patient records was incorporated. The 4.5-percentage point difference between groups (95% CI, 1.7 to 7.2 percentage points) remained significant after adjustment for participant and practice characteristics (P = 0.007). Anxiety scores were similar between groups. LIMITATIONS: Relatively few participants were from ethnic minority or less-educated groups. The potential to explore behavioral change and clinical outcomes was limited. Many data were missing for anxiety scores. CONCLUSION: Systematically collecting family history increases the proportion of persons identified as having high cardiovascular risk for further targeted prevention and seems to have little or no effect on anxiety. PRIMARY FUNDING SOURCE: Genetics Health Services Research program of the United Kingdom Department of Health.

Beyond beliefs: risk assessment technologies shaping patients' experiences of heart disease prevention.

Social science research on lifestyle-related diseases typically focuses on patients' understandings and beliefs and takes the clinical risk for granted. We interviewed 30 healthy UK patients at high risk of heart disease, recruited from a family history trial at 2 weeks and 6 months after a discussion with a clinician about their risk, lifestyle and medications. The participants took four different paths: (i) pharmaceutical (most common, risk reduction with cholesterol lowering statins), (ii) mixed (statins and behaviour change), (iii) behavioural (behaviour change, focus on wellbeing) and (iv) 'lost' (no prevention, difficult social/personal circumstances). Drawing on Berg we argue that coronary heart disease (CHD) risk assessment technologies are formal tools that generate, rather than represent, high risk in a way that patients often experience lifestyle change as futile, because it rarely reduces their cholesterol to targets defined by the tools. We suggest social scientists studying incipient or 'proto-diseases', such as CHD risk, should not only focus on understandings but also investigate the technologies (and the associated guidelines, policies, clinical practice and pharmaceutical industry operations) that generate incipient diseases and patients' experiences of them. However, technologies do not determine experience and we also discuss elements that direct patients down other than the pharmaceutical path.

Diagnosis Between Chaos and Control: Affect and Hospital Clinicians' and Older Adult Patients' Narratives of Urinary Tract Infections.

Research has observed that older adults are frequently overdiagnosed with urinary tract infection (UTI) and unnecessarily prescribed antibiotics in hospitals. In this article we explore the overlooked affective dimension of experiences of diagnosis and prescribing. Drawing on interviews with doctors, nurses and older adult patients (n = 41) on UTI diagnosis in two UK hospitals and Arthur Frank's work on illness narratives we identified two affective ways of experiencing diagnosis. Some clinicians and older adult patients articulated chaos narratives about being overwhelmed by contradictory evidence and events, doubting the repeated UTI diagnoses and courses of antibiotics but being unable to do anything about their concerns. Other clinicians and patients articulated control narratives about UTIs being frequently diagnosed and antibiotics prescribed to restore patients' health, echoing certainty and security, even if the processes described typically did not follow current guidance. We contend that analyzing the affective dimension offers conceptual insights that push forward sociological discussions on diagnosis as reflective or dogmatic in the context of the contradiction between acute care and chronic illnesses of old age. Our findings contribute practical ideas of why overdiagnosis and overprescribing happen in hospitals and complicate notions of patients pressuring for antibiotics. We also present methodological suggestions for analyzing how participants tell about their experiences in order to explore the typically not directly spoken affective dimension that influences thoughts and actions about diagnosis.

Realising the potential of the family history in risk assessment and primary prevention of coronary heart disease in primary care: ADDFAM study protocol.

BACKGROUND: Coronary heart disease (CHD) is the leading cause of death in the developed world, and its prevention a core activity in current UK general practice. Currently, family history is not systematically integrated into cardiovascular risk assessment in the UK, Europe or the US. Further, primary health care professionals' lack the confidence to interpret family history information and there is a low level of recording of family history information in General Practice (GP) records. Primary prevention of CHD through lifestyle advice has sometimes yielded modest results although, for example, behavioural interventions targeted at "at risk" patients have produced encouraging findings. A family history approach, targeted at those requesting CHD assessment, could motivate lifestyle change. The project will assess the clinical value of incorporating systematic family history information into CHD risk assessment in primary care, from the perspective of the users of this service, the health care practitioners providing this service, and the National Health Service. METHODS/DESIGN: The study will include three distinct phases: (1) cross-sectional survey to ascertain baseline information on current recording of family information; (2) through an exploratory matched-pair cluster randomised study, with nested qualitative semi-structured interview and focus group study, to assess the impact of systematic family history recording on participants' and primary care professionals' experience; (3) develop an economic model of the costs and benefits of incorporating family history into CHD risk assessment. DISCUSSION: On completion of the project, users and primary care practitioners will be more informed of the value and utility of including family history in CHD risk assessment. Further, this approach will also act as a model of how familial risk information can be integrated within mainstream primary care preventive services for common chronic diseases. TRIAL REGISTRATION: Current Controlled Trials ISRCTN17943542.

