Exploring the use of social network interventions for adults with mental health difficulties: a systematic review and narrative synthesis.

BACKGROUND: People with mental health difficulties often experience social isolation. The importance of interventions to enhance social networks and reduce this isolation is increasingly being recognised. However, the literature has not yet been systematically reviewed with regards to how these are best used. This narrative synthesis aimed to investigate the role of social network interventions for people with mental health difficulties and identify barriers and facilitators to effective delivery. This was undertaken with a view to understanding how social network interventions might work best in the mental health field. METHODS: Systematic searches using combinations of synonyms for mental health difficulties and social network interventions were undertaken across 7 databases (MEDLINE, Embase, PsycINFO, CINAHL, Cochrane Library, Web of Science) and 2 grey literature databases (EThoS and OpenGrey) from their inception to October 2021. We included studies reporting primary qualitative and quantitative data from all study types relating to the use of social network interventions for people with mental health difficulties. The quality of included studies was assessed using the Mixed Methods Appraisal Tool. Data were extracted and synthesised narratively. RESULTS: The review included 54 studies, reporting data from 6,249 participants. Social network interventions were generally beneficial for people with mental health difficulties but heterogeneity in intervention type, implementation and evaluation made it difficult to draw definitive conclusions. Interventions worked best when they (1) were personalised to individual needs, interests and health, (2) were delivered outside formal health services and (3) provided the opportunity to engage in authentic valued activities. Several barriers to access were identified which, without careful consideration could exacerbate existing health inequalities. Further research is required to fully understand condition-specific barriers which may limit access to, and efficacy of, interventions. CONCLUSIONS: Strategies for improving social networks for people with mental health difficulties should focus on supporting engagement with personalised and supported social activities outside of formal mental health services. To optimise access and uptake, accessibility barriers should be carefully considered within implementation contexts and equality, diversity and inclusion should be prioritised in intervention design, delivery and evaluation and in future research.

Mixed methods feasibility and usability testing of a childhood obesity risk estimation tool.

BACKGROUND: A Childhood Obesity Risk Estimation tool (SLOPE CORE) has been developed based on prediction models using routinely available maternity and early childhood data to estimate risk of childhood obesity at 4-5 years. This study aims to test the feasibility, acceptability and usability of SLOPE CORE within an enhanced health visiting (EHV) service in the UK, as one context in which this tool could be utilised. METHODS: A mixed methods approach was used to assess feasibility of implementing SLOPE CORE. Health Visitors (HVs) were trained to use the tool, and in the processes for recruiting parents into the study. HVs were recruited using purposive sampling and parents by convenience sampling. HVs and parents were invited to take part in interviews or focus groups to explore their experiences of the tool. HVs were asked to complete a system usability scale (SUS) questionnaire. RESULTS: Five HVs and seven parents took part in the study. HVs found SLOPE CORE easy to use with a mean SUS of 84.4, (n = 4, range 70-97.5) indicating excellent usability. Five HVs and three parents took part in qualitative work. The tool was acceptable and useful for both parents and HVs. Parents expressed a desire to know their child's risk of future obesity, provided this was accompanied by additional information, or support to modify risk. HVs appreciated the health promotion opportunity that the tool presented and felt that it facilitated difficult conversations around weight, by providing 'clinical evidence' for risk, and placing the focus of the conversation onto the tool result, rather than their professional judgement. The main potential barriers to use of the tool included the need for internet access, and concerns around time needed to have a sensitive discussion around a conceptually difficult topic (risk). CONCLUSIONS: SLOPE CORE could potentially be useful in clinical practice. It may support targeting limited resources towards families most at risk of childhood obesity. Further research is needed to explore how the tool might be efficiently incorporated into practice, and to evaluate the impact of the tool, and any subsequent interventions, on preventing childhood obesity.

Influence of social networks on cancer survivors' self-management support: A mixed methods study.

