Towards a Socially Situated Understanding of Self-Management Support and Goals for People Living with Chronic Conditions

Submission note: A thesis submitted in total fulfilment of the requirements for the degree of Doctor of Philosophy to the School of Allied Health, Human Services and Sport, College of Science, Health and Engineering, La Trobe University, Victoria, Australia.

Thesis with publications.

Chronic conditions related to lifestyle risk factors are increasing. Supporting selfmanagement – the active involvement of people in their own healthcare – is an integral part of contemporary models of chronic condition care. A person-centred approach which incorporates patients’ preferences, values and needs into decisions made in the clinical setting is promoted in chronic care policy and practice guidelines as a way to support self-management. In practice, patient compliance with standardised medical and lifestyle regimens tends to dominate over a person-centred approach to support self-management. This has the potential to create disconnects between health professionals and people living with chronic conditions on goals for self-management. Due to the potential for disconnects to occur between the goal preferences of people with chronic conditions and their health professionals, greater attention is needed to the relational, social and structural influences which may shape opportunities for goal-negotiation in self-management support. Drawing on Bourdieu’s concepts of field, doxa, habitus, and capital, a qualitative research design was used to investigate self-management support and selfmanagement goals from the perspective of people with chronic conditions and health professionals. Repeat observations of consultations and semi-structured interviews were conducted with a sample of patient-professional dyads comprising people with a chronic health condition (type 2 diabetes, chronic obstructive pulmonary disease and/or obesity) and their health professional. This approach enabled in-depth investigation of self-management support within the context of the patientprofessional consultation, examining the experiences of self-management support and goal preferences of patients and health professionals over time. vi The three principal findings of this research are that: (1) goals for self-management are socially produced and enacted; (2) socially oriented goals are marginalised because of the bounded nature of healthcare encounters; and (3) there is differential provision of self-management support. The findings reported in this thesis reveal goals are complex social phenomena shaped by relational, situational and temporal influences. The differential access to cultural, economic and social capital of people with chronic conditions impacted on their goal options as well as opportunities to participate in more person-centred interactions in which their goal preferences were given legitimacy. Health professionals tended to privilege goals for self-management associated with symptom control and treatment adherence over patients’ goals, which often related to a broader set of medical, emotional and social dimensions. The extent to which goals were legitimised by health professionals and opportunities for patients to be active participants in self-management support were linked to the possession and recognition of power and social status. New insights into how traditional patient and professional roles in self-management support are maintained and, thus, how inequalities in healthcare are reproduced are provided. This thesis adds to knowledge of the mismatch between patient and health professional goals for self-management by identifying goals as social products rather than discrete, individual entities. This thesis provides knowledge about supporting people to live well with their chronic conditions that is more closely aligned with the ideals of a person-centred approach to supporting self-management.