Overprescribing antibiotics for asymptomatic bacteriuria in older adults: a case series review of admissions in two UK hospitals.

Background: Overdiagnosis and overtreatment of urinary tract infection (UTI) with antibiotics is a concern. In older adults, diagnosis of UTI using near-patient urine tests (reagent strip tests, dipsticks) is advised against because the age-related increase in asymptomatic bacteriuria can cause false-positive results. Instead, UTI diagnosis should be based on a full clinical assessment. Previous research lacks systematic information on urine dipstick use in hospitals. The aim of this study was to examine the use of urine dipstick tests and microbiology among older adult hospital admissions in relation to recommended UTI diagnostic criteria. A further aim was to assess factors associated with the use of dipsticks. Methods: A case series review of patients aged ≥70 years admitted to two NHS Trust hospitals in England. Records from 312 patients admitted in 2015 meeting inclusion criteria were selected at random. Results: Of 298 complete patient records, 54% had at least one urine dipstick test recorded. 13% (21/161) of patients who received a urine dipstick test were diagnosed as having a UTI, only 2 out of these 21 cases had two or more clinical signs and symptoms. 60 patients received a second dipstick test, leading to 13 additional cases of UTI diagnosis. Dipstick tests were more likely to be performed on patients with a history of falls (OR 1.93, 95% CI:1.21, 3.07, p < 0.01), and less likely on those with dementia (OR 0.44, 95% CI: 0.22, 0.87, p < 0.05). The most common reason for testing was routine admissions policy (49.1% of cases), but these cases were predominantly in one hospital. Conclusions: Use of urine dipstick tests was high among older adults admitted to hospitals. Most cases were asymptomatic and therefore received inappropriate antibiotic therapy. This paper highlights the need to implement new Public Health England diagnostic guidelines to hospital admission and emergency departments.

Gaps in communication between different staff groups and older adult patients foster unnecessary antibiotic prescribing for urinary tract infections in hospitals: a qualitative translation approach.

Background: Studies have reported large scale overprescribing of antibiotics for urinary tract infection (UTI) in hospitalised older adults. Older adults often have asymptomatic bacteriuria, and clinicians have been found to diagnose UTIs inappropriately based on vague symptoms and positive urinalysis and microbiology. However, the joined perspectives of different staff groups and older adult patients on UTI diagnosis have not been investigated. Methods: Thematic analysis of qualitative interviews with healthcare staff (n = 27) and older adult patients (n = 14) in two UK hospitals. Results: Interviews featured a recurrent theme of discrepant understandings and gaps in communication or translation between different social groups in three key forms: First, between clinicians and older adult patients about symptom recognition. Second, between nurses and doctors about the use and reliability of point-of-care urinary dipsticks. Third, between nurses, patients, microbiologists and doctors about collection of urine specimens, contamination of the specimens and interpretation of mixed growth laboratory results. The three gaps in communication could all foster inappropriate diagnosis and antibiotic prescribing. Conclusion: Interventions to improve diagnosis and prescribing for UTIs in older adults typically focus on educating clinicians. Drawing on the sociological concept of translation and interviews with staff and patients our findings suggest that inappropriate diagnosis and antibiotic prescribing in hospitals can be fuelled by gaps in communication or translation between different staff groups and older adult patients, using different languages and technologies or interpreting them differently. We suggest that interventions in this area may be improved by also addressing discrepant understandings and communication about symptoms, urinary dipsticks and the process of urinalysis.

Findings of the Chronic Obstructive Pulmonary Disease-Sitting and Exacerbations Trial (COPD-SEAT) in Reducing Sedentary Time Using Wearable and Mobile Technologies With Educational Support: Randomized Controlled Feasibility Trial.