OBJECTIVE: The role of social networks, especially weaker ties (e.g. casual acquaintances and hobby groups), in self-management of long-term consequences of cancer is unexplored. This study aimed to explore the structure of cancer survivors' social networks and their contribution to self-management support and health-related quality of life (HRQoL). METHODS: The study used a sequential, exploratory mixed methods design. Phase 1 surveyed 349 lymphoma, colorectal, breast and prostate cancer survivors. Phase 2 analysed 20 semi-structured interviews with respondents recruited from Phase 1. RESULTS: Phase 1 results suggested participants' HRQoL increased if they participated in an exercise group, if their self-management skills increased, and social distress and negative illness perception decreased (p < 0.0005 adj. R2 = 0.631). These findings were explored in Phase 2, identifying underlying mechanisms. Four themes were identified: disrupted networks after cancer treatment; navigating formal support and building individual capacity; peer networks and self-management knowledge and linking networks to enable adaptation in recovery. CONCLUSIONS: This study suggests engagement with community groups, particularly those not directly related to illness management and social interaction with weak ties, make a valuable contribution to self-management support, increase HRQoL and enhance well-being.

Supporting and enabling health research in a local authority (SERLA): an exploratory study.

BACKGROUND: The use of research evidence to underpin public health practice and policy decisions in local government is strongly promoted but its implementation has not been straightforward. This study aimed to explore the factors, relationships and processes that contribute towards accessing, using, and generating research evidence that is relevant to local authority public health and social care and shapes its practice. METHODS: Semi-structured individual interviews with elected councillors, officers directly involved with public health and social care and with community members from one urban unitary authority in South England were conducted. Interviews were audio recorded, transcribed verbatim and thematically analysed. RESULTS: Fourteen participants took part in the semi-structured interviews. Local knowledge and evidence are prioritised, and anecdotal evidence is valued. The Director of Public Health was the principal source of information and support. Academics were rarely mentioned as information sources, and their involvement was ad hoc. The use of research evidence varied between individuals and departments, with wider engagement among public health specialists. Key barriers to the use of research evidence included access (not reported among public health professionals), research timeliness, local applicability, competence in finding and interpreting evidence and the role of research evidence within a political context. Public health and adult social care teams are not currently research active or research ready. Major barriers exist due to financial constraints and the socio-political context of local authorities. COVID-19 disrupted siloed ways of working, strengthening and opening potential collaborations within the local authority. This changed perspectives about the value of research but is likely time-limited unless underpinned by sustainable funding. CONCLUSION: Creating strategic level roles within local government to work with the Director of Public Health to champion the research agenda and embedding researchers within and across teams would build capacity for local authorities to sustainably co-create, undertake, and use evidence to better inform future actions.

Assessing the effectiveness of social network interventions for adults with a diagnosis of mental health problems: a systematic review and narrative synthesis of impact.

BACKGROUND: Social connections have been linked to the genesis and amelioration of mental health problems and thus have potential therapeutic value. PURPOSE: To identify the current evidence base, assess risk of bias and synthesise findings on the effectiveness of social network interventions for people with mental health problems. METHODS: Electronic databases (MEDLINE, Embase, PsycINFO, CINAHL, Cochrane Library, Web of Science, Scopus) and grey literature databases were systematically searched from inception to October 2021 using free text syntax combining synonyms for 'mental health problems' and 'social network interventions'. Articles were eligible for inclusion if they reported data from randomised controlled trials on the effectiveness of interventions designed to improve social networks for adults (18+) with mental health problems. Papers were independently reviewed for inclusion with conflicts resolved through consensus. Included papers were quality assessed and data extracted and synthesized narratively. Risk of bias was assessed using the Cochrane Risk of Bias Tool. RESULTS: Nine studies randomising 2226 participants were included. Four focused on those with a diagnosis of schizophrenia or psychosis, one on major depressive disorder and four included all types of mental health diagnoses. The current evidence base is of unclear quality. However, interventions which focused on supporting social activities appear to hold the most promise for enhancing social networks. Data on cost-effectiveness and research acceptability were limited, but suggest the potential economic feasibility of and acceptability for evaluating these interventions. CONCLUSION: There is emerging evidence that social network interventions can be effective in improving social connections for people with mental health problems. However, further evaluations with robust methodological approaches are required to inform evidence-based recommendations for health services.

