The reflexive imperative in the digital age:Using Archer’s ‘fractured reflexivity’ to theorise widening inequities in UK general practice

‘Reflexivity’, as used by Margaret Archer, means creative self-mastery that enables individuals to evaluate their social situation and act purposively within it. People with complex health and social needs may be less able to reflect on their predicament and act to address it. Reflexivity is imperative in complex and changing social situations. The substantial widening of health inequities since the introduction of remote and digital modalities in health care has been well-documented but inadequately theorised. In this article, we use Archer’s theory of fractured reflexivity to understand digital disparities in data from a 28-month longitudinal ethnographic study of 12 UK general practices and a sample of in-depth clinical cases from ‘Deep End’ practices serving highly deprived populations. Through four composite patient cases crafted to illustrate different dimensions of disadvantage, we show how adverse past experiences and structural inequities intersect with patients’ reflexive capacity to self-advocate and act strategically. In some cases, staff were able to use creative workarounds to compensate for patients’ fractured reflexivity, but such actions were limited by workforce capacity and staff awareness. Unless a more systematic safety net is introduced and resourced, people with complex needs are likely to remain multiply disadvantaged by remote and digital health care

Understanding the integration of artificial intelligence in healthcare organisations and systems through the NASSS framework: a qualitative study in a leading Canadian academic centre

Background: Artificial intelligence (AI) technologies are expected to “revolutionise” healthcare. However, despite their promises, their integration within healthcare organisations and systems remains limited. The objective of this study is to explore and understand the systemic challenges and implications of their integration in a leading Canadian academic hospital. Methods: Semi-structured interviews were conducted with 29 stakeholders concerned by the integration of a large set of AI technologies within the organisation (e.g., managers, clinicians, researchers, patients, technology providers). Data were collected and analysed using the Non-Adoption, Abandonment, Scale-up, Spread, Sustainability (NASSS) framework. Results: Among enabling factors and conditions, our findings highlight: a supportive organisational culture and leadership leading to a coherent organisational innovation narrative; mutual trust and transparent communication between senior management and frontline teams; the presence of champions, translators, and boundary spanners for AI able to build bridges and trust; and the capacity to attract technical and clinical talents and expertise. Constraints and barriers include: contrasting definitions of the value of AI technologies and ways to measure such value; lack of real-life and context-based evidence; varying patients’ digital and health literacy capacities; misalignments between organisational dynamics, clinical and administrative processes, infrastructures, and AI technologies; lack of funding mechanisms covering the implementation, adaptation, and expertise required; challenges arising from practice change, new expertise development, and professional identities; lack of official professional, reimbursement, and insurance guidelines; lack of pre- and post-market approval legal and governance frameworks; diversity of the business and financing models for AI technologies; and misalignments between investors’ priorities and the needs and expectations of healthcare organisations and systems. Conclusion: Thanks to the multidimensional NASSS framework, this study provides original insights and a detailed learning base for analysing AI technologies in healthcare from a thorough socio-technical perspective. Our findings highlight the importance of considering the complexity characterising healthcare organisations and systems in current efforts to introduce AI technologies within clinical routines. This study adds to the existing literature and can inform decision-making towards a judicious, responsible, and sustainable integration of these technologies in healthcare organisations and systems

The reflexive imperative in the digital age:Using Archer’s ‘fractured reflexivity’ to theorise widening inequities in UK general practice

‘Reflexivity’, as used by Margaret Archer, means creative self-mastery that enables individuals to evaluate their social situation and act purposively within it. People with complex health and social needs may be less able to reflect on their predicament and act to address it. Reflexivity is imperative in complex and changing social situations. The substantial widening of health inequities since the introduction of remote and digital modalities in health care has been well-documented but inadequately theorised. In this article, we use Archer’s theory of fractured reflexivity to understand digital disparities in data from a 28-month longitudinal ethnographic study of 12 UK general practices and a sample of in-depth clinical cases from ‘Deep End’ practices serving highly deprived populations. Through four composite patient cases crafted to illustrate different dimensions of disadvantage, we show how adverse past experiences and structural inequities intersect with patients’ reflexive capacity to self-advocate and act strategically. In some cases, staff were able to use creative workarounds to compensate for patients’ fractured reflexivity, but such actions were limited by workforce capacity and staff awareness. Unless a more systematic safety net is introduced and resourced, people with complex needs are likely to remain multiply disadvantaged by remote and digital health care

The impact of multiple sclerosis on the identity of mothers in Italy

Purpose: This paper reports on one of the themes that emerged from the analysis of the study, regarding the perceived influence of multiple sclerosis (MS) on the identity of mothers in the socio-cultural context of Italy. Method: In-depth interviews were conducted with 16 women at various stages of MS, with follow up interviews with seven of the women. Phenomenology guided the methodology and the analysis was conducted using interpretative phenomenological analysis. Results: Through the research the value of motherhood to the women who participated emerged. The findings illustrated how many strove to maintain controlof their MS, which led to some making comparisons of themselves and other mothers and feeling different. Some women described how they adjusted their roles and found strength in being mothers but others spoke of their feelings of loss. Most women described living in the moment, appreciating the present and living each day as it came. Another significant experience was fear of stigma, both realized in the form of “pity” from others, and the perceived and actual associated stigma for their families. This contributed to why some women were reluctant to disclose their condition. The mothers who took part in this study differed in how they perceived their disabled identity. Conclusion: Although this study was conducted in the socio-cultural setting of Italy, the findings have implications for professionals working with disabled mothers and women with MS in Italy and beyond; including recognizing the value associated with fully identifying oneself as a mother, rather than solely focusing on doingmothering tasks. • Implications for Rehabilitation • Professionals need to be mindful of the value of motherhood for women with multiple sclerosis. • Professionals should support women who feel like they are battling with maintaining control of their multiple sclerosis, who may be adjusting their identity as mothers; recognizing that they may be influenced by the stage of their multiple sclerosis and whether they were diagnosed before or after having their children. • Women can have feelings of loss related to their ability to fully participate in their children’s lives and professionals should work with women to help them identify the value of their mothering role not only in physically participating in activities but also in being emotionally and physically present as a mother

Methodological challenges when carrying out research on CKD and AKI using routine electronic health records.

