How do people with multiple long-term health conditions experience the self-management approach to health care? : a thesis presented in fulfilment of the requirements for the degree of Doctor of Philosophy, Massey University, Palmerston North, New Zealand

The health system in New Zealand has devised approaches intended to meet the needs of people with long-term conditions (LTCs) based on the international theories of the Chronic Care Model (CCM) and a self-management framework (Bodenheimer, Wagner, & Grumbach, 2002b; Lorig, 1993; Wagner, 1998). LTCs and multimorbidity are socially patterned so often people with several LTCs are also contending with chaotic lives as well as the implications of their Illnesses. The self-management framework is based on the assumption that everyone has the agency or freewill to make the daily decisions that would benefit their health and ignores the powerful effect of social context. Because the behaviours recommended to optimise health are so entwined with a person’s social context, LTCs are particularly sensitive to the social determinants of health. This multiple case study follows the complex lives of sixteen people with several significant long-term health conditions using the theories of both Cockerham (2005, 2010, 2013b) and Link and Phelan (1995, 2010) to explore their experiences. Ongoing contact with the patient-participants comprised two interviews, four-weekly contacts and interviews with their primary health care clinicians. The patient-participants’ stories reveal complex, entangled lives marked by loss, poverty and daily challenges. They are significantly constrained by the overwhelming social contexts of their lives and reduced to survival mode by their cumulative losses across the four domains of the Whare Tapa Wha model. Personal agency is neither a choice nor readily achieved. They are left too exhausted to work their way through a health system that does not recognise their needs, empower them or compensate for their lack of energy. The weary patient-participants in this study bear little resemblance to the idealised expert patient of the self-management framework. Clinicians are left manoeuvring to compassionately and pragmatically support the patient-participants as best they can within an unhelpful system. The findings however do surface examples of care that are valued by both patient- and clinician-participants that sit outside the self-management approach. These valued aspects are explored alongside the harm reduction, recovery and palliative models of care. These all offer contributions towards an approach that would optimise the quality of life for people with significant, multiple LTCs. An exploration of this re-awakened approach to care is described. Care that is constricted self-management approach could wrap around the patient and support them to use their residual agency in a direction of their choosing. Clinicians would be released from their current programmed response be able to more fully utilise their clinical expertise. Clinicians and patients would have the freedom to be more pragmatic around quality of life and the issues that matter to the individual with LTCs

Are interventions for improving the quality of services provided by specialized drug shops effective in sub-Saharan Africa? A systematic review of the literature.

PURPOSE: We set out to determine effectiveness of interventions for improving the quality of services provided by specialized drug shops in sub-Saharan Africa. DATA SOURCES: We searched PubMed, CAB Abstracts, Web of Science, PsycINFO and Eldis databases and websites for organizations such as WHO and Management Sciences for Health. Finally, we searched manually through the references of retrieved articles. STUDY SELECTION: Our search strategy included randomized trials, time-series studies and before and after studies evaluating six interventions; education, peer review, reorganizing administrative structures, incentives, regulation and legislation. DATA EXTRACTION: We extracted information on design features, participants, interventions and outcomes assessed studies for methodological quality, and extracted results, all using uniform checklists. RESULTS OF DATA SYNTHESIS: We obtained 10 studies, all implementing educational interventions. Outcome measures were heterogeneous and included knowledge, communication and dispensing practices. Education improved knowledge across studies, but gave mixed results on communication between sellers and clients, dispensing of appropriate treatments and referring of patients to health facilities. Profit incentives appeared to constrain behaviour change in certain instances, although cases of shops adopting practices at the expense of sales revenue were also reported. CONCLUSION: Evidence suggests that knowledge and practices of pharmacies and drug shops can be improved across a range of diseases and countries/regions, although variations were reported across studies. Profit incentives appear to bear some influence on the level of success of interventions. More work is required to extend the geographical base of evidence, investigate cost-effectiveness and evaluate sustainability of interventions over periods longer than 1 year