Adapting a social network intervention for use in secondary mental health services using a collaborative approach with service users, carers/supporters and health professionals in the United Kingdom.

BACKGROUND: Social integration, shared decision-making and personalised care are key elements of mental health and social care policy. Although these elements have been shown to improve service user and service-level outcomes, their translation into practice has been inconsistent and social isolation amongst service users persists. AIM: To co-adapt, with service users, carers/supporters and health professionals, a web-based social network intervention, GENIE™, for use in secondary mental health services. The intervention is designed to support social activity and preference discussions between mental healthcare professionals and service users as a means of connecting individuals to local resources. METHODS: In Phase 1 (LEARN), we completed two systematic reviews to synthesise the existing evidence relating to the i) effectiveness and ii) the implementation of social network interventions for people with mental health difficulties. We undertook semi-structured interviews with a convenience sample of 15 stakeholders previously involved in the implementation of the intervention in physical healthcare settings. Interviews were also conducted with 5 national key stakeholders in mental health (e.g., policy makers, commissioners, third sector leads) to explore wider implementation issues. In Phase 2 (ADAPT), we worked iteratively with eight service users, nine carers, six professionals/volunteers and our patient and public advisory group. We drew on a framework for experience-based co-design, consisting of a series of stakeholder consultation events, to discuss the use of the social network intervention, in mental health services. Participants also considered factors that could serve as enablers, barriers, and challenges to local implementation. RESULTS: Across the stakeholder groups there was broad agreement that the social network intervention had potential to be useful within mental health services. In terms of appropriate and effective implementation, such an intervention was predicted to work best within the care planning process, on discharge from hospital and within early intervention services. There were indications that the social connection mapping and needs assessment components were of most value and feasible to implement which points to the potential utility of a simplified version compared to the one used in this study. The training provided to facilitators was considered to be more important than their profession and there were indications that service users should be offered the opportunity to invite a carer, friend, or family member to join them in the intervention. CONCLUSION: The GENIE™ intervention has been co-adapted for use in mental health services and a plan for optimal implementation has been co-produced. The next phase of the programme of work is to design and implement a randomised controlled trial to evaluate clinical and cost effectiveness of a simplified version of the intervention.

PRC2 is dispensable for HOTAIR-mediated transcriptional repression.

Long non-coding RNAs (lncRNAs) play diverse roles in physiological and pathological processes. Several lncRNAs have been suggested to modulate gene expression by guiding chromatin-modifying complexes to specific sites in the genome. However, besides the example of Xist, clear-cut evidence demonstrating this novel mode of regulation remains sparse. Here, we focus on HOTAIR, a lncRNA that is overexpressed in several tumor types and previously proposed to play a key role in gene silencing through direct recruitment of Polycomb Repressive Complex 2 (PRC2) to defined genomic loci. Using genetic tools and a novel RNA-tethering system, we investigated the interplay between HOTAIR and PRC2 in gene silencing. Surprisingly, we observed that forced overexpression of HOTAIR in breast cancer cells leads to subtle transcriptomic changes that appear to be independent of PRC2. Mechanistically, we found that artificial tethering of HOTAIR to chromatin causes transcriptional repression, but that this effect does not require PRC2. Instead, PRC2 recruitment appears to be a consequence of gene silencing. We propose that PRC2 binding to RNA might serve functions other than chromatin targeting.

Mediating engagement in a social network intervention for people living with a long-term condition: A qualitative study of the role of facilitation.