Research regarding chronic kidney disease (CKD) and acute kidney injury (AKI) using routinely collected data presents particular challenges. The availability, consistency, and quality of renal data in electronic health records has changed over time with developments in policy, practice incentives, clinical knowledge, and associated guideline changes. Epidemiologic research may be affected by patchy data resulting in an unrepresentative sample, selection bias, misclassification, and confounding by factors associated with testing for and recognition of reduced kidney function. We systematically explore the issues that may arise in study design and interpretation when using routine data sources for CKD and AKI research. First, we discuss how access to health care and management of patients with CKD may have an impact on defining the target population for epidemiologic study. We then consider how testing and recognition of CKD and AKI may lead to biases and how to potentially mitigate against these. Illustrative examples from our own research within the UK are used to clarify key points. Any research using routine renal data has to consider the local clinical context to achieve meaningful interpretation of the study findings

A 50 Year Accomplishment in Marine Science: A History of the Journal Published by the Gulf Coast Research Laboratory

The Gulf Coast Research Laboratory (GCRL) has a 50 year history of annual publication of the peer-reviewed journal Gulf and Caribbean Research (GCR, 2000-present; formerly Gulf Research Reports (GRR) from 1961—1999). Other extant journals serving the region during this time include Contributions in Marine Science (since 1945), Proceedings of the Gulf and Caribbean Fisheries Institute (since 1948), Bulletin of Marine Science (since 1951), Revista de Biología Tropical (since 1953), and Caribbean Journal of Science (since 1961). In the early years of the GCR publication, papers were primarily concerned with research in Mississippi and the northern Gulf of Mexico (GOM), and the majority of authors were from USM/GCRL or the GOM region. However, in the past 15 years, studies from Mexico and the Caribbean have dramatically increased, with a concurrent increase in the geographical diversity of authors. Overall, surveys and inventories, taxonomy, and life history studies have been most common, and taxa have been dominated by fish and crustaceans. Offshore, benthic and marsh habitats have been the most commonly studied during GCR’s 50 year history. In general, publications during the last 15 years are more similar to each other (≥ 65% similarity based on CLUSTER analysis and MDS ordinations) than to earlier publications for geography, taxon, habitat and subject areas. The journal is well cited in peer-reviewed literature, with 72% of the papers published in GRR and 65% of those published in GCR cited at least once. GCR provides an important outlet for peer-reviewed publications from the GOM and Caribbean region

Evaluating complex interventions in context: systematic, meta-narrative review of case study approaches.

BACKGROUND: There is a growing need for methods that acknowledge and successfully capture the dynamic interaction between context and implementation of complex interventions. Case study research has the potential to provide such understanding, enabling in-depth investigation of the particularities of phenomena. However, there is limited guidance on how and when to best use different case study research approaches when evaluating complex interventions. This study aimed to review and synthesise the literature on case study research across relevant disciplines, and determine relevance to the study of contextual influences on complex interventions in health systems and public health research. METHODS: Systematic meta-narrative review of the literature comprising (i) a scoping review of seminal texts (n = 60) on case study methodology and on context, complexity and interventions, (ii) detailed review of empirical literature on case study, context and complex interventions (n = 71), and (iii) identifying and reviewing 'hybrid papers' (n = 8) focused on the merits and challenges of case study in the evaluation of complex interventions. RESULTS: We identified four broad (and to some extent overlapping) research traditions, all using case study in a slightly different way and with different goals: 1) developing and testing complex interventions in healthcare; 2) analysing change in organisations; 3) undertaking realist evaluations; 4) studying complex change naturalistically. Each tradition conceptualised context differently-respectively as the backdrop to, or factors impacting on, the intervention; sets of interacting conditions and relationships; circumstances triggering intervention mechanisms; and socially structured practices. Overall, these traditions drew on a small number of case study methodologists and disciplines. Few studies problematised the nature and boundaries of 'the case' and 'context' or considered the implications of such conceptualisations for methods and knowledge production. CONCLUSIONS: Case study research on complex interventions in healthcare draws on a number of different research traditions, each with different epistemological and methodological preferences. The approach used and consequences for knowledge produced often remains implicit. This has implications for how researchers, practitioners and decision makers understand, implement and evaluate complex interventions in different settings. Deeper engagement with case study research as a methodology is strongly recommended

Wandering as a sociomaterial practice : extending the theorization of GPS tracking in cognitive impairment

Electronic tracking through global positioning systems (GPSs) is used to monitor people with cognitive impairment who “wander” outside the home. This ethnographic study explored how GPS-monitored wandering was experienced by individuals, lay carers, and professional staff. Seven in-depth case studies revealed that wandering was often an enjoyable and worthwhile activity and helped deal with uncertainty and threats to identity. In what were typically very complex care contexts, GPS devices were useful to the extent that they aligned with a wider sociomaterial care network that included lay carers, call centers, and health and social care professionals. In this context, “safe” wandering was a collaborative accomplishment that depended on the technology’s materiality, affordances, and aesthetic properties; a distributed knowledge of the individual and the places they wandered through, and a collective and dynamic interpretation of risk. Implications for design and delivery of GPS devices and services for cognitive impairment are discussed