BACKGROUND: Targeting sedentary time post exacerbation may be more relevant than targeting structured exercise for individuals with chronic obstructive pulmonary disease. Focusing interventions on sitting less and moving more after an exacerbation may act as a stepping stone to increase uptake to pulmonary rehabilitation. OBJECTIVE: The aim of this paper was to conduct a randomized trial examining trial feasibility and the acceptability of an education and self-monitoring intervention using wearable technology to reduce sedentary behavior for individuals with chronic obstructive pulmonary disease admitted to hospital for an acute exacerbation. METHODS: Participants were recruited and randomized in hospital into 3 groups, with the intervention lasting 2 weeks post discharge. The Education group received verbal and written information about reducing their time in sedentary behavior, sitting face-to-face with a study researcher. The Education+Feedback group received the same education component along with real-time feedback on their sitting time, stand-ups, and steps at home through a waist-worn inclinometer linked to an app. Patients were shown how to use the technology by the same study researcher. The inclinometer also provided vibration prompts to encourage movement at patient-defined intervals of time. Patients and health care professionals involved in chronic obstructive pulmonary disease exacerbation care were interviewed to investigate trial feasibility and acceptability of trial design and methods. Main quantitative outcomes of trial feasibility were eligibility, uptake, and retention, and for acceptability, were behavioral responses to the vibration prompts. RESULTS: In total, 111 patients were approached with 33 patients recruited (11 Control, 10 Education, and 12 Education+Feedback). Retention at 2-week follow-up was 52% (17/33; n=6 for Control, n=3 for Education, and n=8 for Education+Feedback). No study-related adverse events occurred. Collectively, patients responded to 106 out of 325 vibration prompts from the waist-worn inclinometer (32.62%). Within 5 min of the prompt, 41% of responses occurred, with patients standing for a mean 1.4 (SD 0.8) min and walking for 0.4 (SD 0.3) min (21, SD 11, steps). Interviews indicated that being unwell and overwhelmed after an exacerbation was the main reason for not engaging with the intervention. Health care staff considered reducing sedentary behavior potentially attractive for patients but suggested starting the intervention as an inpatient. CONCLUSIONS: Although the data support that it was feasible to conduct the trial, modifications are needed to improve participant retention. The intervention was acceptable to most patients and health care professionals. TRIAL REGISTRATION: International Standard Randomized Controlled Trial Number (ISRCTN) 13790881; http://www.isrctn.com/ISRCTN13790881 (Archived by WebCite at http://www.webcitation.org/6xmnRGjFf).

Patients' understanding of genetic susceptibility testing in mainstream medicine: qualitative study on thrombophilia.

BACKGROUND: UK and US policy initiatives have suggested that, in the future, patients and clinicians in mainstream medicine could use genetic information to prevent common illnesses. There are no studies on patients' experience and understanding of the process of testing for common genetic susceptibilities in mainstream medicine. METHODS: Qualitative interviews with 42 individuals who had undergone testing for a genetic susceptibility for deep vein thrombosis in primary and secondary care in the UK. RESULTS: Some participants, often from higher social classes, had a good understanding of the test and its implications. They had often sought additional information on thrombophilia from relatives and from the Internet. Others, often from less privileged backgrounds, had a poorer understanding of the test--seven individuals were unaware of having had the genetic test. Features of genetic information led to misunderstandings: (i) at referral, (ii) when communicating results, and (iii) when making sense of the implications of testing. Participants' accounts indicated that non-specialist doctors may feel obliged to refer a patient for a genetic test they know little about, because a patient requests it after a relative had tested positive. Sometimes a referral for a genetic test was lost under information overload when multiple tests and issues were considered. The inconsistent and informal ways of communicating test results--for example by phone--in mainstream medicine also led to confusion. Participants did not generally overestimate their risk, but some were uncertain about whether they were taking the right preventive actions and/or whether their children were at risk. Information about genetic susceptibilities was difficult to make sense of, as it related to ambiguous risks for participants and family members, complicated and unfamiliar terminology and multiple genes and preventive strategies. CONCLUSION: Policy visions of clinicians and patients in mainstream medicine seeking and using genetic information at their own initiative may not be realistic. Patients need more direct support in making sense of genetic information, if this information is to bring the anticipated health benefits, and not fuel health inequalities or create ethical problems. Clinicians in secondary and primary care need guidance to help them introduce genetic tests, communicate their results and explain their implications.

Are genetic tests exceptional? Lessons from a qualitative study on thrombophilia.