BACKGROUND: Successful facilitation of patient-centred interventions for self-management support has traditionally focussed on individual behaviour change. A social network approach to self-management support implicates the need for facilitation that includes an orientation to connecting to and mobilizing support and resources from other people and the local environment. OBJECTIVE: To identify the facilitation processes through which engagement with a social network approach to self-management is achieved. METHOD: Thematic analysis was used to analyse data from a longitudinal study design using quasi-ethnographic methods comprising non-participant observation, video and qualitative interviews involving 30 participants living with a long-term condition recruited from a marginalized community. RESULTS: Findings centred on three themes about the social network approach facilitation processes: reversing the focus on the self by bringing others into view; visualization and reflection as a mediator of positive disruption and linking to new connections; personalized matching of valued activities as a means of realizing preference elicitation. DISCUSSION AND CONCLUSIONS: Engagement processes with a social network approach illuminated the relevance of cognizance of an individual's immediate social context and forefronting social participation with others as the bases of self-management support of a long-term condition. This differs from traditional guided facilitation of health behaviour interventions that frame health as a matter of personal choice and individual responsibility.

Findings from a pilot randomised trial of a social network self-management intervention in COPD.

BACKGROUND: Self-Management Support (SMS), refers to the actions taken by individuals to recognise and manage their own health. It is increasingly recognised that individuals with chronic obstructive pulmonary disease (COPD) require additional support with their Self-management. Emerging evidence suggests that the use of a social network intervention can improve health outcomes and increase quality of life. In order to understand the potential benefits of SMS in COPD, the GENIE (Generating Engagement in Network Support) SMS tool was implemented and evaluated in a COPD primary care context. The GENIE intervention is a social networking tool that consists of 3 parts; a concentric circle modelling to map existing social networks; a questions sections to elicit preferences for activities; a map of selected resources is then produced, aligned with the user's interests and suggestions for connections to existing network members and to new resources. METHODS: A pilot, parallel, single blind, block randomised controlled trial. Patients with COPD ranging from mild-very severe were recruited. Participants provided written consent and were then randomised to either the intervention or usual care. The primary aim was to understand the clinical benefit through the analysis of health status, symptom burden and quality of life. The secondary outcome measure was health utilisation. NHS cost differences were reported between groups using the GENIE intervention over usual care. RESULTS: The GENIE pilot results demonstrate maintenance in health status and clinical symptoms with a decrease in anxiety. An overall increase in quality of life was observed, these findings did not reach significance. A cost reduction was demonstrated in inpatient stay with no difference in primary care costs. Overall a cost reduction in NHS service utilisation was indicated in the intervention group. CONCLUSION: This pilot study indicated that using a social network intervention can encourage the development of new social connections and extend existing support networks for COPD patients. Increasing network support in this population is of benefit to both patients and NHS providers in terms of cost reductions and enhancing wellbeing. This broadens the understanding of possible new approaches to SMS in community COPD patients, which could now be investigated in a larger population over a longer period. TRIAL REGISTRATION: Clinical Trials.gov PRS National Library of Medicine. Protocol ID number: 19175, Clinical Trial ID: NCT02935452.

The work and relatedness of ties mediated online in supporting long-term condition self-management.

The 'care transition' is characterised by reduced state involvement in chronic illness management in response to socio-political movements aimed at meeting the challenges presented by an increased prevalence of chronic illness. Amongst these changes has been online communities' rising importance in everyday interactions and attention is being increasingly paid towards the ways online contacts might contribute to self-management. Whilst research has illuminated the relevance of personal networks in long-term condition management, it is relevant to extend this work to consider the place of ties mediated online in this bricolage of support, including better understanding the work drawn from them and the strategies involved in eliciting it. This study examined the work and relatedness of 30 participants, who used online communities. Participants were asked about the role of on and offline ties and ego network mapping was used to frame conversations about the nature of this support. The context of engagement followed three main themes. Participants drew from online communities in response to deficits in offline support, they used online ties to leverage support or action from offline ties and they used online ties to substitute offline support, with less intimate online ties.

Identifying the processes of change and engagement from using a social network intervention for people with long-term conditions. A qualitative study.

BACKGROUND: Personal and community networks are recognized as influencing and shaping self-management activities and practices. An acceptable intervention which facilitates self-management by mobilizing network support and improves network engagement has a positive impact on health and quality of life. This study aims to identify the processes through which such changes and engagement take place. METHODS: The study was conducted in the south of England in 2016-2017 and adopted a longitudinal case study of networks design. Purposive sample of respondents with long-term conditions (n = 15) was recruited from local groups. Barriers and facilitators to implementation were explored in interviews with key stakeholders (5). RESULTS: Intervention engagement leads to a deepening of relationships within networks, adding new links and achieving personal objectives relevant for improving the health and well-being of users and network members. Such changes are supported through two pathways: the mobilization of network capabilities and by acting as a nudge. The first is a gradual process where potentially relevant changes are further contemplated by forefronting immediate concerns and negotiating acceptable means for achieving change, prioritizing objective over subjective valuations of support provided by network members and rehearsing justifications for keeping the status quo or adopting change. The second pathway changes are enacted through the availability of a potential fit between individual, network and environmental conditions of readiness. CONCLUSIONS: The two pathways of network mobilization identified in this study illuminate the individual, network and environmental level processes involved in moving from cognitive engagement with the intervention to adopting changes in existing practice.

The process of incorporating insulin pumps into the everyday lives of people with Type 1 diabetes: A critical interpretive synthesis.

BACKGROUND: Insulin pump therapy (IPT) is a technological advancement that has been developed to help people manage Type 1 diabetes (T1D). However, ways of managing diabetes requiring the implementation of health technologies bring new complexities and a need to understand the factors which enable people with T1D to incorporate a novel device. This new comprehension could provide an exemplar for people with long-term conditions to incorporate new technologies more generally. OBJECTIVE: To determine what influences the incorporation, adaptation and use of IPT into the everyday lives of people living with diabetes. DESIGN: Critical interpretive synthesis (CIS) using systematic searches undertaken in 7 electronic databases of literature, published 2008 onwards. RESULTS: A total of 4998 titles were identified, 274 abstracts reviewed, 39 full articles retrieved and 22 papers selected for analysis. Three themes emerged which were of relevance to the introduction and use of IPT; Tensions between expectations and experiences in adoption and early adaptation; Negotiation of responsibility and accessing support; Reflexivity, active experimentation and feedback. CONCLUSIONS: This CIS builds on earlier reviews on lived experiences of IPT. Novel insights are offered through examination of the experiences of pump users from children through to adults, their families and health-care professionals. Expectations of what the device can do to improve self-management impacts on the early stages of adoption as the reality of the technology requires substantial thought and action. Areas for intervention to improve IPT incorporation include establishing who is responsible for management tasks of the device and enabling navigation to further means of support and resources.

How do people with long-term mental health problems negotiate relationships with network members at times of crisis?

BACKGROUND: Social network processes impact on the genesis and management of mental health problems. There is currently less understanding of the way people negotiate networked relationships in times of crisis compared to how they manage at other times. OBJECTIVE: This paper explores the patterns and nature of personal network involvement at times of crises and how these may differ from day-to-day networks of recovery and maintenance. METHOD: Semi-structured interviews with 25 participants with a diagnosis of long-term mental health (MH) problems drawn from recovery settings in the south of England. Interviews centred on personal network mapping of members and resources providing support. The mapping interviews explored the work of network members and changes in times of crisis. Interviews were recorded, transcribed and analysed using a framework analysis. RESULTS: Three key themes were identified: the fluidity of network relationality between crisis and recovery; isolation as a means of crises management; leaning towards peer support. Personal network input retreated at times of crisis often as result of "ejection" from the network by participants who used self-isolation as a personal management strategy in an attempt to deal with crises. Peer support is considered useful during a crisis, whilst the role of services was viewed with some ambiguity. CONCLUSIONS: Social networks membership, and type and depth of involvement, is subject to change between times of crisis and everyday support. This has implications for managing mental health in terms of engaging with network support differently in times of crises versus recovery and everyday living.