Policy makers have suggested that information about genetic risk factors, which are associated with low risk and for which preventive strategies exist, should not be considered "exceptional" and should not warrant special safeguards, such as data protection or specialist pre-test counselling. There is scant research on how such risk factors are perceived, and to explore this we conducted qualitative interviews with 42 participants who had undergone testing in the South West of England for a low risk genetic susceptibility to deep vein thrombosis (DVT). Generally the participants, who were mostly women, thought the test was less serious than a genetic test for a predisposition to breast cancer or a non-genetic, diagnostic test for diabetes. They had used the genetic information to reduce their risk of DVTs by avoiding oral contraceptives and hormone replacement therapy but had not changed their lifestyle. Many considered pre-test genetic counselling unnecessary. However, a subgroup of participants, who were often less educated or at a high risk, were distressed and/or confused about thrombophilia and thought pre-test counselling would have been helpful. The findings indicate an emerging interpretation of genetics not as revealing exceptional or "in depth" knowledge about one's health and identity but as occasionally relevant surface information, which participants use to make specific health decisions but not to transform their everyday lives. However, the views of the subgroup indicate that some participants interpret thrombophilia as serious and/or need special support.

Study protocol for Chronic Obstructive Pulmonary Disease-Sitting and ExacerbAtions Trial (COPD-SEAT): a randomised controlled feasibility trial of a home-based self-monitoring sedentary behaviour intervention.

INTRODUCTION: An acute exacerbation of chronic obstructive pulmonary disease (COPD) marks a critical life event, which can lower patient quality of life and ability to perform daily activities. Patients with COPD tend to lead inactive and highly sedentary lifestyles, which may contribute to reductions in functional capacity. Targeting sedentary behaviour (SB) may be more attainable than exercise (at a moderate-to-vigorous intensity) for behaviour change in patients following an exacerbation. This study aims to evaluate the feasibility and acceptability of a 2-week at-home intervention providing education and self-monitoring to reduce prolonged periods of SB in patients with COPD discharged following an acute exacerbation. METHODS AND ANALYSIS: Patients will be randomised into 1 of 3 conditions: usual care (control), education or education+feedback. The education group will receive information and suggestions about reducing long periods of sitting. The education+feedback group will receive real-time feedback on their sitting time, stand-ups and step count at home through an inclinometer linked to a smart device app. The inclinometer will also provide vibration prompts to encourage movement when the wearer has been sedentary for too long. Data will be collected during hospital admission and 2 weeks after discharge. Qualitative interviews will be conducted with patients in the intervention groups to explore patient experiences. Interviews with healthcare staff will also be conducted. All data will be collected January to August 2016. The primary outcomes are feasibility and acceptability, which will be assessed by qualitative interviews, uptake and drop-out rates, reasons for refusing the intervention, compliance, app usage and response to vibration prompts. ETHICS AND DISSEMINATION: The research ethics committee East Midlands Leicester-Central has provided ethical approval for the conduct of this study. The results of the study will be disseminated through appropriate conference proceedings and peer-reviewed journals. TRIAL REGISTRATION NUMBER: ISRCTN13790881; Pre-results.

State of play in direct-to-consumer genetic testing for lifestyle-related diseases: market, marketing content, user experiences and regulation.

Direct-to-consumer (DTC) genetic tests have aroused controversy. Critics have argued many of the tests are not backed by scientific evidence, misguide their customers and should be regulated more stringently. Proponents suggest that finding out genetic susceptibilities for diseases could encourage healthier behaviours and makes the results of genetics research available to the public. This paper reviews the state of play in DTC genetic testing, focusing on tests identifying susceptibilities for lifestyle-related diseases. It will start with mapping the market for the tests. The paper will review (1) research on the content of the online marketing of DTC tests, (2) studies on the effects of DTC genetic tests on customers and (3) academic and policy proposals on how to regulate the tests. Current studies suggest that the marketing of DTC genetic tests often exaggerates their predictive powers, which could misguide consumers. However, research indicates that the tests do not seem to have major negative effects (worry and confusion) but neither do they engender positive effects (lifestyle change) on current users. Research on regulation of the tests has most commonly suggested regulating the marketing claims of the companies. In conclusion, the risks and benefits of DTC genetic tests are less significant than what has been predicted by critics and proponents, which will be argued reflects broader historical trends transforming health and medicine.

Negotiating the boundary between medicine and consumer culture: online marketing of nutrigenetic tests.