Stakeholders in support systems for self-care for chronic illness: the gap between expectations and reality regarding their identity, roles and relationships.

BACKGROUND AND OBJECTIVE: The spread of self-care holds the promise of containing chronic illness burden. Falling within the framework of a FP7 collaborative research project, this paper reports the views of key informants from six countries regarding who the main stakeholders are at different levels in the support system for self-care for patients with chronic illness (SSSC) and how they accomplish their role and collaborate. METHODS: 90 Interviews with purposefully selected key informants from Bulgaria, Greece, the Netherlands, Norway, Spain and United Kingdom were conducted. Interviews involved government and local authorities, politicians, academics, health professionals and private sector representatives. Interviewers followed an expert opinion-based guide. Analysis involved a cross-country examination with thematic analysis and framework method techniques. RESULTS: Key informants described the ideal SSSC as inclusive, interdependent and patient-centred. The following main stakeholders in SSSC were identified: patients, governments, health-care professionals, associations, private companies and the media. In the current SSSCs, collaboration among stakeholders within and across different levels was said to be lacking. Patients were seen as playing a passive subordinate role based on the following: their own attitudes; the paternalistic and medicalized attitudes of the health-care professionals; their misrepresentation by patient associations; and their exposure to the damaging influences of media and industries. CONCLUSIONS: Making SSSC patient-centred constitutes the greatest challenge for European authorities. Strategies must be revised for promoting patient participation. They should undergo changes so as to promote industry and media social responsibility and patient association advocacy capacity.

The articulation of neoliberalism: narratives of experience of chronic illness management in Bulgaria and the UK.

The shift from social democratic to a neoliberal consensus in modern welfare capitalist states is characterised by an emphasis on individual responsibility, consumer choice, market rationality and growing social inequalities. There has been little exploration of how neoliberalism has shaped the environment within which chronic illness is experienced and managed. This article explores the different articulations of neoliberalism manifest in the arena of personal illness management in Bulgaria and the UK. People with type 2 diabetes discussed their experiences in terms of struggling with diet, diabetes as a personal failure, integrating illness management and valued activities, and the trustworthiness of the healthcare system. The UK narratives were framed within an individual responsibility discourse while in Bulgaria lack of resources dominated discussions, which were framed as structurally generated and unrelated to individual capabilities and choices. Respondents faced personal management challenges related to consumer and healthcare market failures in both countries. Differences in market regulation and emerging stakeholder and interest coalitions influenced users' expectations and their navigation and adaption to market failures in managing their everyday illnesses. The UK and Bulgarian articulations of neoliberalism can be described differently: the first as a logic of managed choice and the second as a logic of unmanaged consumerism.

Brief encounters: what do primary care professionals contribute to peoples' self-care support network for long-term conditions? A mixed methods study.

BACKGROUND: Primary care professionals are presumed to play a central role in delivering long-term condition management. However the value of their contribution relative to other sources of support in the life worlds of patients has been less acknowledged. Here we explore the value of primary care professionals in people's personal communities of support for long-term condition management. METHODS: A mixed methods survey with nested qualitative study designed to identify relationships and social network member's (SNM) contributions to the support work of managing a long-term condition conducted in 2010 in the North West of England. Through engagement with a concentric circles diagram three hundred participants identified 2544 network members who contributed to illness management. RESULTS: The results demonstrated how primary care professionals are involved relative to others in ongoing self-care management. Primary care professionals constituted 15.5 % of overall network members involved in chronic illness work. Their contribution was identified as being related to illness specific work providing less in terms of emotional work than close family members or pets and little to everyday work. The qualitative accounts suggested that primary care professionals are valued mainly for access to medication and nurses for informational and monitoring activities. Overall primary care is perceived as providing less input in terms of extended self-management support than the current literature on policy and practice suggests. Thus primary care professionals can be described as providing 'minimally provided support'. This sense of a 'minimally' provided input reinforces limited expectations and value about what primary care professionals can provide in terms of support for long-term condition management. CONCLUSIONS: Primary care was perceived as having an essential but limited role in making a contribution to support work for long-term conditions. This coalesces with evidence of a restricted capacity of primary care to take on the work load of self-management support work. There is a need to prioritise exploring the means by which extended self-care support could be enhanced out-with primary care. Central to this is building a system capable of engaging network capacity to mobilise resources for self-management support from open settings and the broader community.

Long-Term Condition Self-Management Support in Online Communities: A Meta-Synthesis of Qualitative Papers.

BACKGROUND: Recent years have seen an exponential increase in people with long-term conditions using the Internet for information and support. Prior research has examined support for long-term condition self-management through the provision of illness, everyday, and emotional work in the context of traditional offline communities. However, less is known about how communities hosted in digital spaces contribute through the creation of social ties and the mobilization of an online illness "workforce." OBJECTIVE: The aim was to understand the negotiation of long-term condition illness work in patient online communities and how such work may assist the self-management of long-term conditions in daily life. METHODS: A systematic search of qualitative papers was undertaken using various online databases for articles published since 2004. A total of 21 papers met the inclusion criteria of using qualitative methods and examined the use of peer-led online communities for those with a long-term condition. A qualitative meta-synthesis was undertaken and the review followed a line of argument synthesis. RESULTS: The main themes identified in relation to the negotiation of self-management support were (1) redressing offline experiential information and knowledge deficits, (2) the influence of modeling and learning behaviors from others on self-management, (3) engagement that validates illness and negates offline frustrations, (4) tie formation and community building, (5) narrative expression and cathartic release, and (6) dissociative anonymity and invisibility. These translated into a line of argument synthesis in which four network mechanisms for self-management support in patient online communities were identified. These were (1) collective knowledge and identification through lived experience; (2) support, information, and engagement through readily accessible gifting relationships; (3) sociability that extends beyond illness; and (4) online disinhibition as a facilitator in the negotiation of self-management support. CONCLUSIONS: Social ties forged in online spaces provide the basis for performing relevant self-management work that can improve an individual's illness experience, tackling aspects of self-management that are particularly difficult to meet offline. Membership in online groups can provide those living with a long-term condition with ready access to a self-management support illness workforce and illness and emotional support. The substitutability of offline illness work may be particularly important to those whose access to support offline is either limited or absent. Furthermore, such resources require little negotiation online because information and support is seemingly gifted to the community by its members.

Dynamics and nature of support in the personal networks of people with type 2 diabetes living in Europe: qualitative analysis of network properties.

BACKGROUND: Living with and self-managing a long-term condition implicates a diversity of networked relationships. This qualitative study examines the personal communities of support of people with type 2 diabetes. METHODS: We conducted 170 biographical interviews in six European countries (Bulgaria, Greece, the Netherlands, Norway, Spain and UK) to explore social support and networks. Analysis was framed with reference to three predetermined social support mechanisms: the negotiation of support enabling engagement with healthy practices, navigation to sources of support and collective efficacy. Each interview was summarized to describe navigation and negotiation of participants' networks and the degree of collective efficacy. RESULTS: Analysis highlighted the similarities and differences between countries and provided insights into capacities of networks to support self-management. The network support mechanisms were identified in all interviews, and losses and gains in networks impacted on diabetes management. There were contextual differences between countries, most notably the impact of financial austerity on network dynamics. Four types of network are suggested: generative, diverse and beneficial to individuals; proxy, network members undertook diabetes management work; avoidant, support not engaged with; and struggling, diabetes management a struggle or not prioritized. CONCLUSIONS: It is possible to differentiate types of network input to living with and managing diabetes. Recognizing the nature of active, generative aspects of networks support is likely to have relevance for self-management support interventions either through encouraging continuing development and maintenance of these contacts or intervening to address struggling networks through introducing the means to connect people to additional sources of support.