Genomics researchers and policy makers have accused nutrigenetic testing companies--which provide DNA-based nutritional advice online--of misleading the public. The UK and USA regulation of the tests has hinged on whether they are classed as "medical" devices, and alternative regulatory categories for "lifestyle" and less-serious genetic tests have been proposed. This article presents the findings of a qualitative thematic analysis of the webpages of nine nutrigenetic testing companies. We argue that the companies, mirroring and negotiating the regulatory debates, were creating a new social space for products between medicine and consumer culture. This space was articulated through three themes: (i) how "genes" and tests were framed, (ii) how the individual was imagined vis a vis health information, and (iii) the advice and treatments offered. The themes mapped onto four frames or models for genetic testing: (i) clinical genetics, (ii) medicine, (iii) intermediate, and (iv) lifestyle. We suggest that the genomics researchers and policy makers appeared to perform what Gieryn (Gieryn, T.F. (1983). Boundary-work and the demarcation of science from non-science: strains and interests in professional ideologies of scientists. American Sociological Review, 48, 781-795.) has termed "boundary work", i.e., to delegitimize the tests as outside proper medicine and science. Yet, they legitimated them, though in a different way, by defining them as lifestyle, and we contend that the transformation of the boundaries of science into a creation of such hybrid or compromise categories is symptomatic of current historical times. Social scientists studying medicine have referred to the emergence of "lifestyle" products. This article contributes to this literature by examining the historical, regulatory and marketing processes through which certain goods and services become defined this way.

Making sense of being at 'high risk' of coronary heart disease within primary prevention.

Current National Health Service policy advocates screening to identify individuals at 'high risk' of cardio-vascular disease (CHD) in primary care. This article utilizes the work of Radley to explore how 'high risk' of CHD patients make sense of their new risk status. Results are presented here from a nested qualitative study within a quantitative randomized trial of a CHD risk intervention in primary care. 'Discovery' interviews were conducted with 'high risk' participants (n = 38, mean age = 55) two weeks after intervention and thematically analysed. In response to perceived threat, many participants sought to both 'minimize' and 'normalize' their risk status. They also reported intentions to act, particularly concerning dietary change and exercise, although less so for smoking amongst the lower socio-economic status participants. Such perceptions and intentions were contextualized within the life-course of later middle-age, so that both being at risk, and being treated for risk, were normalized as part of growing older. Social position, such as gender and SES, was also implicated. CHD risk interventions should be context-sensitive to the life-course and social position of those who find themselves at 'high risk' of CHD in later middle-age.

Assessing family history of heart disease in primary care consultations: a qualitative study.

BACKGROUND: Current primary prevention guidelines recommend the assessment of family history of coronary heart disease (CHD) to identify at-risk individuals. OBJECTIVE: To examine how clinicians and patients understand and communicate family history in the context of CHD risk assessment in primary care. METHODS: A qualitative study. Patients completed a validated family history questionnaire. Consultations with clinicians were video recorded, and semi-structured interviews conducted with patients after consultation. The participants were 21 primary care patients and seven primary care clinicians (two practice nurses, five GPs). Four practices in South West England. RESULTS: Patients and clinicians usually agreed about the patient's level of risk and how to reduce it. Patients were mostly satisfied with their consultations and having their family history assessed. However, three issues were identified from the consultations which contributed to concerns and unanswered questions for patients. Problems arose when there were few modifiable risk factors to address. Firstly, patients' explanations of their family history were not explored in the consultation. Secondly, the relationship between the patient's family history and their other risk factors, such as smoking or cholesterol, was rarely discussed. Thirdly, clinicians did not explain the integration of family history into the patient's overall cardiovascular disease risk. CONCLUSIONS: Clinicians appeared to lack a rhetoric to discuss family history, in terms of capturing both genetic and environmental factors and its relation to other risk factors. This created uncertainties for patients and carries potential clinical and social implications. There is a need for better guidance for primary care clinicians about family history assessment.

Genomic susceptibility-testing and pregnancy: something old, something new.

This essay explores how testing for common and complex or genomic, as opposed to genetic, susceptibility to deep vein thrombosis both challenges and consolidates old social discourses on genes, gender and pregnancy. The nexus between genetics and reproduction usually crystallizes in the moral dilemma of selective termination. This essay examines online discussion among women with a genomic predisposition to deep vein thrombosis, which is associated with miscarriage and stillbirth. It explores the women's exchanges on what to 'do' in order to safely carry to term a foetus, which may always also have the genomic susceptibility. Interpreting DNA not in terms of predicting fate but of suggesting how to modify one's behaviour in order to give and care for life blunts its eugenic edge. However, this interpretation also shoulders discussants with the complicated and laborious responsibility of modifying themselves, their life styles and the life styles of their families--all of which falls within women's traditional labour of love in the privatized age of bioindividuality.