Meso level influences on long term condition self-management: stakeholder accounts of commonalities and differences across six European countries.

BACKGROUND: European countries are increasingly adopting systems of self -care support (SMS) for long term conditions which focus on enhancing individual, competencies, skills, behaviour and lifestyle changes. To date the focus of policy for engendering greater self- management in the population has been focused in the main on the actions and motivations of individuals. Less attention has been paid to how the broader influences relevant to SMS policy and practice such as those related to food production, distribution and consumption and the structural aspects and economics relating to physical exercise and governance of health care delivery systems might be implicated in the populations ability to self- manage. This study aimed to identify key informants operating with knowledge of both policy and practice related to SMS in order to explore how these influences are seen to impact on the self-management support environment for diabetes type 2. METHODS: Ninety semi-structured interviews were conducted with key stakeholder informants in Bulgaria, Spain, Greece, Norway, Netherlands and UK. Interviews were transcribed and analysed using thematic and textual analysis. RESULTS: Stakeholders in the six countries identified a range of influences which shaped diabetes self-management (SM). The infrastructure and culture for supporting self- management practice is viewed as driven by political decision-makers, the socio-economic and policy environment, and the ethos and delivery of chronic illness management in formal health care systems. Three key themes emerged during the analysis of data. These were 1) social environmental influences on diabetes self-management 2) reluctance or inability of policy makers to regulate processes and environments related to chronic illness management 3) the focus of healthcare system governance and gaps in provision of self-management support (SMS). Nuances in the salience and content of these themes between partner countries related to the presence and articulation of dedicated prevention and self- management policies, behavioural interventions in primary care, drug company involvement and the impact of measures resulting from economic crises, and differences between countries with higher versus lower social welfare support and public spending on shaping illness management. CONCLUSIONS: The results suggest reasons for giving increasing prominence to meso level influences as a means of rebalancing and improving the effectiveness of implementing an agenda for SMS. There is a need to acknowledge the greater economic and policy challenging environment operating in some countries which act as a source of inequality between countries in addressing SMS for chronic illness management and impacts on people's capacity to undertake self-care activities.

Modelling self-management pathways for people with diabetes in primary care.

BACKGROUND: Self-management support to facilitate people with type 2 diabetes to effectively manage their condition is complex to implement. Organisational and system elements operating in relation to providing optimal self-management support in primary care are poorly understood. We have applied operational research techniques to model pathways in primary care to explore and illuminate the processes and points where people struggle to find self-management support. METHODS: Primary care clinicians and support staff in 21 NHS general practices created maps to represent their experience of patients' progress through the system following diagnosis. These were collated into a combined pathway. Following consideration of how patients reduce dependency on the system to become enhanced self-managers, a model was created to show the influences on patients' pathways to self-management. RESULTS: Following establishment of diagnosis and treatment, appointment frequency decreases and patient self-management is expected to increase. However, capacity to consistently assess self-management capabilities; provide self-management support; or enhance patient-led self-care activities is missing from the pathways. Appointment frequencies are orientated to bio-medical monitoring rather than increasing the ability to mobilise resources or undertake self-management activities. CONCLUSIONS: The model provides a clear visual picture of the complexities implicated in achieving optimal self-management support. Self-management is quickly hidden from view in a system orientated to treatment delivery rather than to enhancing patient self-management. The model created highlights the limited self-management support currently provided and illuminates points where service change might impact on providing support for self-management. Ensuring professionals are aware of locally available support and people's existing network support has potential to provide appropriate and timely direction to community facilities and the mobilisation of resources.